# NTSB CEN14LA331: Cessna A188, N8157V, Arlington, TX, June 27, 2014

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: June 27, 2014, 16:45 local (21:45 UTC)
- Place: Arlington, TX
- Coordinates: 32.669445, -97.237777 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.6694&lon=-97.2378&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: No injuries
- Injuries: 1 uninjured
- Status: Completed, report January 12, 2015
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Continental Motors, Federal Aviation Admisistration
- ADs cited in the narratives: [AD 96-12-22](https://openairdocs.org/ad/96-12-22) (OpenAirDocs)
- NTSB case key (mKey): 89572
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA331
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89572/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89572
- Page: https://openairdocs.org/ntsb/CEN14LA331

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=2073004), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md)
- [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073004), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md)
- [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=2073004), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md)
- [Maintenance/inspections: return to service](https://openairdocs.org/ntsb-findings/01010530): Aircraft › Aircraft handling/service · Not serviced/maintained; cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/01010530/cases.md?model=2073004), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/01010530/cases.md)
- [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Not serviced/maintained (probable cause); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=2073004), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md)
- [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Inadequate inspection (probable cause); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=2073004), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073004), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Maneuvering-low-alt flying: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna A188, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073004), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)

## 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](https://openairdocs.org/aircraft/N8157V), registered now, S/N 188-0407, built 1968 (OpenAirDocs)
- Reported make and model: CESSNA A188
- Registry model: [Cessna A188](https://openairdocs.org/model/cessna-a188) (registry code 2073004) (OpenAirDocs)
- Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 188-0407
- Year built: 1968
- Airframe hours: 9136
- Engines: Continental Motors Inc 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 67; injuries: none; 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 files)

The files NTSB released with the investigation on October 29, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89572. 23.2 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418325&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Engine Logbook Excerpts (item 2, .PDF, 647 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418326&FileExtension=.PDF&FileName=Engine%20Logbook%20Excerpts-Redacted.PDF
- Airworthiness Directive AD 96-12-22 - Oil Filter Adapter (item 3, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418327&FileExtension=.PDF&FileName=Airworthiness%20Directive%20AD%2096-12-22%20-%20Oil%20Filter%20Adapter-Master.PDF
- Engine Examination Report – Continental Motors (item 4, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418328&FileExtension=.PDF&FileName=Engine%20Examination%20Report%20%E2%80%93%20Continental%20Motors-Redacted.PDF
- AD Inspection Information (item 5, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418329&FileExtension=.PDF&FileName=AD%20Inspection%20Information-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418330&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 198 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418331&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF
- Revised Factual Report (item 8, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40420265&FileExtension=.PDF&FileName=Revised%20Factual%20Report-Master.PDF
- Photo 1 - Main Wreckage at Accident Site (item 9, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418332&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage%20at%20Accident%20Site-Master.PDF
- Photo 2 - Accident Airplane at Examination Facility (item 10, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418333&FileExtension=.PDF&FileName=Photo%202%20-%20Accident%20Airplane%20at%20Examination%20Facility-Master.PDF
- Photo 3 - Oil Filter Adapter (item 11, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418334&FileExtension=.PDF&FileName=Photo%203%20-%20Oil%20Filter%20Adapter-Master.PDF
- Photo 4 - Oil Filter Element (item 12, .PDF, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418335&FileExtension=.PDF&FileName=Photo%204%20-%20Oil%20Filter%20Element-Master.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.

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