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Atlas / NTSB / CEN23LA261

NTSB CAROL · Event

Event CEN23LA261

2023-06-23 Cedar Creek, Missouri, United States Airport · PVT None 1 aircraft Status: Completed

Aircraft involved

Probable cause & findings

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.

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. 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. 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 oil sys-Damaged/degraded
  • Aircraft-Fluids/misc hardware-Fluids-Oil-Not serviced/maintained
  • Personnel issues-Action/decision-Action-Lack of action-Pilot
  • Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Pilot

Verbatim from NTSB's published report. Source file NTSB_2023_CEN23LA261.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, engine failure, 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.

Browse the full corpus — academia portal ↗