National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

La Grange, TX

Accident Number:

CEN13LA056

Date & Time:

11/09/2012, 0721 CST

Registration:

N732BL

Aircraft:

CESSNA 210L

Aircraft Damage:

Substantial

Defining Event:

Loss of engine power (total)

Injuries:

3 Minor

Flight Conducted Under:

Part 91: General Aviation - Business

Analysis

The pilot reported that the airplane was in cruise flight at 7,000 ft mean sea level when he noticed that the engine oil pressure had dropped to an unacceptable level. He then attempted to divert to land at a nearby airport. However, when the airplane was on the downwind leg and after the landing gear had been extended, the engine experienced a total loss of power, so the pilot made an off-airport landing. During the landing on a soft, plowed field, the airplane flipped over and then came to rest inverted.

Review of maintenance records revealed that recent maintenance, which included the replacement of the engine oil filter, had been performed on the engine. A postaccident examination of the airframe revealed an abundance of engine oil on the airplane’s belly; the oil extended from the engine compartment to the tail surfaces. A teardown examination of the engine revealed that a connecting rod had released from the crankshaft due to lubrication distress. An examination of the oil filter revealed that the oil filter adapter fiber seal washer was torn where the adaptor attaches to the oil pump housing and that the washer and the oil filter adaptor were misaligned. The improper installation of the oil filter adaptor likely caused the loss of oil to the engine and the subsequent total loss of engine power.

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The total loss of engine power due to the loss of oil to the engine. Contributing to the accident was maintenance personnel’s improper installation of the engine oil filter adaptor, which resulted in the loss of oil to the engine.

 

Findings

Aircraft

Recip eng oil sys - Damaged/degraded (Cause)

Engine (reciprocating) - Failure (Cause)

Recip eng oil sys - Incorrect service/maintenance (Factor)

Personnel issues

Incorrect action performance - Maintenance personnel (Factor)

Factual Information

On November 9, 2012, about 0721 central standard time, N732BL, a Cessna 210L, single engine airplane, was substantially damaged during a forced landing near Fayette Regional Air Center Airport (3T5), La Grange, Texas. The pilot and both passengers sustained minor injures. The airplane was registered to and operated by a private individual. Day visual meteorological conditions (VMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed for the 14 Code of Federal Regulations Part 91 business flight. The airplane departed San Marcos Municipal Airport (HYI), San Marcos, Texas, about 0650 destined for Baytown Airport (HPY), Baytown, Texas.

The airplane was in cruise flight at 7,000 feet mean sea level when the pilot noticed that the engine oil pressure had dropped to an unacceptable level. The pilot requested a descent and vectors to divert for landing at 3T5. Radar data showed the airplane was about 2,500 feet above ground level when it overflew 3T5. When the airplane was on downwind and after the lowering the landing gear the pilot reported that he had a total loss of engine power and made an off-airport landing about a mile north from 3T5. During the landing on a soft plowed field the airplane flipped and came to rest inverted.

A review of aircraft maintenance logbook entries showed that maintenance had been performed on the engine about three weeks prior to the accident. That maintenance included replacement of the engine oil filter.

A postaccident examination of the airframe revealed an abundance of engine oil on the belly of the airplane which extended from the engine compartment all the way to the tail surfaces. A teardown examination of the engine revealed lubrication distress, and mechanical damage on all connecting rod journals with damage concentrated where the number four connecting rod had released from the crankshaft and had penetrated through the crankcase. An examination of the oil filter showed that it contained an abundance of flakes and slivers from the damaged internal engine components. The oil filter adapter fiber seal washer was observed to be torn where the adaptor attaches to the oil pump housing and had signatures of misalignment with the oil filter adaptor.

 

History of Flight

Prior to flight

Aircraft maintenance event

Enroute-cruise

Miscellaneous/other

Approach

Loss of engine power (partial)

Emergency descent

Loss of engine power (total) (Defining event)

Off-field or emergency landing

Landing

Collision with terr/obj (non-CFIT)

Nose over/nose down

Post-impact

Cabin safety event

 

 

Pilot Information

Certificate:

Airline Transport; Flight Instructor; Commercial

Age:

36

Airplane Rating(s):

Multi-engine Land; Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt

Instrument Rating(s):

Airplane

Second Pilot Present:

No

Instructor Rating(s):

Airplane Multi-engine; Airplane Single-engine; Instrument Airplane

Toxicology Performed:

No

Medical Certification:

Class 1 With Waivers/Limitations

Last FAA Medical Exam:

06/08/2011

Occupational Pilot:

Yes

Last Flight Review or Equivalent:

07/14/2011

Flight Time:

(Estimated) 6642 hours (Total, all aircraft), 418 hours (Total, this make and model), 5402 hours (Pilot In Command, all aircraft), 28 hours (Last 90 days, all aircraft), 17 hours (Last 30 days, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

CESSNA

Registration:

N732BL

Model/Series:

210L

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

21061386

Landing Gear Type:

Retractable - Tricycle

Seats:

6

Date/Type of Last Inspection:

10/15/2012, Annual

Certified Max Gross Wt.:

3800 lbs

Time Since Last Inspection:

17 Hours

Engines:

1 Reciprocating

Airframe Total Time:

3128 Hours at time of accident

Engine Manufacturer:

CONT MOTOR

ELT:

Installed, activated, did not aid in locating accident

Engine Model/Series:

IO 520 SERIES

Registered Owner:

On file

Rated Power:

300 hp

Operator:

On file

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

K3TS, 324 ft msl

Distance from Accident Site:

1 Nautical Miles

Observation Time:

0715 CST

Direction from Accident Site:

182°

Lowest Cloud Condition:

 / 2900 ft agl

Visibility

10 Miles

Lowest Ceiling:

Broken / 2900 ft agl

Visibility (RVR):

 

Wind Speed/Gusts:

4 knots /

Turbulence Type Forecast/Actual:

/

Wind Direction:

150°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

30.05 inches Hg

Temperature/Dew Point:

19°C / 17°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

San Marcos, TX (HYI)

Type of Flight Plan Filed:

IFR

Destination:

Baytown, TX (HPY)

Type of Clearance:

IFR

Departure Time:

0650 CST

Type of Airspace:

Class G

 

Airport Information

Airport:

Fayette Regl Air Center Airpor (3T5)

Runway Surface Type:

Asphalt

Airport Elevation:

324 ft

Runway Surface Condition:

Dry

Runway Used:

16

IFR Approach:

None

Runway Length/Width:

5000 ft / 75 ft

VFR Approach/Landing:

Forced Landing; Traffic Pattern

 

Wreckage and Impact Information

Crew Injuries:

1 Minor

Aircraft Damage:

Substantial

Passenger Injuries:

2 Minor

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

3 Minor

Latitude, Longitude:

29.928333, -96.946389 (est)

 


 


Administrative Information

Investigator In Charge (IIC):

Thomas Latson

Report Date:

03/10/2015

Additional Participating Persons:

Del Scott; FAA Houston FSDO; Houston, TX

Peter J Basile; Cessna Aircraft Company; Wichita, KS

John Kent; Continental Motors, Inc.; Mobile, AL

Publish Date:

03/10/2015

Note:

The NTSB did not travel to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=85551