# NTSB CEN23LA261: Quad City Challenger, Cedar Creek, MO, June 23, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 23, 2023, 10:00 local (15:00 UTC) - Place: Cedar Creek, MO - Coordinates: 36.57, -92.99 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.5700&lon=-92.9900&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA, Rotech Motor Ltd - NTSB case key (mKey): 192453 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA261 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192453/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192453 - Page: https://openairdocs.org/ntsb/CEN23LA261 ## Probable cause A seizure of the power takeoff piston due to inadequate maintenance to the lubrication system, which resulted in a lack of oil lubrication and subsequent engine failure. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Not serviced/maintained (probable cause); cases with it: [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis On the day before the accident, the pilot reported that he drained the fuel and replaced it with new fuel, replaced the fuel filter, and checked all fluid levels and lines; the airplane had not flown since October 2021. The pilot reported that on the day of the accident, he flew the airplane for about 20 minutes and then returned to pick up a passenger. On the second flight, the airplane’s engine lost power after flying about 10 minutes. During the forced landing, the airplane impacted trees and terrain which resulted in substantial damage to both wings and the fuselage. A postaccident examination of the airplane and engine were performed at the pilot’s residence. The examination of the engine revealed oil around the power take-off (PTO) piston and cylinder head. The PTO piston displayed signatures consistent with seizure. A piece of old, brittle oil injection line was discovered near the oil injection pump and the fuel, primer, and vent lines were also found in an aged and hardened state. Given the evidence, the PTO piston likely failed due to a lack of oil as a result of the poorly maintained lubrication system, which resulted in a loss of engine power. There were no maintenance records for the airplane and according to the pilot, the hoses had not been replaced since 2009. The engine manufacturer’s maintenance manual states that all lubrication system hoses must be replaced every 5 years. ## Factual narrative On June 23, 2023, at about 1000 central daylight time, an unregistered Quad City Challenger II airplane was substantially damaged when it was involved in an accident near Cedar Creek, Missouri. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the airplane had not been flown since October 2021. On the day before the accident, he drained the fuel and replaced it with new fuel, replaced the fuel filter, and checked all fluid levels and lines. On the day of the accident the pilot flew the airplane for about 20 minutes and then landed to pick up the passenger. After takeoff, he flew for about 10 minutes when the engine sputtered, and the engine performance degraded despite his advancing the throttle. The pilot executed a forced landing to a field, impacted trees, and substantially damaged the wings and fuselage. A postaccident examination of the airplane and engine were performed at the pilot’s residence. During the examination, it was noted that the exterior of the engine was covered in oil, particularly concentrated near the power take-off (PTO) piston and cylinder head. A blue oil coating was also evident on the side of the aircraft consistent with the color of the injected oil. The oil injection lines appeared to be in pristine, unused condition and were lacking securing clamps. However, a piece of old, brittle oil injection line was discovered near the oil injection pump, and the fuel, primer, and vent lines were also found in an aged and hardened state. The magneto piston, cylinder, and combustion chamber appeared to be in normal condition with no anomalies found. However, the PTO piston exhibited vertical scoring, and metal transfer marks were observed on the corresponding locations of the cylinder wall. The transfer of metal was indicative of a piston seizure. According to the pilot, when he purchased the airplane in 2008, there were no maintenance records available. In 2009, he installed new fuel lines and fuel pump, rebuilt the carburetor, replaced the spark plugs, safety wires, brake lines, wheel innertubes, checked cylinder compressions, drained old fuel, and replaced the trim tab. There was no maintenance performed after 2009 other than annual fuel filter replacement. According to the Rotax maintenance manual for the 582 UL engine, all hoses of the lubrication system must be replaced every 5 years. ## Aircraft - Registration: UNREG (not matched to a registry record) - Reported make and model: QUAD CITY CHALLENGER (II) - Category: Airplane, amateur-built - Serial number: unknown - Year built: 1995 - Airframe hours: 700 - Engines: Rotax 582 65 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Destination: Same as departure - Airport: PVT - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; sport pilot; airplane ratings: single-engine land; medical: sport pilot; last flight review July 31, 2009; seat: left; flight hours: 230 total, 230 as pilot in command, 1 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 66 °F - Altimeter: 30.06 inHg - Observed at: KBBG, 10 nm away - METAR: KBBG 231445Z 00000KT 10SM CLR 25/19 A3006 ## Docket (5 files) The files NTSB released with the investigation on May 9, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192453. 2.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16199059&FileExtension=pdf&FileName=Scanned%20from%20a%20Xerox%20Multifunction%20Printer_Redacted-Rel.pdf - Photos (item 2, PDF, 7 pages, 769 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16207256&FileExtension=pdf&FileName=Photo%20SHeet%20261-Rel.pdf - Memorandum of record-engine exam-jordan paskevich (item 3, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16207720&FileExtension=pdf&FileName=MOR261-Rel.pdf - Time limit for parts (item 4, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16198891&FileExtension=pdf&FileName=Time%20Limit%20for%20Parts-Rel.pdf - Memorandum for record a�� interview, airplane owner (item 5, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16992457&FileExtension=pdf&FileName=MOR-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.