A Cessna 441 Conquest had an engine issue and landed without incident. A fix was made, but that’s not the end of the story. A second incident occurred that revealed damage not initially discovered. The Flight Safety Detectives share major safety takeaways from this sequence of events.

The focus is on an Australian investigation of a 2021 incident. During some engine maintenance, two adjacent oil lines were transposed. The error was discovered when the engine did not operate properly in flight. A field repair was done, but a short time later there was another engine problem.

The transposed lines led to damage to the oil pump. Fortunately, neither engine incident caused an accident.

This incident would not have met the NTSB criteria for investigation, but the Australian ATSB did gather information and generate a report. That report highlights how seemingly small maintenance errors can cause larger problems.

John Goglia, Todd Curtis, and Greg Feith review the findings. They go beyond the general recommendations made by the ATSB and discuss specific maintenance procedure changes that could improve aviation safety.

Related document: ATSB Aviation Occurrence Report: ATSB Report AO-2021-039 Cessna Conquest.pdf

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

Don’t miss what’s to come from the Flight Safety Detectives - subscribe to the Flight Safety Detectives YouTube channel, listen at your favorite podcast service and visit the Flight Safety Detectives website.

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