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Tris pilot forgot to put oil in the engine after changing the engine oil. He then did not check the oil prior to flight, did not notice the lack of oil pressure, and did not check the propeller control prior to takeoff.
| Attributes | |
| ACN | 593169 |
| Time | |
| Date | 200308 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : clm.airport |
| State Reference | WA |
| Altitude | msl single value : 1500 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : bjc.tower |
| Operator | common carrier : air taxi |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Operating Under FAR Part | Part 135 |
| Flight Phase | climbout : initial climbout : intermediate altitude |
| Flight Plan | VFR |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : single pilot |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 5600 flight time type : 700 |
| ASRS Report | 593169 |
| Events | |
| Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : company policies non adherence : far non adherence : published procedure |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : landed as precaution flight crew : diverted to another airport |
| Consequence | other other |
| Factors | |
| Maintenance | contributing factor : work cards contributing factor : schedule pressure performance deficiency : inspection performance deficiency : non compliance with legal requirements performance deficiency : scheduled maintenance performance deficiency : training |
| Supplementary | |
| Problem Areas | Company FAA Flight Crew Human Performance Aircraft |
| Primary Problem | Flight Crew Human Performance |
Narrative:
I didn't put oil in center engine during an oil change. I didn't check the oil on preflight. Checked oil pressure on start-up. It was moving, but I didn't see it go in the green. Before takeoff check, I looked down at oil pressure and I didn't pick up on the reading of no pressure. I didn't do a feather check or exercise propeller. On takeoff, propeller wouldn't synchronize, then at a safe altitude, I checked oil pressure. Was unable to stop engine, returned for landing. Contributing factor: was behind schedule, fatigue, and starting aircraft in confined area.
Original NASA ASRS Text
Title: TRIS PLT FORGOT TO PUT OIL IN THE ENG AFTER CHANGING THE ENG OIL. HE THEN DID NOT CHK THE OIL PRIOR TO FLT, DID NOT NOTICE THE LACK OF OIL PRESSURE, AND DID NOT CHK THE PROP CTL PRIOR TO TKOF.
Narrative: I DIDN'T PUT OIL IN CTR ENG DURING AN OIL CHANGE. I DIDN'T CHK THE OIL ON PREFLT. CHKED OIL PRESSURE ON START-UP. IT WAS MOVING, BUT I DIDN'T SEE IT GO IN THE GREEN. BEFORE TKOF CHK, I LOOKED DOWN AT OIL PRESSURE AND I DIDN'T PICK UP ON THE READING OF NO PRESSURE. I DIDN'T DO A FEATHER CHK OR EXERCISE PROP. ON TKOF, PROP WOULDN'T SYNCHRONIZE, THEN AT A SAFE ALT, I CHKED OIL PRESSURE. WAS UNABLE TO STOP ENG, RETURNED FOR LNDG. CONTRIBUTING FACTOR: WAS BEHIND SCHEDULE, FATIGUE, AND STARTING ACFT IN CONFINED AREA.
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.