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|
Attributes | |
ACN | 566361 |
Time | |
Date | 200211 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 1650 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : bos.tower |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee Arrow IV |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Route In Use | approach : traffic pattern |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : private pilot : instrument |
Experience | flight time last 90 days : 0 flight time total : 550 flight time type : 150 |
ASRS Report | 566361 |
Person 2 | |
Affiliation | other |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : eng low press warn light other other : person 1 |
Resolutory Action | flight crew : diverted to another airport flight crew : declared emergency |
Consequence | other other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : installation performance deficiency : inspection performance deficiency : testing |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
The engine was overhauled and returned with the turbo to FBO. (Your part number, your serial number, our work order number.) the engine was installed in the airplane and run for about 1 - 1.5 hours for testing and adjustment. On wednesday evening, 11/xa/02, I inspected the engine visually to assure myself that nothing obvious had been missed. I saw no oil leakage and I was looking for this kind of thing. I discussed my first flight with ground personnel at ZZZ and at overhaul station prior to starting the engine. The plan was to taxi out, do a runup, takeoff on runway 24, circle in the pattern for 15 mins after takeoff (about 1.5 circuits around the pattern) and land. The engine was then to be checked out of leaks, or other problems prior to a 3 hour flight. WX at the time was less than ideal by my standards, but nothing I was not accustomed to. I expected no problems. Clear, visibility 10 mi, wind 190 degrees at 19 KTS gusting to 26 KTS. On thursday afternoon, nov/xa/02, I checked the oil prior to starting the aircraft and found 7.5 quarts of oil. During my preflight (which was extra long and careful) I found no evidence of oil leakage. I even had the cowling removed and found no leakage or loose wires, etc. I started the engine. The oil pressure was at the high end of the green range which is typical for this aircraft with a cold engine. I ran through the checklist and taxied to the runway. During my runup I was dissatisfied with propeller response. I returned to the hangar and the mechanic came out to observe the problem. The result was that while I was still not satisfied, it was safe to fly and further work would be done after the first shakedown run. The engine was not turned off, but the oil pressure was in the middle of the green when I left the hangar heading back to the runway. A second runup was done with no change in operation or performance. The oil pressure was still in the mid green range (this is typical for a warm engine with this aircraft). I took the runway and took off. Total elapsed time from engine start to takeoff was about 20 mins. Operation was normal through the first half circuit of the field. About three quarters around the field the engine oil idiot light came on. I immediately checked the oil pressure and it was zero. I radioed the tower for immediate landing. I pulled the power back to about 20%, but did not turn the engine off because I was concerned about my ability to make a runway safely considering the wind, my altitude and position on the field. I expected the engine to quit at any time. Luckily, I was able to use the engine for 2 bursts of power during my descent (about 50% -- maybe 70%) and managed to land safely in spite of being forced to land with a left quartering tail wind and questionable engine. I did throttle back as I turned to line up over the runway, but did not turn off the engine (frankly, with the wind and landing issues it never occurred to me). I landed and turned onto the taxiway. I then realized the engine was still running (and I was surprised) and pulled the mixture to shut the engine down. I called for a tow back to the hangar. When I got back to the hangar and exited the aircraft it was obvious that a very large portion of the oil had leaked out of the engine since it was dripping off the whole underside of the aircraft. We were unable to determine by visual inspection what the source of the oil leak was. The dip stick showed zero oil. We made a preliminary diagnosis that the oil had leaked from the quick drain on the sump. The plan was to replace the quick drain with a plug and I would call the overhauler the next day prior to doing anything else to the engine. A check of the oil left in the sump the next day showed about 1 quart left (this oil has been saved). I had a conversation with engine overhaul facility on the morning of 11/02. He advised me to simply put oil into the engine, run it, and see where the leak was. We did this and after about 10 seconds of operation at idle we had lost at least a pint of oil. It took a second run to see that the oil was coming from the turbo. At first we thought a gasket had gone but using a mirror we were able to see that an 1/4INCH (approximately) diameter plug was missing from the rear of the turbo unit. The maintenance personnel who installed the engine indicated that they had done no work to this port and did not even remember that it was there. I called engine overhaul facility to discuss the plug and they indicate that they had no control over the turbo. It was shipped as shipped to them from accessory manufacture.
