Aviation Accident Summaries

Aviation Accident Summary LAX89LA233

LOS ANGELES, CA, USA

Aircraft #1

N609AC

CESSNA P210N

Analysis

ON THE FIRST FLT AFTER THE ACFT'S ANNUAL INSPECTION FOLLOWING REPLACEMENT OF ALL OIL LINES, THE CFI PLANNED TO GIVE THE ACFT'S OWNER/PLT A BFR. FIVE MIN AFTER TAKEOFF, THE CREW OBSERVED THAT THE OIL PRESSURE GAGE INDICATED NEAR ZERO LBS OF PRESSURE. THE CFI MONITORED THE OIL TEMP GAGE & THE TEMP WAS IN THE GREEN ARC. THE CREW ALERTED ATC OF THE SITUATION & REC'D AN IFR CLEARANCE BACK TO THE ARPT. DURING THE NEXT 14 MIN, THE OIL PRESSURE NEEDLE REMAINED SLIGHTLY ABOVE RED LINE, THE OIL TEMP REMAINED STABLE & IN THE GREEN ARC. THE ACFT PASSED THE FINAL APPROACH FIX & CONTINUED TO OPERATE NORMALLY. SUDDENLY, ALL ENG PWR WAS LOST. THE CFI MADE A FORCED LDG ON A GOLF COURSE 3 MI FM THE ARPT. EXAM OF THE ENG REVEALED INTERNAL HEAT DISTRESS & BROKEN CONN RODS. FURTHER EXAM REVEALED A 'B' NUT ON A NEWLY INSTALLED OIL LINE HAD NOT BEEN SECURELY TORQUED & HAD COME LOOSE AT ITS ENG CASE ATTACHMENT FITTING. THE OIL LINE WAS FOUND SATURATED WITH OIL.

Probable Cause and Findings

AN UNDERTORQUED OIL LINE FITTING, DUE TO ITS IMPROPER INSTALLATION BY MAINTENANCE PERSONNEL, WHICH RESULTED IN A LOOSE OIL LINE FITTING, AN OIL LINE LEAK, OIL EXHAUSTION, AND SUBSEQUENT FAILURE OF THE ENGINE.

 

Source: NTSB Aviation Accident Database

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