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Reconstructing The Data

According to the NTSB, Data downloaded from the primary and multifunction cockpit displays indicate that the engine began steadily losing oil pressure during the airplanes initial climb until it leveled off at a cruise altitude of 5000 feet msl. Data suggest that, at that time, the pilot leaned the fuel mixture for cruise flight. Although the pilot could have detected the decreasing oil pressure at that time, [s]he did not report a loss of fuel pressure and engine power to the air traffic controller until about six minutes later.

Gemini Sparkle

Key Takeaways:

  • An aircraft experienced a steady loss of engine oil pressure from initial climb through cruise altitude, indicated by cockpit displays.
  • The pilot delayed recognizing and reporting the decreasing oil pressure and other related indications for several minutes after the issue became apparent.
  • The NTSB concluded that the delayed recognition was likely due to a breakdown in the pilot's instrument scan and systems monitoring, as attention was focused on airplane control, power, and navigation.
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According to the NTSB, Data downloaded from the primary and multifunction cockpit displays indicate that the engine began steadily losing oil pressure during the airplanes initial climb until it leveled off at a cruise altitude of 5000 feet msl. Data suggest that, at that time, the pilot leaned the fuel mixture for cruise flight. Although the pilot could have detected the decreasing oil pressure at that time, [s]he did not report a loss of fuel pressure and engine power to the air traffic controller until about six minutes later. Data also indicate that there were multiple additional indications and cues of a loss of engine oil pressure in the cockpit but that the pilot did not respond to these in a timely manner…. The pilots delayed recognition of the drop in engine oil pressure was likely the result of a breakdown in her instrument scan, specifically, her systems monitoring during the climb and initial cruise phases of flight, during which time, her attention was likely directed at airplane control, power management, and navigation.

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