Original NASA ASRS Text
Title: A PIPER PA-28 AT 1650 FT DECLARED AN EMER AND DIVERTED DUE TO LOSS OF ENG OIL PRESSURE AND QUANTITY. CAUSED BY A FAILED TURBO OIL PLUG.
Narrative: THE ENG WAS OVERHAULED AND RETURNED WITH THE TURBO TO FBO. (YOUR PART NUMBER, YOUR SERIAL NUMBER, OUR WORK ORDER NUMBER.) THE ENG WAS INSTALLED IN THE AIRPLANE AND RUN FOR ABOUT 1 - 1.5 HRS FOR TESTING AND ADJUSTMENT. ON WEDNESDAY EVENING, 11/XA/02, I INSPECTED THE ENG VISUALLY TO ASSURE MYSELF THAT NOTHING OBVIOUS HAD BEEN MISSED. I SAW NO OIL LEAKAGE AND I WAS LOOKING FOR THIS KIND OF THING. I DISCUSSED MY FIRST FLT WITH GND PERSONNEL AT ZZZ AND AT OVERHAUL STATION PRIOR TO STARTING THE ENG. THE PLAN WAS TO TAXI OUT, DO A RUNUP, TKOF ON RWY 24, CIRCLE IN THE PATTERN FOR 15 MINS AFTER TKOF (ABOUT 1.5 CIRCUITS AROUND THE PATTERN) AND LAND. THE ENG WAS THEN TO BE CHKED OUT OF LEAKS, OR OTHER PROBS PRIOR TO A 3 HR FLT. WX AT THE TIME WAS LESS THAN IDEAL BY MY STANDARDS, BUT NOTHING I WAS NOT ACCUSTOMED TO. I EXPECTED NO PROBS. CLR, VISIBILITY 10 MI, WIND 190 DEGS AT 19 KTS GUSTING TO 26 KTS. ON THURSDAY AFTERNOON, NOV/XA/02, I CHKED THE OIL PRIOR TO STARTING THE ACFT AND FOUND 7.5 QUARTS OF OIL. DURING MY PREFLT (WHICH WAS EXTRA LONG AND CAREFUL) I FOUND NO EVIDENCE OF OIL LEAKAGE. I EVEN HAD THE COWLING REMOVED AND FOUND NO LEAKAGE OR LOOSE WIRES, ETC. I STARTED THE ENG. THE OIL PRESSURE WAS AT THE HIGH END OF THE GREEN RANGE WHICH IS TYPICAL FOR THIS ACFT WITH A COLD ENG. I RAN THROUGH THE CHKLIST AND TAXIED TO THE RWY. DURING MY RUNUP I WAS DISSATISFIED WITH PROP RESPONSE. I RETURNED TO THE HANGAR AND THE MECH CAME OUT TO OBSERVE THE PROBLEM. THE RESULT WAS THAT WHILE I WAS STILL NOT SATISFIED, IT WAS SAFE TO FLY AND FURTHER WORK WOULD BE DONE AFTER THE FIRST SHAKEDOWN RUN. THE ENG WAS NOT TURNED OFF, BUT THE OIL PRESSURE WAS IN THE MIDDLE OF THE GREEN WHEN I LEFT THE HANGAR HEADING BACK TO THE RWY. A SECOND RUNUP WAS DONE WITH NO CHANGE IN OP OR PERFORMANCE. THE OIL PRESSURE WAS STILL IN THE MID GREEN RANGE (THIS IS TYPICAL FOR A WARM ENG WITH THIS ACFT). I TOOK THE RWY AND TOOK OFF. TOTAL ELAPSED TIME FROM ENG START TO TKOF WAS ABOUT 20 MINS. OP WAS NORMAL THROUGH THE FIRST HALF CIRCUIT OF THE FIELD. ABOUT THREE QUARTERS AROUND THE FIELD THE ENG OIL IDIOT LIGHT CAME ON. I IMMEDIATELY