# NTSB CEN23LA246: Piper PA46, N463HP, College Station, TX, June 18, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 18, 2023, 08:43 local (13:43 UTC) - Place: College Station, TX - Coordinates: 30.683, -96.263 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.6830&lon=-96.2630&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 192399 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA246 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192399/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192399 - Page: https://openairdocs.org/ntsb/CEN23LA246 ## Probable cause The mechanic’s failure to properly secure the oil suction screen plug during recent maintenance, which resulted in an oil leak and subsequent loss of engine power due to oil starvation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA 46-350P, 3 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7104620), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=7104620), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7104620), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7104620), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7104620), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=7104620), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis While climbing the airplane to cruise altitude after takeoff, the pilot observed an increase in engine oil temperature above the normal range and requested to return to the departure airport. While receiving vectors for an instrument approach, the pilot saw smoke in the cabin and the engine lost total power. Unable to glide to any runway, the pilot selected a field for the forced landing, during which the airplane sustained substantial damage to the wings and fuselage. Postaccident examination revealed that about 2 quarts of oil remained in the engine, and the recovered oil displayed evidence of metal contamination. There was evidence of an oil leak in the engine compartment and along the lower fuselage. There was evidence of a crankcase fracture near the oil dip stick port; however, a laboratory examination determined the fracture to be consistent with overload and likely due to impact-related damage. The engine exhibited no evidence of any loose or disconnected oil lines. The oil filter was removed, and the filter material was found to be saturated with metallic particles. The oil suction screen plug, located on the oil sump, was not secured with safety wire as required per the manufacturer’s maintenance manual. There was no evidence that the plug or required safety wire was damaged by other objects. The oil suction screen plug was found to be loose, with engine oil observed below the oil suction screen plug. The crush washer behind the oil screen plug was intact and exhibited no damage. Laboratory analysis of the metallic debris recovered from the oil suction screen was consistent with connecting rod material as well as steel from fittings, fasteners, and brackets. The metallic debris found in the recovered oil, oil filter, and oil suction screen was likely due to mechanical damage associated with oil starvation. Eleven days before the accident flight, the pilot observed decreased engine manifold pressure and a partial loss of engine power. He diverted to an airport, where he had the turbocharger replaced by an aviation mechanic. In addition to replacing the turbocharger, the mechanic also drained and replaced the engine oil, which included removal and reinstallation of the oil suction screen plug. The loss of engine power was likely due to a loss of oil during the flight that led to oil starvation within the engine. The loose oil suction screen plug, the absence of safety wire on the plug, and the evidence of an oil leak beneath the plug were consistent with the mechanic’s failure to properly secure the oil suction screen plug during recent maintenance. ## Factual narrative On June 18, 2023, about 0843 central daytime time, a Piper PA46-350P airplane, N463HP, was substantially damaged when it was involved in an accident near College Station, Texas. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, during the climb through 4,000 ft mean sea level (msl), the oil temperature began increasing to 215°F, which was higher than the normal range of 190-200°F. The pilot reduced the airplane’s climb rate to increase cooling, but the oil temperature continued to climb to 230°F. At that time, the pilot requested an instrument clearance back to Easterwood Field Airport (CLL), College Station, Texas. While receiving vectors for the RNAV 11 approach at CLL, the pilot descended to about 2,000 ft msl when he noted smoke in the cabin and a loss of engine power. Unable to glide to any runway, the pilot selected a field to perform a forced landing. The airplane sustained substantial damage to the wings and fuselage during the forced landing. Eleven days before the accident flight, on June 7, 2023, the pilot was conducting a cross-country flight when he observed decreased manifold pressure and a partial loss of engine power. The pilot diverted to CLL, where after troubleshooting, an aviation mechanic told