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|
Attributes | |
ACN | 633232 |
Time | |
Date | 200410 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 2500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : personal |
Make Model Name | SR20 |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Flight Plan | None |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 122 flight time total : 1047 flight time type : 150 |
ASRS Report | 633232 |
Person 2 | |
Function | maintenance : technician |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : lo oil p. light mfd other flight crewa |
Resolutory Action | flight crew : diverted to another airport flight crew : landed in emergency condition |
Consequence | other other other Other |
Factors | |
Maintenance | contributing factor : engineering procedure contributing factor : schedule pressure performance deficiency : testing performance deficiency : inspection |
Supplementary | |
Problem Areas | Company Aircraft Maintenance Human Performance Flight Crew Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
The aircraft was taken to ZZZ airport for an oil change and some simple service bulletins. Discussion was made about scheduling the 100 hour inspection and it was agreed that the engine portion would be done at this time and the aircraft would be brought back in 2 weeks for the airframe portion. 2 mechanics were working on the aircraft. After the cowl was reinstalled on the aircraft, the engine was run and leaks checked for following the oil change. The aircraft was taxied out for takeoff and a full run-up was performed using the checklist. About 12 mins into the flight, the low oil pressure light came on and upon checking the mfd (multi-functional display), the oil pressure was noted to be at 18 psi. A power reduction was made, glide speed established and a field was selected for a forced landing. Once established for a landing, the GPS was checked for the closest airport. This happened to be the airport 4 mi to the east. The decision was made to head towards the airport keeping fields underneath as possible landing sites if the engine should seize. Oil pressure was reading 0 psi at this point. A right base to runway 17 was entered and a non-eventful landing performed. Once safely off the runway, the engine was shut down and the aircraft secured into a tie down. The cowl was removed which revealed the oil plug sitting on the bottom of the cowl. It had not been safety wired to the oil pan. The cause of this problem could be any combination of the following: pressure from the pilot to do extra work due to tight schedules, lack of communication between 2 mechanics working on the aircraft and or failure to perform a detailed inspection prior to returning the aircraft to service. No persons or property were injured in this situation. Callback conversation with reporter revealed the following information: reporter responded to the question regarding the state of the engine after being run with zero oil pressure by stating that the filter was found to have some metal chips inside during the postflt run-up inspection. The maintenance facility owned up to the mistake made by one of their maintenance persons and replaced the 'cont io 360' engine with a new one. The aircraft was new and was on a least back.
Original NASA ASRS Text
Title: AFTER COMPLETE LOSS OF OIL PRESSURE A CIRRUS SR20 PLT PERFORMS AN EMER DIVERSION AND LNDG AT ZZZ-US.
Narrative: THE ACFT WAS TAKEN TO ZZZ ARPT FOR AN OIL CHANGE AND SOME SIMPLE SVC BULLETINS. DISCUSSION WAS MADE ABOUT SCHEDULING THE 100 HR INSPECTION AND IT WAS AGREED THAT THE ENG PORTION WOULD BE DONE AT THIS TIME AND THE ACFT WOULD BE BROUGHT BACK IN 2 WKS FOR THE AIRFRAME PORTION. 2 MECHS WERE WORKING ON THE ACFT. AFTER THE COWL WAS REINSTALLED ON THE ACFT, THE ENG WAS RUN AND LEAKS CHKED FOR FOLLOWING THE OIL CHANGE. THE ACFT WAS TAXIED OUT FOR TKOF AND A FULL RUN-UP WAS PERFORMED USING THE CHKLIST. ABOUT 12 MINS INTO THE FLT, THE LOW OIL PRESSURE LIGHT CAME ON AND UPON CHKING THE MFD (MULTI-FUNCTIONAL DISPLAY), THE OIL PRESSURE WAS NOTED TO BE AT 18 PSI. A PWR REDUCTION WAS MADE, GLIDE SPD ESTABLISHED AND A FIELD WAS SELECTED FOR A FORCED LNDG. ONCE ESTABLISHED FOR A LNDG, THE GPS WAS CHKED FOR THE CLOSEST ARPT. THIS HAPPENED TO BE THE ARPT 4 MI TO THE E. THE DECISION WAS MADE TO HEAD TOWARDS THE ARPT KEEPING FIELDS UNDERNEATH AS POSSIBLE LNDG SITES IF THE ENG SHOULD SEIZE. OIL PRESSURE WAS READING 0 PSI AT THIS POINT. A R BASE TO RWY 17 WAS ENTERED AND A NON-EVENTFUL LNDG PERFORMED. ONCE SAFELY OFF THE RWY, THE ENG WAS SHUT DOWN AND THE ACFT SECURED INTO A TIE DOWN. THE COWL WAS REMOVED WHICH REVEALED THE OIL PLUG SITTING ON THE BOTTOM OF THE COWL. IT HAD NOT BEEN SAFETY WIRED TO THE OIL PAN. THE CAUSE OF THIS PROB COULD BE ANY COMBINATION OF THE FOLLOWING: PRESSURE FROM THE PLT TO DO EXTRA WORK DUE TO TIGHT SCHEDULES, LACK OF COM BTWN 2 MECHS WORKING ON THE ACFT AND OR FAILURE TO PERFORM A DETAILED INSPECTION PRIOR TO RETURNING THE ACFT TO SVC. NO PERSONS OR PROPERTY WERE INJURED IN THIS SIT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR RESPONDED TO THE QUESTION REGARDING THE STATE OF THE ENG AFTER BEING RUN WITH ZERO OIL PRESSURE BY STATING THAT THE FILTER WAS FOUND TO HAVE SOME METAL CHIPS INSIDE DURING THE POSTFLT RUN-UP INSPECTION. THE MAINT FACILITY OWNED UP TO THE MISTAKE MADE BY ONE OF THEIR MAINT PERSONS AND REPLACED THE 'CONT IO 360' ENG WITH A NEW ONE. THE ACFT WAS NEW AND WAS ON A LEAST BACK.
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.