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A PA22-162 arrived at station with an oil leak. Reporter found bulkhead fittings leaking. Checked seals and hoses. Aircraft departed and within 15 mi lost engine oil pressure resulting in an off field landing.
| Attributes | |
| ACN | 708750 |
| Time | |
| Date | 200609 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : zzz.airport |
| State Reference | US |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | general aviation : personal |
| Make Model Name | Piper Single Undifferentiated or Other Model |
| Operating Under FAR Part | Part 91 |
| Flight Phase | ground : maintenance |
| Person 1 | |
| Affiliation | other |
| Function | maintenance : technician |
| Qualification | technician : inspection authority technician : powerplant technician : airframe |
| Experience | maintenance lead technician : 14 maintenance technician : 2 |
| ASRS Report | 708750 |
| Person 2 | |
| Affiliation | other |
| Function | flight crew : single pilot oversight : pic |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far |
| Independent Detector | aircraft equipment other aircraft equipment : oil press indication other flight crewa |
| Resolutory Action | flight crew : declared emergency other |
| Consequence | other |
| Factors | |
| Maintenance | performance deficiency : inspection performance deficiency : repair performance deficiency : fault isolation |
| Supplementary | |
| Problem Areas | Chart Or Publication Maintenance Human Performance Aircraft |
| Primary Problem | Maintenance Human Performance |
Narrative:
Transient aircraft arrived with complaint of oil leaking from the engine. Owner stated that it just had the annual inspection completed. Investigated for source and found 2 fittings in a remote oil filter assembly: AN833; AN877 with AN6289 type bulkhead fitting nuts extremely loose in oil screen housing. Removed hoses from fittings; removed oil screen housing assembly from engine; inspected o-ring seals under bulkhead nuts; re-indexed fitting position and tightened nuts. Re-torqued and safetied thermostatic valve and oil temperature bulb adapter. Reinstalled housing assembly onto engine with new gasket; torqued the 4 housing attach bolts; reinstalled hoses to fittings; washed down aft portion of engine with solvent. Performed ground run-up and leak inspection. No more leakage detected. Re-cowled aircraft and signed off work order as airworthy. All work was done in accordance with lycoming direct drive overhaul manual section 5; paragraph 5-5; figure 5-1; table of limits page 1-37 and AC43 13-1B; chapter 9; section 2; paragraph 9-3 and table 9-2. Aircraft departed to the north and at approximately 15 mi out lost all oil pressure and landed on highway with no damage to the aircraft or injuries to the occupants. Post inspection found the repair performed was not the cause and at this time has yet to be determined. After dwelling on the situation; I feel that a test flight around the pattern and post inspection would have found a second problem not detected during the ground run-up. I also feel that if the installation instructions and documents addressed stc'ed installations on the aircraft would help greatly in troubleshooting these installations. Fatigue was a factor. I clocked in at XA36; the aircraft was released at XB12. The pilot desired to return home due to no lights at the home field. No one other than the pilot was on hand to double inspect the work or aircraft for other possible problems.
Original NASA ASRS Text
Title: A PA22-162 ARRIVED AT STATION WITH AN OIL LEAK. RPTR FOUND BULKHEAD FITTINGS LEAKING. CHKED SEALS AND HOSES. ACFT DEPARTED AND WITHIN 15 MI LOST ENG OIL PRESSURE RESULTING IN AN OFF FIELD LNDG.
Narrative: TRANSIENT ACFT ARRIVED WITH COMPLAINT OF OIL LEAKING FROM THE ENG. OWNER STATED THAT IT JUST HAD THE ANNUAL INSPECTION COMPLETED. INVESTIGATED FOR SOURCE AND FOUND 2 FITTINGS IN A REMOTE OIL FILTER ASSEMBLY: AN833; AN877 WITH AN6289 TYPE BULKHEAD FITTING NUTS EXTREMELY LOOSE IN OIL SCREEN HOUSING. REMOVED HOSES FROM FITTINGS; REMOVED OIL SCREEN HOUSING ASSEMBLY FROM ENG; INSPECTED O-RING SEALS UNDER BULKHEAD NUTS; RE-INDEXED FITTING POS AND TIGHTENED NUTS. RE-TORQUED AND SAFETIED THERMOSTATIC VALVE AND OIL TEMP BULB ADAPTER. REINSTALLED HOUSING ASSEMBLY ONTO ENG WITH NEW GASKET; TORQUED THE 4 HOUSING ATTACH BOLTS; REINSTALLED HOSES TO FITTINGS; WASHED DOWN AFT PORTION OF ENG WITH SOLVENT. PERFORMED GND RUN-UP AND LEAK INSPECTION. NO MORE LEAKAGE DETECTED. RE-COWLED ACFT AND SIGNED OFF WORK ORDER AS AIRWORTHY. ALL WORK WAS DONE IN ACCORDANCE WITH LYCOMING DIRECT DRIVE OVERHAUL MANUAL SECTION 5; PARAGRAPH 5-5; FIGURE 5-1; TABLE OF LIMITS PAGE 1-37 AND AC43 13-1B; CHAPTER 9; SECTION 2; PARAGRAPH 9-3 AND TABLE 9-2. ACFT DEPARTED TO THE N AND AT APPROX 15 MI OUT LOST ALL OIL PRESSURE AND LANDED ON HWY WITH NO DAMAGE TO THE ACFT OR INJURIES TO THE OCCUPANTS. POST INSPECTION FOUND THE REPAIR PERFORMED WAS NOT THE CAUSE AND AT THIS TIME HAS YET TO BE DETERMINED. AFTER DWELLING ON THE SITUATION; I FEEL THAT A TEST FLT AROUND THE PATTERN AND POST INSPECTION WOULD HAVE FOUND A SECOND PROB NOT DETECTED DURING THE GND RUN-UP. I ALSO FEEL THAT IF THE INSTALLATION INSTRUCTIONS AND DOCUMENTS ADDRESSED STC'ED INSTALLATIONS ON THE ACFT WOULD HELP GREATLY IN TROUBLESHOOTING THESE INSTALLATIONS. FATIGUE WAS A FACTOR. I CLOCKED IN AT XA36; THE ACFT WAS RELEASED AT XB12. THE PLT DESIRED TO RETURN HOME DUE TO NO LIGHTS AT THE HOME FIELD. NO ONE OTHER THAN THE PLT WAS ON HAND TO DOUBLE INSPECT THE WORK OR ACFT FOR OTHER POSSIBLE PROBS.
Data retrieved from NASA's ASRS site as of January 2009 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.