El Dorado, AR, USA
N9318R
Cessna 182RG
The 1,643.4-hour pilot reported that during cruise flight on a dark night, he saw "sparks under the cowling in front, and lost cylinders one, two, and three, according to the engine monitoring unit installed in the airplane." The pilot attempted to return to the airport, but the engine lost power, and he initiated a forced landing to a field with the flaps and gear retracted. Examination of the airplane revealed visible signs of oil streaks were observed throughout the entire length of the bottom of the fuselage. Flight control continuity was established throughout the airplane at the accident site. Examination of the engine revealed that the oil filter converter plate gasket was extruded in multiple locations. An Emergency Airworthiness Directive (AD) had previously been issued requiring the replacement of the oil filter converter plate gasket, but no entries were found in the airplane maintenance log books pertaining to its compliance.
HISTORY OF FLIGHT On January 5, 2004, approximately 1825 central standard time, a Cessna 182RG, single-engine airplane, N9318R, sustained substantial damage during a forced landing following a loss of engine power near El Dorado, Arkansas. The non-instrument rated private pilot sustained serious injuries, and the passenger was fatally injured. The airplane was registered to and operated by the pilot. Night visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight originated from South Arkansas Regional Airport at Goodwin Field (ELD) near El Dorado, Arkansas, approximately 1815, and was destined for the Memphis International Airport (MEM), near Memphis, Tennessee. According to local authorities, the pilot reported that during cruise flight at 3,000 feet mean sea level (msl), he saw "sparks under the cowling in front, and lost cylinders one, two, and three, according to the engine monitoring unit installed in the airplane." The pilot added that he attempted to return to ELD, but the engine lost total power, and he initiated a forced landing to a field with landing gear retracted. During a telephone interview with the NTSB investigator-in-charge (IIC), the pilot stated that on the day of the accident, approximately 1630, he attempted to start the airplane's engine, but was unable to get it started. The pilot then plugged-in an engine heater, and went away for more than a hour. After he returned, the engine started without any problems; however, by the time the pilot departed ELD, it was getting very dark. After departure and approximately 19 miles from the airport, while at a cruise altitude of 3,000 feet msl, he heard "a very loud bang, followed by another loud bang." When he was attempting to look for a place to land, the engine "seized up." He saw sparks from the engine, and smoke had filled the cabin area. The cockpit doors were partially opened to ventilate the smoke, and with the evening darkness, the pilot could barely see the landing area. He further stated that he was unable to see any of the obstacles that the airplane struck before impacting the ground. A witness located near the accident site reported to local authorities that she observed an airplane circling above her house until it descended below a tree line. Moments later, she heard a boom, and what she thought was the airplane crash. PERSONEL INFORMATION A review of Federal Aviation Administration (FAA) airmen records revealed the pilot held a private pilot certificate with an airplane single-engine land rating, issued on April 10, 1995, and was issued a third-class medical certificate on April 22, 2002, with two restrictions: "Must have available glasses for near vision. Not valid for any class after April 30, 2004." A review of the pilot's logbook indicated a total flight time of 1,643.4 hours, as of the last entry on November 5, 2003. A "Daily Flight Record" was found inside the airplane, which included flights between November 5, 2003 and December 31, 2003, that amounted to an additional 41.9 hours. AIRCRAFT INFORMATION The 1979-model Cessna 182RG airplane, serial number R18200688, was a high wing, semimonocoque design airplane, with a retractable landing gear, configured to carry a maximum of four occupants. The airplane was powered by a normally aspirated, direct drive, air-cooled, horizontally opposed, carbureted, six-cylinder Textron-Lycoming O-540-J3C5D engine, serial number L-23505-40A, rated at 235 horsepower. The airplane's maintenance records that were provided to the FAA and reviewed by the NTSB IIC, revealed the engine was overhauled by a factory authorized repair station to manufacturer's new part limits, including all applicable airworthiness directives, on April 25, 2000. The engine was then installed on the accident airplane on June 1, 2000, during an annual inspection that included an oil change, with 2,835.4 hours time-in-service and 0 hours since major overhaul (SMOH). On November 11, 2000, the engine oil was changed at time since overhaul (TSOH) of 29.9 hours. On February 10, 2001, the engine oil was changed at TSOH of 59.1 hours. An annual inspection was performed including an oil change on July 18, 2001, at TSOH of 64.1 hours, with time-in-service of 2,916.2 hours and tachometer meter time of 2,916.2 hours. An annual inspection was performed including an oil change on January 21, 2002, at TSOH of 128.9 hours, with time-in-service of 2,981.0 hours and tachometer meter time of 2,981.0 hours. On February 15, 2003, the airplane underwent its most recent annual inspection including an oil change at TSOH of 225.6 hours, with time-in-service of 3,077.7 hours and tachometer meter time of 3,077.7 hours. On June 10, 2003, the engine oil was changed at tachometer meter time of 3,118.9 hours. On September 29, 2003, the engine oil was