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Atlas / NTSB / CEN24LA286

NTSB CAROL · Event

Event CEN24LA286

2024-07-28 Radisson, Wisconsin, United States None 1 aircraft Status: Completed

Registry · N4646G

FAA Aircraft Registry record.

Make / Model

PIPER PA-46-310P

Year of manufacture

1985 · 39 years old at event

Engine

CONT MOTOR TSIO-520-BE (310 hp)

Seats / Engines

6 seats · 1 engine

Last airworthiness date

19850930

ADS-B equipped

Yes — Mode-S A5ABA8

Registrant of record

SALE REPORTED

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

The non-certificated mechanic’s failure to properly tighten and torque the fuel system pressure test port cap, which resulted in a total loss of engine power, and a subsequent forced landing.

Factual narrative

On July 28, 2024, about 1130 central daylight time, a Piper PA-46-310P airplane, N4646G, sustained substantial damage when it was involved in an accident near Radisson, Wisconsin. The commercial pilot sustained no injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal cross-country flight. The airplane departed from the Lake in the Hills Airport (3CK), Lake in the Hills, Illinois, about 0930. Before departure from 3CK, the pilot reported the airplane had 85 gallons of 100 low-lead fuel onboard. The airplane, operating on an instrument flight rules flight plan, traveled to the northwest, toward the destination of the Sawyer County Airport (HYR), Hayward, Wisconsin. About 25 miles southeast of HYR, the reciprocating engine sustained a total loss of power, and the pilot declared an emergency to air traffic control. The pilot performed a forced landing to a rural grass field containing trees. The airplane came to rest upright, and the pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the empennage. An on-site examination of the engine by the FAA found that a cap was missing from the fuel pressure test port (a 90° brass elbow port) near the front top of the engine. The test port had blue staining present, and the exposed threading was found intact. The test port is where a gauge would connect during maintenance work to test the fuel pressure. The aluminum housing that the port connects to also had blue staining present. The missing cap was not recovered. A J.P. Instruments Engine Data Monitor 900 unit was removed from the airframe and the engine performance data was downloaded and reviewed. The engine performance data showed that the fuel flow rate had increased up to the maximum reading, about 80 gallons per hour, at the time the total loss of engine power occurred. Per the engine manufacturer the fuel system is a closed system. With the test port cap off, it becomes an open system, as shown with the blue staining in the two areas. As fuel is lost, fuel pressure is lost, and the engine then quits. A review of the most recent airplane maintenance records showed than an annual inspection was performed on the airframe, engine, and propeller on June 14, 2024, about 6 weeks before the accident. The records reflected work completed on the fuel injection system, including the installation of new fuel injectors. The entries for the annual inspections stated that the airplane was found in to be in an airworthy condition and the airplane was returned to service. According to the Continental Motors Standard Practice Maintenance Manual M-0, a fuel system operational check is required if fuel injectors are replaced. Test equipment is connected to the fuel pressure test port and a test is performed. Once the test work is completed, a cap (Continental Motors part number 639494) is required to be tightened and torqued on the test port. Continental Motors Standard Practice Maintenance Manual M-0 includes a warning that states: Failure to connect and torque fuel system fittings to the proper specification will result in a fuel leak and potential fire hazard. The individual who performed the most recent annual inspections on the airplane did not hold an airframe and powerplant certificate, nor did he hold inspection authorization. The non-certificated mechanic signed off the annual inspections and returned the airplane to service using the airframe and powerplant mechanic certificate number of his deceased father, who held inspection authorization. The father passed away on June 25, 2007. The engine sustained a total loss of power when nearing the destination airport during a cross-country flight. The pilot performed a forced landing to a rural grass field and the airplane landed hard, coming to rest upright. The pilot was able to egress from the airplane without further incident. The airplane sustained substantial damage to the fuselage and the empennage. An on-site examination of the engine found that a cap was missing from the fuel pressure test port near the front top area of the engine. The test port is where a gauge would connect during maintenance work to test the fuel pressure. The test port and the aluminum housing that the port connects to both had blue staining. The exposed threading that the cap screws onto was found intact and the missing cap was not located. A review of the engine monitor performance data showed performance consistent with a total loss of engine power. The fuel flow rate had increased up to the maximum reading, about 80 gallons per hour, at the time the total loss of engine power occurred. A review of the most recent airplane maintenance records showed than an annual inspection was performed on the airframe, engine, and propeller about six weeks before the accident. The records reflected work completed on the fuel injection system, including the installation of new fuel injectors. According to the engine manufacturer, a fuel system operational check is required if fuel injectors are replaced. Test equipment is connected to the fuel pressure test port and a test is performed. Once the test work is completed, a cap is required to be tightened and torqued on the test port. The individual who performed the most recent annual inspections on the airplane did not hold an airframe and powerplant certificate, nor did he hold inspection authorization. The non-certificated mechanic signed off the annual inspections and returned the airplane to service using the airframe and powerplant mechanic certificate number of his deceased father, who held inspection authorization. The test port had blue staining present, and the exposed threading was found intact. The aluminum housing that the port connects to also had blue staining present. The blue staining was likely from a 100 low-lead fuel leak while in-flight. It is likely the loss of fuel and fuel system pressure caused a total loss of engine power. Based on the available evidence, it is likely that the non-certificated mechanic forgot to properly tighten and torque the fuel pressure test port cap, which resulted in a total loss of engine power. The non-certificated mechanic fraudulently represented himself as a certificated mechanic with inspection authorization and the appropriate knowledge, training, and experience by signing off the annual inspections and returning the airplane to service. 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)-(general)-Failure
  • Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel
  • Personnel issues-Experience/knowledge-Experience/qualifications-Qualification/certification-Maintenance personnel
  • Aircraft-Aircraft power plant-Engine fuel and control-(general)-Incorrect service/maintenance
  • Personnel issues-Action/decision-Action-Forgotten action/omission-Maintenance personnel

Verbatim from NTSB's published report. Source file NTSB_2024_CEN24LA286.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, 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 ↗