NTSB CAROL · Event
Event MIA99LA003
Aircraft involved
Probable cause & findings
The failure of maintenance personnel to refill the engine oil following the draining of the oil and changing of the oil filter. Also, inadequate preflight of the airplane by the pilot for his failure to noted the absence of engine oil.
Factual narrative
On October 3, 1998, about 0930 eastern daylight time, a Piper PA-28R-200, N53EN, registered to Universal Technologies/Unitec, collided with trees during a descent for a forced landing shortly after takeoff from the Charlotte County Airport, Punta Gorda, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal flight. The airplane was substantially damaged and the commercial-rated pilot, the sole occupant, sustained minor injuries. The flight originated about 12 minutes earlier from the airport. The pilot stated that he performed a preflight to the airplane and noted that the oil quantity was full. The flight departed and he performed one touch-and-go landing and remained in the traffic pattern for a second touch-and-go landing. During the initial climb following the second landing, he heard a noise and noted that the airplane was not climbing as expected. He retracted the landing gear and while descending for a forced landing in a clearing, the airplane collided with trees. The General Manager of Universal Technologies/Unitec examined the airplane at the accident site, about 20-30 minutes after being notified that the airplane was involved in an off airport landing. He stated that the airplane was upright with evidence that it came to rest within about 6 feet from the initial ground impact point. He visually noted that the oil sump pan was cracked, and there was no oil showing on the oil dipstick. The lower engine cowling was displaced, and there was no evidence of oil on the interior portion of the lower cowling. He stated it was difficult to note whether there was oil on the ground beneath the engine due to the fuel leakage and wet terrain. He did note oil clinging to the left side of the horizontal stabilator that covered the size of 2 hands put together. Post accident examination of the airplane by an FAA inspector 2 days after the accident revealed no evidence of oil discharge during flight. The engine was removed from the airplane for further examination which revealed that the connecting rod bearings for cylinder Nos. 2 and 4 were destroyed and the connecting rod bearings for cylinder Nos. 1 and 3 were damaged. The oil pump gears were inspected and found to be in good condition. Examination of the oil filter and oil screen revealed the absence of metal and very little oil was found. According to the General Manager of Universal Technologies/Unitec, he personally checked the engine oil quantity the day of the accident by removing the engine oil dipstick and visually noted that the engine oil was full. He reported that he did not use a rag to wipe the dipstick. He also stated that the engine oil was drained after a flight on September 30, 1998. The engine oil was changed by an individual (trainee) who is not an A & P mechanic but was supervised by a A & P mechanic. The trainee reported that both he and the A & P mechanic removed the engine cowling, the trainee drained the oil and removed and replaced the oil filter and safety wired it. The A & P mechanic then checked that the filter was secured properly, and the trainee serviced the engine oil. The engine was then cleaned and the engine was started and operated for a period of about 5 minutes-10 minutes, during which the propeller control was exercised. The engine was then leak checked; no leaks were noted. The cowling was replaced and the old oil filter was cut open and examined with no evidence of metal contamination. The airplane was equipped with a hour meter and a tachometer. The hour meter is electrically actuated following closing of a pressure switch which occurs when oil pressure reaching the switch is greater than 3 psi. The tachometer is cable driven. The operator utilized a sheet called the "Daily Aircraft Trip Log" which recorded the billing ticket number, date, instructor name, student name, tach start, tach end, hobb start, hobb end, and hobbs fly time. Review of a sampling of the daily aircraft trip log sheets for a 5 month period which included 47 flights of varying lengths, revealed that the elapsed time of the hour meter was always greater than the elapsed time of the tachometer for all of the 47 recorded flights. With respect to the accident flight, the elapsed time recorded by the tachometer was greater (.19 hour) than the elapsed time recorded by the hour meter (.17) hour. The hour meter and pressure switch were retained by the NTSB for further examination. Bench testing of the hour meter and pressure switch was accomplished using regulated air pressure and electrical power. At 2, 5, 11, 16, and 23.5 minutes elapsed time as determined by a stop watch, the hour meter was noted to change from the previous reading by approximately .03, .05, .10, .10, and .10 respectively. The wreckage minus the retained hour meter and pressure switch was released to Mr. Steve A. Wentworth, CEO of Wentworth Aircraft, Inc., on April 26, 1999. The retained hour meter and pressure switch were released to Mr. Ted Davies of Wentworth Aircraft, Inc., on June 1, 1999. Wentworth Aircraft, Inc., purchased the aircraft wreckage for salvage. The engine oil was reportedly changed and replenished then the engine was started and operated for about 5-10 minutes. The pilot and General Manager reported verifying that the engine oil quantity was full before the flight departed. During the upwind leg of the second touch-and-go landing, the engine failed. While descending for a forced landing, the airplane collided with trees then the ground. Examination of the airplane by an FAA airworthiness inspector 2 days after the accident revealed no evidence of oil discharge during flight. Disassembly of the engine revealed that the Nos. 2 and 4 connecting rod bearings were failed, and the Nos. 1 and 3 connecting rod bearings were damaged. Minimal oil was found in the engine. No failure or malfunction was noted on the oil pump gears. The hour meter historically indicated a greater elapsed time than the cable driven tachometer during flights of varying lengths; however, during the accident flight, the tachometer elapsed time was greater than the hour meter time. The hour meter is electrically activated by a pressure switch which requires a minimum oil pressure of 3 psi. No malfunction of the hour meter and pressure switch were noted when tested post accident. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1998_MIA99LA003.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.
Browse the full corpus — academia portal ↗