ERA23LA173
2023-03-05 · Perry, Florida, United States · None · 1 aircraft · Status: Completed
Airport NONE
Current FAA registration · N9777Y
- Make / Model
- BEECH P35
- Year of manufacture
- 1963 · 60 years old at event
- Engine
- CONT MOTOR I0-470 SERIES (260 hp)
- Seats / Engines
- 4 seats · 1 engine
- Last airworthiness date
- 19630408
- ADS-B equipped
- Yes — Mode-S ADA10A
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
Maintenance personnel’s incorrect torquing of the oil filter adapter jam nut, resulting in the failure of the adapter threads, a complete loss of oil, and subsequent total loss of engine power.
Factual narrative
On March 5, 2023, about 1645 eastern daylight time, a Beech P35 airplane, N9777Y, was substantially damaged when it was involved in an accident near Perry, Florida. 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 he was on a cross-country flight from Peter O Knight Airport (TPF), Tampa, Florida, to Apalachicola Regional Airport (AAF), Apalachicola, Florida. About an hour into the flight, while cruising at 8,500 ft, light smoke entered the cabin momentarily and the engine oil pressure dropped to zero. The pilot turned toward Perry-Foley Airport (FPY), Perry, Florida, and shortly thereafter, the engine lost power. Unable to glide to the airport, he saw a cleared field and set up for a forced landing. He lowered flaps to full and lowered the landing gear. The airplane touched down on sandy soil. The nose landing gear dug in and separated. The airplane came to rest upright and the pilot egressed the cockpit and was met by first responders. An initial examination of the wreckage by a Federal Aviation Administration inspector revealed that the lower, forward fuselage had structural damage. The pilot initially reported that the air hose to the oil-air separator failed, and the separator’s canister was split open and empty of oil. The engine crankcase did not contain any oil and the engine was seized. Oil covered the lower fuselage surfaces. Further examination of the engine by an airframe and powerplant mechanic revealed that the oil filter adapter was separated at the engine case. There was residual oil covering the area around the adapter-to-engine case opening and below. The adapter threads appeared stripped. The adapter was safety wired in position, and there was red torque putty applied as well. A review of the maintenance logbooks revealed that an annual inspection of the airframe and engine was completed on December 9, 2022. At the time of the accident, about 29 hours had accrued on the engine since the last annual inspection. The logbook entries noted that Airworthiness Directive (AD) 96-12-22 had been complied with. The AD addressed security of the connection (jam nut) between the oil filter adapter and the engine case, including checking for proper torque. An article from AOPA [Aircraft Owners and Pilots Association] Pilot Magazine, dated May 5, 2005, addressed the oil filter adapter AD. The article stated that, “If the proper torque isn’t applied to the jam nut, the weight of the oil-filled filter combined with normal vibrations will soon cause thread damage to the adapter. In a few cases maintenance practices have been so mindless that the threads got in bad enough shape that the adapter was blown completely out of the engine.” About an hour into the flight, while cruising at 8,500 ft, light smoke entered the cabin momentarily, and the engine oil pressure dropped to zero. The pilot turned toward a nearby airport and shortly thereafter the engine lost power. Unable to glide to the airport, he saw a cleared field and set up for a forced landing. The airplane touched down on sandy soil, the nose gear dug in and separated, and the airframe was substantially damaged. The pilot was not injured. A postaccident examination of the engine revealed that the oil filter adapter separated at the engine case which likely resulted in a depletion of the engine’s oil supply and the subsequent total loss of engine power due to lack of lubrication. Residual oil covered the area around the adapter-to-engine case opening and below. The adapter threads appeared stripped. The adapter was safety wired in position and there was red torque putty applied as well. A review of the maintenance logbooks revealed that an annual inspection of the airframe and engine was completed about 29 hours before the accident. The logbook entries noted that an airworthiness directive that addressed security of the connection between the oil filter adapter and the engine case, including checking for proper torque, had been complied with during the inspection. The separation of the filter and stripping of the adapter threads were likely indicative of the oil filter adapter threads having failed due to improper torquing of the jam nut. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- — Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng oil sys-Incorrect service/maintenance
- — Personnel issues-Task performance-Inspection-Scheduled/routine inspection-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2023_ERA23LA173.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- 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 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- 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.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- 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 (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…