NTSB CAROL · Event
Event ANC19LA011
Aircraft involved
Probable cause & findings
A loss of engine power due to oil starvation as the result of a loose B-nut fitting on the engine oil cooler, resulting in a forced landing to a soft, snow-covered surface, and a subsequent nose over.
Factual narrative
On January 22, 2019, about 0915 Alaska standard time, a Piper PA-22-150 airplane, N7640D, sustained substantial damage when it was involved in an accident near Anchorage, Alaska. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while in level cruise flight over the tidal waters of the Cook Inlet, he noticed the smell of burning oil, which was immediately followed by a change in engine sound. He turned the airplane 180° to return to the southern shoreline of the Cook Inlet, and as the airplane approached the shoreline, the engine began to run rough and lose power. As the airplane passed over the shoreline, the engine continued to lose power and the pilot selected a snow-covered beach as a forced landing site. During touchdown, as the airplane's main landing gear wheels contacted an area of deep snow, it abruptly nosed over, sustaining substantial damage to the wings, fuselage, and empennage. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed a loose oil cooler B-nut located on the right side of the oil cooler. The FAA inspector also reported that there was significant oil streaking on the right side of the fuselage extending from the engine cowling to the empennage. The engine dipstick revealed no engine oil in the sump. A review of the accident airplane’s maintenance records revealed that there was no recent maintenance activity to the oil cooler or other engine components adjacent to the loose B-nut. In a follow-up conversation with the FAA inspector, the pilot noted that during his preflight, just before the accident flight, there were no oil leaks found, and that he routinely checked around the oil cooler during every preflight. The pilot reported that while in level cruise flight he noticed the smell of burning oil, which was immediately followed by a change in engine sound, followed by a partial loss of engine power. The engine continued to lose power and the pilot selected a snow-covered beach as a forced landing site. During touchdown, as the airplane's main landing gear wheels contacted an area of deep snow, it abruptly nosed over, sustaining substantial damage to the wings, fuselage, and empennage. Examination of the engine revealed that there was no engine oil in the sump. An oil cooler B-nut, which was located on the right side of the oil cooler, was found loose, and there was a significant oil streaking on the right side of the fuselage. Review of maintenance records revealed that there had been no recent maintenance activity to the oil cooler or other engine components adjacent to the loose B-nut. Given the accident pilot’s account of the accident, along with the discovery of the loose oil cooler B-nut, it is likely that the engine failed due to oil starvation after all engine oil was lost through the loose B-nut. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Environmental issues-Physical environment-Runway/land/takeoff/taxi surface-Soft surface-Contributed to outcome
- — Aircraft-Fluids/misc hardware-Fluids-Oil-Fluid level
- — Aircraft-Aircraft power plant-Eng oil sys (airframe furnish)-Cooler-Not serviced/maintained
Verbatim from NTSB's published report. Source file
NTSB_2019_ANC19LA011.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
Browse the full corpus — academia portal ↗