NTSB CAROL · Event
Event LAX92LA328
Aircraft involved
Probable cause & findings
THE BINDING AND OVER TEMPERATURE OF AN EXHAUST VALVE DUE TO THE LACK OF COMPLIANCE WITH FACTORY SERVICE INSTRUCTIONS AND BULLETINS REGARDING VALVE STICKING BY OTHER MAINTENANCE PERSONNEL.
Factual narrative
DURING THE INITIAL CLIMB AFTER TAKEOFF AT ABOUT 300 FEET AN UNUSUAL NOISE WAS HEARD BY THE PILOT AND THE PASSENGER WHO WAS RECORDING THE TAKEOFF ON A VIDEO CAMERA RECORDER. THE NOISE WAS A METALLIC TAPPING SOUND WHICH VARIED WITH ENGINE RPM. THE PILOT ATTEMPTED TO LAND ON THE REMAINING RUNWAY. THE AIRPLANE OVERRAN THE RUNWAY THRESHOLD AND COLLIDED WITH A SECURITY FENCE. A POST CRASH EXAMINATION OF THE AIRPLANE AND A TEST RUN OF THE ENGINE FAILED TO DUPLICATE OR EXPLAIN THE SOUNDS AS RECORDED ON THE TAPE. FURTHER EXAMINATION OF THE TAPE BY AN FAA APPROVED ENGINE REPAIR STATION PERSONNEL CONCLUDED THAT THE NOISE WAS A METALLIC 'TAPPET' TYPE OF A SOUND. DURING A DISASSEMBLY OF THE ENGINE A STICKING EXHAUST VALVE WAS FOUND IN NUMBER TWO CYLINDER WITH EVIDENCE OF HIGH TEMPERATURES AND OIL BURNING RESIDUE ON THE SPRINGS OF THAT VALVE. TEXTRON LYCOMING ADDRESSES THE POTENTIAL PROBLEM IN SERVICE BULLETIN NUMBER 388A, DATED APRIL 14, 1978, WHICH RECOMMENDS COMPLIANCE AT 1000 HOURS OF OPERATION. LYCOMING SERVICE LETTER L197A, DATED JANUARY 19, 1988, CONTAINS RECOMMENDATIONS TO AVOID VALVE STICKING. LYCOMING SERVICE INSTRUCTIONS 1425A, DATED JANUARY 19,1988, CONTAINS SUGGESTED MAINTENANCE PROCEDURES TO REDUCE THE POSSIBILITY OF VALVE STICKING. NO RECORD OF COMPLIANCE WAS FOUND. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1992_LAX92LA328.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.
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