# NTSB CEN13LA056: Cessna 210L, N732BL, La Grange, TX, November 9, 2012 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 9, 2012, 07:21 local (13:21 UTC) - Place: La Grange, TX - Coordinates: 29.928333, -96.946388 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9283&lon=-96.9464&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed, report March 10, 2015 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Houston FSDO, Continental Motors, Inc., Cessna Aircraft Company - NTSB case key (mKey): 85551 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA056 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85551/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85551 - Page: https://openairdocs.org/ntsb/CEN13LA056 ## Probable cause The total loss of engine power due to the loss of oil to the engine. Contributing to the accident was maintenance personnel’s improper installation of the engine oil filter adaptor, which resulted in the loss of oil to the engine. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073448), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2073448), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2073448), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073448), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073448), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 210L, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2073448), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2073448), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 210L, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073448), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 210L, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073448), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 210L, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073448), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 210L, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073448), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Post-impact: Cabin safety event](https://openairdocs.org/ntsb-events/110); cases with it: [Cessna 210L, 1 case](https://openairdocs.org/ntsb-events/110/sequence.md?model=2073448), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md) ## Analysis The pilot reported that the airplane was in cruise flight at 7,000 ft mean sea level when he noticed that the engine oil pressure had dropped to an unacceptable level. He then attempted to divert to land at a nearby airport. However, when the airplane was on the downwind leg and after the landing gear had been extended, the engine experienced a total loss of power, so the pilot made an off-airport landing. During the landing on a soft, plowed field, the airplane flipped over and then came to rest inverted. Review of maintenance records revealed that recent maintenance, which included the replacement of the engine oil filter, had been performed on the engine. A postaccident examination of the airframe revealed an abundance of engine oil on the airplane's belly; the oil extended from the engine compartment to the tail surfaces. A teardown examination of the engine revealed that a connecting rod had released from the crankshaft due to lubrication distress. An examination of the oil filter revealed that the oil filter adapter fiber seal washer was torn where the adaptor attaches to the oil pump housing and that the washer and the oil filter adaptor were misaligned. The improper installation of the oil filter adaptor likely caused the loss of oil to the engine and the subsequent total loss of engine power. ## Factual narrative On November 9, 2012, about 0721 central standard time, N732BL, a Cessna 210L, single engine airplane, was substantially damaged during a forced landing near Fayette Regional Air Center Airport (3T5), La Grange, Texas. The pilot and both passengers sustained minor injures. The airplane was registered to and operated by a private individual. Day visual meteorological conditions (VMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed for the 14 Code of Federal Regulations Part 91 business flight. The airplane departed San Marcos Municipal Airport (HYI), San Marcos, Texas, about 0650 destined for Baytown Airport (HPY), Baytown, Texas.The airplane was in cruise flight at 7,000 feet mean sea level when the pilot noticed that the engine oil pressure had dropped to an unacceptable level. The pilot requested a descent and vectors to divert for landing at 3T5. Radar data showed the airplane was about 2,500 feet above ground level when it overflew 3T5. When the airplane was on downwind and after the lowering the landing gear the pilot reported that he had a total loss of engine power and made an off-airport landing about a mile north from 3T5. During the landing on a soft plowed field the airplane flipped and came to rest inverted. A review of aircraft maintenance logbook entries showed that maintenance had been performed on the engine about three weeks prior to the accident. That maintenance included replacement of the engine oil filter. A postaccident examination of the airframe revealed an abundance of engine oil on the belly of the airplane which extended from the engine compartment all the way to the tail surfaces. A teardown examination of the engine revealed lubrication distress, and mechanical damage on all connecting rod journals with damage concentrated where the number four connecting rod had released from the crankshaft and had penetrated through the crankcase. An examination of the oil filter showed that it contained an abundance of flakes and slivers from the damaged internal engine components. The oil filter adapter fiber seal washer was observed to be torn where the adaptor attaches to the oil pump housing and had signatures of misalignment with the oil filter adaptor. ## Aircraft - Registration: [N732BL](https://openairdocs.org/deregistered/N732BL-2019-03-25), registration cancelled 2019-03-25, S/N 21061386, built 1976 (OpenAirDocs) - Reported make and model: CESSNA 210L - Registry model: [Cessna 210L](https://openairdocs.org/model/cessna-210l) (registry code 2073448) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061386 - Year built: 1976 - Airframe hours: 3128 - Engines: CONT MOTOR IO 520 SERIES 300 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 15, 2012, 17 hours before - Departed: HYI, San Marcos, TX - Destination: HPY, Baytown, TX - Flight plan: IFR - Airport: 3T5, Fayette Regl Air Center Airpor, runway 16, 5,000 × 75 ft, asphalt - Equipment: Stall warning system, Handheld GPS, Data recorder, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 36; injuries: minor; airline transport, commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review July 14, 2011; seat: left; restraint: lap only; flight hours: 6,642 total, 418 in this make and model, 5,402 as pilot in command, 28 in the last 90 days, 17 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 2,900 ft broken - Temperature: 66 °F, dew point 63 °F - Altimeter: 30.04 inHg - Observed at: K3TS, 1 nm away ## 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 20121109028179A](https://openairdocs.org/incident/20121109028179A), Nov 9, 2012: Cessna 210L, La Grange, TX, Substantial damage. On November 9th, 2012 at approximately 07:00AM aircraft N732BL Cessna 210 enroute from san marcus, Texas (khyi) to baytown, Texas (khpy) experienced a loss… ## Other investigations on N732BL (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 MIA90IA144](https://openairdocs.org/ntsb/MIA90IA144), Jun 25, 1990: Cessna 210L (N732BL), Fort Lauderdale, FL, incident, minor damage. Probable cause: INCORRECT PLACEMENT OF THE RETAINING RING IN THE LEFT MAIN LANDING GEAR DOOR ACTUATOR BY THE MECHANIC RESULTING IN THE LOSS OF HYDRAULIC FLUID. THIS PREVENTED THE GEAR FROM EXTENDING RESULTING IN THE… ## Docket (12 files) The files NTSB released with the investigation on January 20, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85551. 8.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383192&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - NTSB Examination Report (item 2, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420821&FileExtension=.PDF&FileName=NTSB%20Examination%20Report%20-Master.PDF - Electronic Devices 17 - Specialist's Factual Report (item 3, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388814&FileExtension=.PDF&FileName=Electronic%20Devices%2017%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Electronic Devices 17 - Attachment 1 - Tabular Data (CSV) (item 4, .CSV, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388815&FileExtension=.csv&FileName=Electronic%20Devices%2017%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)-Master.csv - Passenger Statements (item 5, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383193&FileExtension=.PDF&FileName=Passenger%20Statements-Master.PDF - Maps (item 6, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381484&FileExtension=.PDF&FileName=Maps-Master.PDF - Weather Summary (item 7, .PDF, 358 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381485&FileExtension=.PDF&FileName=Weather%20Summary-Master.PDF - Photo 1 – Wreckage at the Accident Scene (FAA Photo) (item 8, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420822&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Wreckage%20at%20the%20Accident%20Scene%20(FAA%20Photo)-Master.PDF - Continental Motors Report of Engine Examination w/photos (item 9, .PDF, 6.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420823&FileExtension=.PDF&FileName=Continental%20Motors%20Report%20of%20Engine%20Examination%20w%2Fphotos-Redacted.PDF - Airport Record of Fuel Quality Testing (item 10, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420824&FileExtension=.PDF&FileName=Airport%20Record%20of%20Fuel%20Quality%20Testing-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420825&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420827&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF 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.