CEN14LA331

NTSB accident investigation · Cessna A188 · Arlington, TX · June 27, 2014

Accident · No injuriesLimited investigationFinal report
Date
June 27, 2014, 16:45 local (21:45 UTC)
Place
Arlington, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N8157VCessna A188
Defining event
Maneuvering-low-alt flying: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 12, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Federal Aviation Admisistration
Case key
89572

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The total loss of engine power due to a loose oil filter adapter, which resulted in oil starvation. Contributing to the accident was maintenance personnel’s failure to comply with a Federal Aviation Administration airworthiness directive.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna A188: 1 caseAll aircraft: 174 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Not serviced/maintainedCessna A188: 1 caseAll aircraft: 130 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelCessna A188: 1 caseAll aircraft: 70 casesProbable cause
Maintenance/inspections: return to serviceAircraft › Aircraft handling/service · Not serviced/maintainedCessna A188: 1 caseAll aircraft: 14 cases
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Not serviced/maintainedCessna A188: 1 caseAll aircraft: 76 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Inadequate inspectionCessna A188: 1 caseAll aircraft: 76 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that he was maneuvering the airplane with a banner attached when he noticed a loss of oil pressure. He notified an air traffic controller of the emergency and indicated that he could not reach an airport. The engine then experienced a total loss of power, and the pilot made an emergency landing to a grassy area near a highway interchange. During the landing, the airplane collided with a vehicle, and then another vehicle struck the airplane. A postaccident examination of the engine revealed that the oil filter adapter was loose, and no oil was observed inside the engine. The threads on the adapter were worn and damaged. The lock nut on the adapter was not properly torqued, and oil residue was observed on the engine near the adapter and on the underside of the airframe. A large amount of metallic debris was found throughout the entire oil filter element, which is consistent with engine oil starvation. Maintenance personnel replaced the oil and oil filter 4 days before the accident; however, they did not comply with Federal Aviation Administration Airworthiness Directive 96-12-22, which required, in part, inspecting the oil filter and adapter assembly for oil leakage and proper installation of the adapter retaining nut and replacing any oil filter adapter assembly with security problems to prevent loss of engine oil caused by loose or separated oil filter adapters because the loss of oil could result in engine stoppage while in flight and loss of airplane control.

Factual narrative

On June 27, 2014, about 1700, central daylight time, a Cessna A188 airplane, N8157V, made a forced landing to a road after a loss of engine oil pressure near Arlington, Texas. The airline transport pilot, who was the sole occupant, was not injured. The airplane sustained substantial damage. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a banner tow flight. Visual meteorological conditions prevailed for the flight and no flight plan was filed. The local flight originated from the Dallas Executive Airport (KRBD), Dallas, Texas about 1600. According to the pilot, he was maneuvering the airplane with the banner attached when he noticed a loss of oil pressure. He notified air traffic control of the emergency and that he could not reach an airport. The engine experienced a total loss of power and the pilot made an emergency landing to a grass area near a highway interchange. During the landing roll, the airplane continued onto the highway interchange and struck a vehicle. After the airplane came to rest, another vehicle struck the airplane from the rear. The airplane's empennage was twisted to the right but remained attached to the rear fuselage. A postaccident examination of the engine revealed insignificant impact exterior damage, although the engine mounts had excessive wear, and several cracks had been stop drilled in the muffler. The oil dip stick was removed and no oil was observed. The propeller was rotated by hand; the crankshaft was stiff and made a grinding sound as it rotated inside the crankcase. The oil filter adapter was loose from its fitting and had "CESSNA" branded on the side of the unit. The threads on the adapter were worn and damaged. The lock nut on the adapter was not properly torqued. Oil residue was observed on the engine near the adapter and on the underside of the airframe. The oil filter was removed and cut open. The filter element contained metallic debris throughout the entire filter. On July 31, 1996, the Federal Aviation Administration issued Airworthiness Directive (AD) 96-12-22: CESSNA AIRCRAFT COMPANY: Amendment 39-9665, for Cessna Models 100, 200, 300, and 400 Series airplanes (all serial numbers), certificated in any category, that are equipped with at least one Teledyne Continental Motors engine. The AD required, in part, inspecting the oil filter and adapter assembly for oil leakage and proper installation of the adapter retaining nut and replacing any oil filter adapter assembly with security problems "to prevent loss of engine oil caused by loose or separated oil filter adapters, which could result in engine stoppage while in flight and loss of control of the airplane." According to the airplane's maintenance logbooks, the oil and oil filter had been changed five times since October 6, 2013. The most recent oil and oil filter change was completed on June 23, 2014. There are no records that show AD 96-12-22 was completed. Themaintenance personnel stated that the AD did not apply to the oil filter adapter because it was replaced by a different type of filter adapter from Continental Motors. According to the manufacturer, there are no Continental Motors oil filter adapters.

Aircraft

Registration
N8157V
Reported as
Cessna A188
Category
Airplane
Serial number
188-0407
Built
1968
Airframe hours
9,136
Engine
Continental Motors IO-520-D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Banner tow · Part 91
Operator
Patrick D Champagne, doing business as We Fly Ads
Registered owner
Patrick D Champagne
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · April 5, 2014
Departed
RBD · Dallas, TX
Destination
RBD · Dallas, TX

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 1, With waivers/limitations
Last flight review
September 30, 2013
Seat
Single
Restraint
3-point
Flight hours
26,564 total · 681 in this make and model · 20,564 as pilot in command · 66 in the last 90 days · 43 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 16 knots, gusting 24
Visibility
10 statute miles
Temperature
90 °F, dew point 70 °F
Altimeter
29.79 inHg
Observed at
KGKY, 7 nm away

Docket · 12

The files NTSB released with the investigation on October 29, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.2 MB in all.