<< >> NASA ASRS Report 510433, May 2001

A piper PA23 landed in emergency condition due to right engine low oil pressure and high temperature caused by incorrect piston ring installation.

Attributes
ACN	510433
Time
Date	200105
Day	Sat
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Aircraft 1
Controlling Facilities	tower : phx.tower
Operator	general aviation : personal
Make Model Name	PA-23-250 Aztec
Operating Under FAR Part	Part 91
Flight Phase	ground : parked
Person 1
Affiliation	other
Function	maintenance : technician
Qualification	technician : powerplant technician : airframe
ASRS Report	510433
Person 2
Affiliation	other
Function	flight crew : single pilot
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : published procedure non adherence : far
Independent Detector	aircraft equipment other aircraft equipment : right engine oil press and temp
Resolutory Action	flight crew : diverted to another airport flight crew : landed in emergency condition
Consequence	other other
Factors
Maintenance	contributing factor : manuals performance deficiency : inspection performance deficiency : installation performance deficiency : non compliance with legal requirements
Supplementary
Problem Areas	Maintenance Human Performance Chart Or Publication Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

Right engine oil pressure decreased and oil temperature increased during flight. A non emergency landing had been completed and a mechanic at the airport looked over the engine. The #1 cylinder on the right engine was found cold and metal was found in the oil filter. The suspected cylinder was removed and found that chrome rings were installed in a chrome cylinder. The engine was brought in at an earlier date with a complaint of oil coming out of the exhaust and the engine running rough. I, the mechanic, had pulled the cylinder initially and measured all the cylinder tolerances and inspected the cylinder under the supervision of my inspector. I found the rings to have been worn and the exhaust valve leaking. I had topped the exhaust valve and ordered new piston rings from the parts manual. I failed to order the proper rings due to the fact I had not noticed the cylinder was chrome. I installed the wrong rings (chrome) in the cylinder (chrome causing the failure of the #1 cylinder.

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Original NASA ASRS Text

Title: A PIPER PA23 LANDED IN EMER CONDITION DUE TO R ENG LOW OIL PRESSURE AND HIGH TEMP CAUSED BY INCORRECT PISTON RING INSTALLATION.

Narrative: R ENG OIL PRESSURE DECREASED AND OIL TEMP INCREASED DURING FLT. A NON EMER LNDG HAD BEEN COMPLETED AND A MECH AT THE ARPT LOOKED OVER THE ENG. THE #1 CYLINDER ON THE R ENG WAS FOUND COLD AND METAL WAS FOUND IN THE OIL FILTER. THE SUSPECTED CYLINDER WAS REMOVED AND FOUND THAT CHROME RINGS WERE INSTALLED IN A CHROME CYLINDER. THE ENG WAS BROUGHT IN AT AN EARLIER DATE WITH A COMPLAINT OF OIL COMING OUT OF THE EXHAUST AND THE ENG RUNNING ROUGH. I, THE MECH, HAD PULLED THE CYLINDER INITIALLY AND MEASURED ALL THE CYLINDER TOLERANCES AND INSPECTED THE CYLINDER UNDER THE SUPERVISION OF MY INSPECTOR. I FOUND THE RINGS TO HAVE BEEN WORN AND THE EXHAUST VALVE LEAKING. I HAD TOPPED THE EXHAUST VALVE AND ORDERED NEW PISTON RINGS FROM THE PARTS MANUAL. I FAILED TO ORDER THE PROPER RINGS DUE TO THE FACT I HAD NOT NOTICED THE CYLINDER WAS CHROME. I INSTALLED THE WRONG RINGS (CHROME) IN THE CYLINDER (CHROME CAUSING THE FAILURE OF THE #1 CYLINDER.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.