CHKED THE OIL PRESSURE AND IT WAS ZERO. I RADIOED THE TWR FOR IMMEDIATE LNDG. I PULLED THE POWER BACK TO ABOUT 20%, BUT DID NOT TURN THE ENG OFF BECAUSE I WAS CONCERNED ABOUT MY ABILITY TO MAKE A RWY SAFELY CONSIDERING THE WIND, MY ALT AND POS ON THE FIELD. I EXPECTED THE ENG TO QUIT AT ANY TIME. LUCKILY, I WAS ABLE TO USE THE ENG FOR 2 BURSTS OF POWER DURING MY DSCNT (ABOUT 50% -- MAYBE 70%) AND MANAGED TO LAND SAFELY IN SPITE OF BEING FORCED TO LAND WITH A L QUARTERING TAIL WIND AND QUESTIONABLE ENG. I DID THROTTLE BACK AS I TURNED TO LINE UP OVER THE RWY, BUT DID NOT TURN OFF THE ENG (FRANKLY, WITH THE WIND AND LNDG ISSUES IT NEVER OCCURRED TO ME). I LANDED AND TURNED ONTO THE TXWY. I THEN REALIZED THE ENG WAS STILL RUNNING (AND I WAS SURPRISED) AND PULLED THE MIXTURE TO SHUT THE ENG DOWN. I CALLED FOR A TOW BACK TO THE HANGAR. WHEN I GOT BACK TO THE HANGAR AND EXITED THE ACFT IT WAS OBVIOUS THAT A VERY LARGE PORTION OF THE OIL HAD LEAKED OUT OF THE ENG SINCE IT WAS DRIPPING OFF THE WHOLE UNDERSIDE OF THE ACFT. WE WERE UNABLE TO DETERMINE BY VISUAL INSPECTION WHAT THE SOURCE OF THE OIL LEAK WAS. THE DIP STICK SHOWED ZERO OIL. WE MADE A PRELIMINARY DIAGNOSIS THAT THE OIL HAD LEAKED FROM THE QUICK DRAIN ON THE SUMP. THE PLAN WAS TO REPLACE THE QUICK DRAIN WITH A PLUG AND I WOULD CALL THE OVERHAULER THE NEXT DAY PRIOR TO DOING ANYTHING ELSE TO THE ENG. A CHK OF THE OIL LEFT IN THE SUMP THE NEXT DAY SHOWED ABOUT 1 QUART LEFT (THIS OIL HAS BEEN SAVED). I HAD A CONVERSATION WITH ENG OVERHAUL FACILITY ON THE MORNING OF 11/02. HE ADVISED ME TO SIMPLY PUT OIL INTO THE ENG, RUN IT, AND SEE WHERE THE LEAK WAS. WE DID THIS AND AFTER ABOUT 10 SECONDS OF OP AT IDLE WE HAD LOST AT LEAST A PINT OF OIL. IT TOOK A SECOND RUN TO SEE THAT THE OIL WAS COMING FROM THE TURBO. AT FIRST WE THOUGHT A GASKET HAD GONE BUT USING A MIRROR WE WERE ABLE TO SEE THAT AN 1/4INCH (APPROX) DIAMETER PLUG WAS MISSING FROM THE REAR OF THE TURBO UNIT. THE MAINT PERSONNEL WHO INSTALLED THE ENG INDICATED THAT THEY HAD DONE NO WORK TO THIS PORT AND DID NOT EVEN REMEMBER THAT IT WAS THERE. I CALLED ENG OVERHAUL FACILITY TO DISCUSS THE PLUG AND THEY INDICATE THAT THEY HAD NO CTL OVER THE TURBO. IT WAS SHIPPED AS SHIPPED TO THEM FROM ACCESSORY MANUFACTURE.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.