NTSB CAROL · Event
Event MIA95LA069
Aircraft involved
Probable cause & findings
THE IMPROPER ADJUSTMENT OF THE TURBOCHARGER INLET PIPE SECURING CLAMP BY UNKNOWN MAINTENANCE PERSONNEL.
Factual narrative
On February 4, 1995, about 1430 eastern standard time, a Lake LA-4, registered to Phillip Adams, lost engine power and was landed gear up shortly after takeoff from St. Augustine Airport, St. Augustine, Florida, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane sustained substantial damage, and the private-rated pilot and one passenger were not injured. The flight was originating at the time of the accident. The pilot stated that upon reaching an altitude of 100-125 feet after takeoff the engine stopped. Time did not allow him to extend the landing gear and he landed gear up on the remaining runway. After exiting the aircraft he determined that the engine was on fire. Postcrash examination of the aircraft by an FAA inspector indicated a securing clamp and cable on the turbocharger inlet pipe was not properly adjusted. The inlet pipe separated from the turbocharger and the escaping exhaust burned through the main fuel line to the engine and through the oil lines to the oil cooler. THE ENGINE LOST POWER SHORTLY AFTER TAKEOFF AND THE PILOT DID NOT HAVE TIME TO EXTEND THE LANDING GEAR BEFORE LANDING BACK ON THE RUNWAY. AFTER THE PILOT AND PASSENGER EXITED THE AIRCRAFT THEY NOTICED THE ENGINE COMPARTMENT WAS ENGULFED IN FLAMES. POST CRASH EXAMINATION BY FAA INSPECTORS REVEALED A SECURING CLAMP ON THE TURBOCHARGER INLET PIPE WAS NOT PROPERLY ADJUSTED AND THE INLET PIPE SEPARATED FROM THE TURBOCHARGER. THE ESCAPING EXHAUST BURNED THROUGH THE MAIN FUEL LINE TO THE ENGINE AND THROUGH THE OIL LINES TO THE OIL COOLER. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1995_MIA95LA069.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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