Pilot Debrief

CESSNA 310 near Stotts City, MO — 2012-11-05

Final reportCEN13FA044
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Date
2012-11-05
Location
Stotts City, MO, USA
Aircraft
CESSNA 310
Registration
N6BS
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Descent

Probable cause

The pilot's failure to maintain airplane control after he shut down the right engine in flight due a loss of oil pressure. Contributing to the accident was the pilot's decision to reposition the unairworthy airplane during twilight after extensive maintenance had been done to the right engine along with a known mechanical deficiency with the landing gear. Contributing to the accident was the mechanic's improper assembly and installation of the right engine's oil filter adapter, which resulted in a loss of oil to that engine.

NTSB narrative

The pilot and the pilot-rated passenger originally planned to make several circuits in the traffic pattern to test the right engine, which recently underwent extensive maintenance, before repositioning the airplane to a nearby airport. However, the flight was delayed to make an adjustment to the propeller lever friction lock. Because of the delay, the pilots departed after the sun had set and decided to fly directly to the other airport, which did not have runway lights. While en route, the right engine began to lose oil pressure and lost total power, so the pilot shut the engine down and feathered the propeller. The pilot elected to return to the departure airport, but was unable to maintain altitude. The airplane impacted trees and a postimpact fire consumed most of the airplane. According to witnesses, the airplane's nose gear landing strut was flat before departure and the pilots agreed they would leave the landing gear extended for the flight. Witnesses who saw the airplane just before impact confirmed the landing gear was extended. Postaccident examination of the right engine revealed the oil filter adapter was not properly assembled or adequately secured to the engine. The mechanic who performed maintenance to the oil adapter admitted that he did not follow the manufacturer's instructions when reassembling the adapter and when installing it on the engine. As a result, the adapter came loose during flight, which resulted in a loss of oil. Based on the single-engine performance data provided by the airplane manufacturer, the airplane should have had a single-engine climb rate of about 166 feet per minute with the landing gear extended, assuming the airplane was properly configured and the operating engine was producing full power. Although the airplane did not have a current annual inspection, no mechanical malfunctions or failures were noted with the airplane or the left engine that would have precluded normal operation.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilots could have postponed the flight due to mechanical issues and darkness.

NTSB coding

Evidence available

  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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