the pilot that the turbocharger required replacement. After the turbocharger was replaced, the mechanic completed an uneventful engine test run. An engine logbook entry dated June 16, 2023, stated that in addition to replacing the turbocharger, the mechanic drained the engine oil, opened the oil filter, and cleaned the oil pickup screen, where a small amount of metal was observed. The oil sump was flushed, and 11 quarts of new oil added to the engine. The maintenance logbook entry noted that after the maintenance, the engine ran normally at 42 inches of manifold pressure. Postaccident examination of the engine was conducted with the assistance of a technical representative from Lycoming Engines. The engine oil sump contained about 2 quarts of oil, and the recovered oil displayed evidence of metal contamination. The oil filter was removed, and the filter material was found to be saturated with metallic particles. There was no evidence of any loose or disconnected oil lines. Engine crankshaft continuity was established with cylinder compression noted on all cylinders except for cylinder No. 6. The sparkplugs exhibited signatures of normal operation. The oil suction screen plug located in the oil sump was found not secured with safety wire as required per the manufacturer’s maintenance manual. There was no evidence that the plug or its required safety wire were damaged by other objects. The oil suction screen plug was found loose, with engine oil observed below the oil suction screen plug. The crush washer behind the oil screen plug was found intact with no damage. A portion of the oil dipstick port and fractured crankcase were submitted foradditional metallurgical examination. The laboratory examination revealed no evidence of material defects in the crankcase material, and the observed fracture features were consistent with overload. Additional laboratory analysis of the metallic debris recovered from the oil suction screen was consistent with connecting rod material as well as steel from fittings, fasteners, and brackets. ## Aircraft - Registration: [N463HP](https://openairdocs.org/aircraft/N463HP), registered now, S/N 4636335, built 2002 (OpenAirDocs) - Reported make and model: PIPER PA46 (350P) - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4636335 - Year built: 2002 - Airframe hours: 1871 - Engines: Lycoming TIO-540-AE2A 350 horsepower reciprocating - Damage: Substantial damage - Fire: In-Flight - Flight: Personal, Part 91 - Registered owner: 3 Siblings LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 22, 2023, 70 hours before - Departed: KCLL, College Station, TX - Destination: KAID, Anderson, IN - Flight plan: IFR - Airport: CLL - Equipment: Data recorder, Auto-pilot, Angle of attack indicator, ADS-B, Stall warning system, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: none; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review January 12, 2023; seat: left; restraint: 3-point; flight hours: 1,066 total, 189 in this make and model, 1,008 as pilot in command, 101 in the last 90 days, 34 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 12 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft overcast - Temperature: 84 °F, dew point 77 °F - Altimeter: 29.77 inHg - Observed at: KCLL, 8 nm away - METAR: METAR KCLL 181353Z 20012G19KT 10SM OVC015 29/25 A2977 RMK AO2 SLP075 T02940250= ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20230618007159A](https://openairdocs.org/incident/20230618007159A), Jun 18, 2023: Piper PA 46-350P, College Station, TX, Substantial damage. The aircraft engine began to overheat in climb out from College Station, Tx (cll). The pilot reduced power and turned around to return to cll. The cockpit… ## Docket (7 files) The files NTSB released with the investigation on August 29, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192399. 18.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16757079&FileExtension=pdf&FileName=NTSB%20Form%206120%20CEN23LA246_Redacted-Rel.pdf - Log entries (item 2, PDF, 3 pages, 10.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16756825&FileExtension=pdf&FileName=Logs%20Entries_Redacted-Rel.pdf - Engine examination (item 3, PDF, 5 pages, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17146447&FileExtension=pdf&FileName=CEN23LA246%20(N463HP)%20-%20Examination%20Report%20MJH%20-%20Copy-Rel.pdf - Statement of party representatives to NTSB investigation (item 4, PDF, 1 page, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16965600&FileExtension=pdf&FileName=N463HP%20Lycoming%20Party%20Form_Redacted-Rel.pdf - Photos (item 5, PDF, 5 pages, 4 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17140166&FileExtension=pdf&FileName=Photos%20cen23la246-Rel.pdf - Lab work memorandum (item 6, PDF, 2 pages, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16966156&FileExtension=pdf&FileName=Lycoming%20Laboratory%20Work-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 993 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17143666&FileExtension=pdf&FileName=Release%20N463HP%20(signed)_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.