Pilot Debrief

CESSNA 210K near Show Low, AZ — 2009-08-27

Final reportWPR09LA422
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Date
2009-08-27
Location
Show Low, AZ, USA
Aircraft
CESSNA 210K
Registration
N4600Q
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

A total loss of engine power due to the displaced oil filter adapter gasket, which resulted in an oil leak and oil exhaustion. Contributing to the accident was the unsuitable terrain for a forced landing.

NTSB narrative

The pilot reported that during cruise flight he observed an oil pressure reading of zero, followed about 4 minutes later by a total loss of engine power. He made a successful forced landing to an open meadow, which resulted in substantial damage to the engine’s firewall. A post accident examination of the engine revealed that the engine’s crankshaft and connecting rod bearings exhibited lubrication distress and thermal damage, and that the number 3 crankshaft main bearing exhibited lubrication distress. It was also observed that a gasket located between the STC oil filter adapter and the oil pump housing was displaced and contained dark stains. STC instructions require that after the oil filter adapter has been installed, to re-torque the adapter after 10 hours of operation. An airframe and power plant mechanic stated that he had re-torqued the oil filter adapter, but could not produce a record of the completed maintenance action.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Proper maintenance of the oil filter adapter could have prevented engine failure.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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