# NTSB ANC92LA095: Cessna 207, N23CF, Quinhagak, AK, June 19, 1992 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 18, 1992, 19:30 local (Jun 19, 1992, 03:30 UTC) - Place: Quinhagak, AK - Coordinates: 60.809646, -161.850723 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=60.8096&lon=-161.8507&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 5 uninjured - Status: Completed, report May 26, 1993 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Safety recommendations: Yes - NTSB case key (mKey): 5746 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC92LA095 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/5746/pdf - Page: https://openairdocs.org/ntsb/ANC92LA095 ## Probable cause ENGINE FAILURE DUE TO TOTAL OIL LOSS. CONTRIBUTING TO THE ACCIDENT WERE THE SEPARATION OF THE OIL FILTER ADAPTER FROM THE OIL PUMP DUE TO IMPROPER MAINTENANCE PROCEDURES AND NON ADHERENCE TO RECOMMENDED DIRECTIVES BY COMPANY MAINTENANCE PERSONNEL, AND THE UNSUITABLE TERRAIN ON WHICH TO MAKE THE FORCED LANDING. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - lubricating system,oil filter/screen - separation (contributing factor) - procedures/directives - not followed, company maintenance personnel (contributing factor) - insufficient standards/requirements, company/operator mgmt - fluid,oil - loss,total (cause) - Forced landing, descent - emergency - Gear collapsed, landing - flare/touchdown - terrain condition - none suitable (contributing factor) ## Analysis JUST AFTER MAKING THE INITIAL TAKEOFF CLIMB POWER REDUCTION THE PILOT NOTICED THAT THE ENGINE OIL PRESSURE WAS INDICATING ZERO. BEFORE HE COULD LAND AT HIS DEPARTURE AIRPORT THE ENGINE SEIZED. AN OFF AIRPORT FORCED LANDING RESULTED IN SUBSTANTIAL DAMAGE TO THE AIRPLANE. THE ENGINE OIL FILTER ADAPTER HAD SEPARATED FROM THE OIL PUMP HOUSING, AND ALL ENGINE OIL WAS LOST. THE THREADS ON THE ADAPTER AND HOUSING WERE WORN AND DAMAGED. THE ADAPTER HAD LAST BEEN INSTALLED USING WATER PUMP PLIERS INSTEAD OF THE SPECIAL WRENCH AS PER THE CESSNA MAINTENANCE MANUAL. ## Aircraft - Registration: [N23CF](https://openairdocs.org/aircraft/N23CF), registered now, S/N 20700276, built 1974 (OpenAirDocs) - Reported make and model: CESSNA 207 - Registry model: [Cessna 207](https://openairdocs.org/model/cessna-207) (registry code 2073602) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 20700276 - Airframe hours: 8092 - Engines: CONTINENTAL IO-520-F 300 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Hageland Avn. Services, Inc. - Registered owner: Hageland Avn. Services, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 8, 1992, 29 hours before - Departed: AQH, AK - Destination: BET, BETHEL, AK - Flight plan: Company VFR - Airport: AQH, Quinhagak, runway 22, 2,600 × 50 ft, gravel ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 9,140 total, 1,850 in this make and model, 8,400 as pilot in command, 155 in the last 90 days, 60 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 15 knots - Visibility: 30 statute miles - Lowest ceiling: none - Temperature: 55 °F ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19920618021179A](https://openairdocs.org/incident/19920618021179A), Jun 18, 1992: Cessna 207, Quinhagak, AK, Substantial damage. Lost oil pressure on climbout. Engine seized. Force landed. Oil filter adapter not properly torqued came loose. ## Other investigations on N23CF (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ANC23LA006](https://openairdocs.org/ntsb/ANC23LA006), Nov 20, 2022: Cessna 207 (N23CF), Bethel, AK, substantial damage. Probable cause: The total loss of engine power during cruise flight due to fuel starvation and the pilot’s mismanagement of the available fuel. From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.