NTSB CAROL · Event
Event CEN21LA138
Aircraft involved
Probable cause & findings
The inadequate maintenance/inspection of the airplane, which resulted in a total loss of engine power due to oil starvation.
Factual narrative
On February 24, 2021, about 1600 central standard time, a Cessna 182F, N3209U, was substantially damaged when it was involved in an accident near Millville, Iowa. The commercial pilot and a passenger received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that, during a cruise climb from the departure airport, the engine made a “loud growling” noise and lost power. He turned the magnetos off when he saw smoke near the propeller and trimmed the airplane for a best glide airspeed. He said there was no suitable landing area in front of the airplane, but there was a road to the left of the airplane. During the approach to the road, he maneuvered the airplane below powerlines and avoided buildings before the airplane impacted the road and a snowbank. The airplane nosed over during the landing, resulting in substantial damage to the fuselage, right wing and right-wing strut. Postaccident examination of the airplane revealed a hole in the engine crankcase located between the Nos. 2 and 5 cylinders. The No. 2 cylinder connecting rod was protruding through the hole and exhibited scoring consistent with oil starvation. The vacuum pump did not exhibit any mechanical anomalies and the inside of its vacuum tube did not contain oil. There was a relatively large amount oil on the underside of the top engine cowling. There was no oil on the interior or exterior side of the bottom engine cowling. There was no oil on the engine firewall. There was oil on the underside of the fuselage extending aft of the engine crankcase breather tube to the empennage. There was oil around the crankcase nose seal consistent with a leak. The inside of the crankcase breather tube, which alleviates normal crankcase pressure, was unobstructed and contained oil. The tube contained a whistle stop/vent located about three inches from the bottom of the tube, which was in accordance with its design. The oil breather tube whistle stop/hole was positioned aft and parallel to the airplane’s longitudinal axis. Examination of the breather tube showed dried and caked oil residue which were signs of progressive leakage. Similar signatures were observed at the crankcase nose seal. These would have been apparent during routine maintenance and/or a preflight inspection. Continental Service Bulletin (SB) M89-9, Excessive Crankcase Pressures, provides a troubleshooting test when excessive crankcase pressures are suspected. The SB notes: Excessive crankcase pressure in flight can be induced by ram air entering through an improper fitting oil cap seal and/or defective crankshaft nose seal. If the problem occurs on turbocharged engines only at higher altitudes, then it is possible that the turbocharger is suspect. The pilot stated that, during climb from the departure airport, the engine made a loud growling noise, lost power, and began producing smoke. The pilot then performed a forced landing on a road, during which the airplane nosed over and impacted terrain. Postaccident examination of the airplane revealed a hole in the crankcase and a failure of two cylinders consistent with oil starvation. The majority of oil residue was located below and aft of the oil breather tube, which was to alleviate normal crankcase pressures. The crankcase nose seal exhibited an oil leak that would have also allowed ram air pressure to pressurize the crankcase above normal pressures and force engine oil out through the oil breather tube resulting in oil starvation/exhaustion. Oil leakage from the crankcase breather tube would have been progressive and not instantaneous. The oil leakage from the crankcase nose seal and breather tube should have been identified by those performing maintenance and/or preflight inspections of the airplane after seeing decreased oil levels, oil residue external to the engine, and seepage from the crankcase nose seal. 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).
- — Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng front section-Not specified
- — Aircraft-Aircraft handling/service-Maintenance/inspections-(general)-Inadequate inspection
- — Aircraft-Fluids/misc hardware-Fluids-Oil-Fluid level
Verbatim from NTSB's published report. Source file
NTSB_2021_CEN21LA138.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 ↗