changed at tachometer meter time of 3,196.7 hours. On November 4, 2003, the engine oil was changed at tachometer meter time of 3,246.5 hours. The most recent engine oil change was on December 23, 2003, at tachometer meter time of 3,277.6 hours. At the time of the accident, records indicated the engine had accumulated 438.6 hours SMOH. On July 24, 2000, Mandatory Service Bulletin (SB) 543 was issued by the engine manufacturer for engine models TIO-540-J2BD and LTIO-540-J2BD for an oil filter base seal inspection because of "reports indicating that the seal on the oil filter base can become extruded from its seat, allowing oil to leak out between the base and the accessory housing." This SB was not applicable to model O-540-J3C5D. On August 30, 2000, Mandatory Service Bulletin 543A was issued by the engine manufacturer that required the replacement of the oil filter converter plate gasket before further flight and at each 50 hour oil change thereafter. The SB was issued because of "reports indicating that operation at high temperatures can cause the converter plate gasket on the oil filter base to become extruded from its seat, allowing oil to leak out between the plate and the accessory housing." This bulletin listed many affected engine models, including model O-540-J3C5D. On September 5, 2000, Emergency Airworthiness Directive (AD) 2000-18-53 was issued by the FAA. Differences between the AD and SB543A being "only engines with more than 50 hours time since new (TSN), time since overhaul (TSO), or time since last replacement of the oil filter converter plate or gasket must have the gasket replaced before further flight." This AD was "to prevent complete loss of engine oil and subsequent seizing of the engine, and possibility of fire." The AD also included the model O-540-J3C5D engine. On October 4, 2000, Supplement Number 1 to Mandatory Service Bulletin 543A was issued by the engine manufacturer that provided an alternate means of compliance to the affective engine models only if: 1. They were shipped from the factory between April 1, 1999, and October 4, 2000. 2. They have had the oil filter converter plate gasket field replaced after April 1, 1999, with part number (P/N) LW-13388. 3. They have had the oil filter converter plate field replaced after April 1, 1999, with P/N LW-13904. The FAA published a Notice of Proposed Rulemaking (NPRM) for Airworthiness Directive (AD) 2002-12-07, as an amendment to supersede AD 2000-18-53. The amendment required "the same replacements and inspections, and introduced the installation of an improved design gasket or converter plate kit as terminating action for the repetitive gasket replacements." The effective date was July 3, 2002, with comments for inclusion in the Rules Docket being received on or before August 19, 2002. On July 1, 2003, Mandatory Service Bulletin 543B (Supersedes SB 543A and Supplement No. 1 to SB 543A) was issued by the engine manufacturer for the replacement of the oil filter converter plate gasket. The time of the compliance was the next 50 hour oil change unless gasket P/N 06B23072 had previously been installed. The engine manufacturer "determined that P/N LW-13388 oil filter converter plate gaskets were made from incorrect material." The SB, which included engine model O-540-J3C5D, added that "this could cause some converter plate gaskets to become extruded from the seat, allowing oil to leak out between the plate and the accessory housing." No entries were found pertaining to the compliance of Mandatory Service Bulletins 543A, 543B, or AD 2000-18-53, during the review of N9318R's aircraft maintenance logbook or AD compliance record. Examination of the engine overhaul work order revealed the oil filter converter plate gasket, part number LW-13388, was installed at the time of engine overhaul. METEORLOGICAL INFORMATION At 1753, the automated surface observing station at ELD, reported the wind from 020 degrees at 7 knots, visibility 10 statue miles with fog, sky condition overcast at 3,300 feet agl, temperature 36 degrees Fahrenheit, dew point 25 degrees Fahrenheit, and an altimeter setting of 30.39 inches of mercury. WRECKAGE AND IMPACT INFORMATION An on-scene examination revealed that the airplane struck the top of a tree approximately 35-40 feet in height, prior to impacting the ground. Subsequently, the airplane collided with a steel fence and came to rest on its left side. The nose of the aiplane was on a 115 degree magnetic heading, approximately 113 feet from the tree, at a field elevation of 141 feet msl. The wreckage distribution path measured 242 feet, and was aligned on a magnetic heading of 336 degrees. The global positioning system (GPS) location of the accident site was 33 degrees 17.823 minutes North latitude and 092 degrees 38.664 minutes West longitude. A ground scar containing portions of plastic, consistent with a wingtip fairing, approximately five feet in length, was located 79 feet from the base of the tree. A second ground scar was located 94 feet from the base of the tree, approximately five feet in length. Freshly cut tree branches were found within the area of the initial ground scar and debris path. Examination of the airplane revealed that the left wing remained attached to its respective mounts, but was bent upwards approximately 90 degrees at the wing root. The left wing lift strut was separated from the fuselage and wing, but the wing strut fitting remained attached to the wing. The leading edge of the left wing, adjacent to the pitot/static tube, was torn open aft to the forward wing spar. The aileron and flap remained attached, and flight control continuity was established from the cockpit flight controls through the doorpost and throughout the wing. The auto pilot roll-servo was intact and remained