What happened
On September 11, 2018, a Tecnam P92 Echo S, registration I-6430, experienced a sudden engine failure immediately after departing from the Calatabiano airfield in Sicily. Following the loss of power, the aircraft entered a right-hand turn and subsequently lost control, impacting the ground near the edge of the airfield. The pilot, who was the sole occupant of the aircraft, sustained fatal injuries upon impact.
The investigation
The ANSV investigation focused on the mechanical state of the BRP-Rotax 912 ULS engine and the maintenance history of the aircraft. Investigators examined the engine's lubrication system and the oil tank cover, which featured "IN" and "OUT" markings. The investigation also reviewed the pilot's flight experience and the aircraft's maintenance records. Evidence showed that the engine had undergone a 100-hour inspection and an oil and filter change by the aircraft owner shortly before the flight. Furthermore, the investigation analyzed the emergency procedures outlined in the aircraft's flight manual regarding engine failures during takeoff.
Findings
- The primary cause of the accident was an asymmetric stall that led to a loss of control at an altitude too low for recovery.
- The engine failure was triggered by a total loss of lubrication.
- This loss of lubrication was caused by the accidental reversal of the oil supply and return lines during recent maintenance.
- The maintenance was performed by an individual without the required aeronautical maintenance certification.
- The markings "IN" and "out" on the oil tank cover were ambiguous, as they could be interpreted from either the perspective of the tank or the engine, and the fittings for both lines were identical.
- The pilot's limited flight experience and the haste of pre-flight operations may have contributed to the event.
- The flight manual for this specific VDS version lacked a specific instruction to maintain an appropriate glide attitude or airspeed during an immediate engine failure after takeoff, unlike the procedures for the certified P92-JS model.