attached to the wing. The left flap was found in the retracted position. The left wingtip fairing remained intact. The left vented fuel tank cap was found secure with seals in good condition. No visible signs of fuel were observed within the fuel tank, but a strong odor of fuel was noted. The right wing remained attached to its respective mounts. The wingtip fairing remained attached, with damage to the forward area. The strobe light and navigation light housing was separated and located adjacent to the main wreckage. The outboard three feet of the leading edge was crushed aft. The wing structure was compromised at the lift-strut attach point. The outboard section of the wing, outboard of the lift-strut attach point, was bent downward approximately 90 degrees. The wing lift-strut was separated from the wing and fuselage, and was located adjacent to the fuselage. Three separate impact marks were found on the wing lift-strut. The aileron and flap remained attached, and flight control continuity was established from the cockpit flight controls through the doorpost throughout the wing. The right flap was found in the retracted position. The flap actuator was observed in a retracted position. The right vented fuel tank cap was found secure, with the seals in good condition. No visible signs of fuel were observed within the tank. The vertical stabilizer and rudder sustained minor damage. The outboard two feet of the left horizontal stabilizer and elevator were bent upwards approximately 45 - 90 degrees. The right horizontal stabilizer and elevator remained attached to the empennage by the control cables. The pitch-trim actuator measured 1 9/16ths inches, which the manufacturer equated to approximately a 10 degree tab up position. The trim tab remained attached to the elevator. The right elevator counter weight was separated from the elevator and was located near the main wreckage. Flight control continuity was established from the control column aft throughout the fuselage to the elevators and rudders. The fuselage was partially separated aft of the cabin at the baggage door on the left side. The main landing gear remained in the retracted position. Severe crushing was observed on the forward floorboard of the cockpit area. Visible signs of oil streaks were observed throughout the length of the bottom of the fuselage. Examination of the cockpit revealed the left seat was separated from its respective seat rails. The seat rails were deformed and broken in multiple places. The left seat lap belt remained intact. The left shoulder harness was found stowed in the tray above the door. The right seat remained attached to the inboard seat rail with the forward roller assembly. The lap belt and shoulder harness remained intact. The instrument panel was severely deformed with greater damage to the left side. Cockpit instrumentation was documented at the accident site. The Hobbs meter was observed at 1,588.4 hours, tachometer at 0 rpm, and 3,290.7 hours. The airspeed indicator indicated 0, and the altimeter displayed 6,020 feet, with an altimeter setting of 30.28. The left horn was broken from the left control yoke. The right control yoke was intact. The throttle and propeller handles were observed in the full forward position, and the mixture handle was approximately 3/4 inch out. The fuel selector was observed to be in the "both" position. The magneto switch was found in the "both" position. The landing gear handle was observed in the "up" position. The flap position selector and indicator displayed approximately the 10 degrees position. The engine and cowling remained attached to the engine firewall. The crankcase had a hole located at the top front of the left crankcase-half, near the number two cylinder intake tappet boss. The breach was approximately one inch long and 1/2 inch wide. The crankcase also had a hole at the top rear of the left crankcase-half, near the number six cylinder exhaust tappet boss. The breach was approximately two inches in diameter. The rear accessory housing and components were wet with fresh oil. The propeller spinner, which was entangled in the wire of the fence, was removed and inspected; no rotation scarring was observed inside the interior of the spinner dome. The propeller remained attached to the engine. One propeller blade displayed no leading edge polishing or gouging. The blade was bent aft approximately five degrees, starting at mid-blade. The other propeller blade was bent aft approximately ninety degrees, approximately six inches outboard from the propeller hub. There was one gouge in the leading edge approximately 1/2 inch in depth and length at the mid-blade point. The fuel lines to the fuselage fuel sump drain were removed and fuel was observed. The sump drain screen was removed, and was free of contaminants. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy and toxicological tests were not requested for the passenger. The FAA's Civil Aeromedical Institute's (CAMI) Forensic and Accident Research Center, Oklahoma City, Oklahoma, examined the blood sample from the pilot taken by the local sheriff department during transport to the local hospital. Tests were performed for carbon monoxide, volatiles, and drugs, and the list and values are confirmed by the FAA. Carbon monoxide and ethanol were not detected in the blood. TESTS AND RESEARCH On March 17, 2004, at the facilities of Textron
The loss of engine power as a result of loss of engine oil due to the failure of the oil filter converter plate gasket and the noncompliance to an airworthiness directive. Contributing factors were the lack of suitable terrain for the forced landing and the dark night lighting conditions.
Source: NTSB Aviation Accident Database
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