CEN21LA034

NTSB accident investigation · Cessna 182 · Lebanon, OH · October 28, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 28, 2020, 11:40 local (15:40 UTC)
Place
Lebanon, OH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3537CCessna 182
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA
FAA report
20201028018609A
Case key
102207

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

Improper maintenance that resulted in a blocked crankcase breather port and a subsequent total loss of engine power.

Findings · 5

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.

Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelCessna 182T: 1 caseAll aircraft: 70 casesProbable cause
Eng oil sys (airframe furnish): eng oil dist (airframe furn)Aircraft › Aircraft power plant · Incorrect service/maintenanceCessna 182T: 1 caseAll aircraft: 18 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 182T: 1 caseAll aircraft: 130 casesProbable cause
Power plantAircraft › Aircraft power plant · FailureCessna 182T: 2 casesAll aircraft: 198 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 182T: 3 casesAll aircraft: 1,310 cases

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 and passenger were on a cross-country flight after maintenance personnel installed new avionics in the airplane. While at cruise altitude, the engine began to knock and vibrate and subsequently the engine lost all power. The pilot was unable to maintain altitude or reach an airport and landed the airplane in a field. The airplane overran the field and impacted trees; the wings and fuselage sustained substantial damage. The wreckage was examined, and a plastic cap was found installed on the engine crankcase breather port; the engine crankcase seal was found dislodged. Oil was found on the underside of the engine compartment and cowling. The blocked breather port likely allowed excessive pressure to build up inside the engine and resulted in the dislodged crankcase seal and a loss of oil. The investigation determined the mechanic who installed the avionics on the airplane also performed maintenance on the engine, which was outside of the repair station’s operations specifications. The mechanic did not have technical data for the work performed on the engine, did not document the work performed, and did not remove the plastic cap from the crankcase breather port following the installation of avionics. The accident is consistent with a total loss of engine power due to oil starvation as a result of improper maintenance.

Factual narrative

On October 28, 2020, about 1140 eastern daylight time, a Cessna 182T airplane, N3537C, was substantially damaged when it was involved in an accident near Lebanon, Ohio. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he and the passenger were on a cross-country flight from Clermont County Airport (I69), Ohio, to Warren County Airport (I68), Ohio, after maintenance was performed to install new avionics the day before. While level at 3,000 ft mean sea level (MSL), in instrument meteorological conditions, the oil pressure dropped to zero. The engine initially ran smooth after the drop in oil pressure, but then it began to knock and vibrate. The pilot declared an emergency with air traffic control, proceeded direct to I68, but was unable to maintain altitude. The airplane descended below the clouds about 600 ft above the ground and the engine lost all power. Unable to make the runway, the pilot landed in a harvested corn field. The pilot could not stop the airplane before it hit trees at the end of the field; the airplane’s wings and fuselage sustained substantial damage. The engine was examined, and a brightly colored plastic cap was found installed on the crankcase breather port, which completely blocked the port. The engine crankcase seal on the front of the engine was found dislodged and oil was found on the underside of engine compartment and cowling. The purpose of the crankcase breather port is to vent engine pressure. The crankcase seal provides the next location for pressure to vent if the breather port becomes blocked. The Federal Aviation Administration visited the repair station that installed the avionics on the airplane. They determined that the mechanic also performed maintenance on the engine which was outside of the repair station’s operations specifications. The mechanic did not have the technical data for the work performed. Further, the mechanic did not document the maintenance that he performed in the engine maintenance logbook. Maintenance records documented the installation of a Garmin avionics suite at the repair station. The last entry in the engine maintenance logbook was an oil change dated September 23, 2020.

Aircraft

Registration
N3537C
Reported as
Cessna 182 (T)
Category
Airplane
Serial number
18280966
Built
2001
Airframe hours
5,114
Engine
Lycoming IO540-AB1A5, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Flying Neutrons LLC
Registered owner
Flying Neutrons LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 3, 2020
Departed
I69 · Batavia, OH
Destination
Same as departure
Flight plan
IFR
Airport
I68 · Warren County Airport
Equipment
ADS-B, Auto-pilot, Data recorder, Electronic flight bag or handheld device

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
66
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
December 20, 2018
Seat
Left
Restraint
3-point
Flight hours
5,014 total · 688 in this make and model · 5,004 as pilot in command · 72 in the last 90 days · 18 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
5 statute miles
Lowest ceiling
700 ft overcast
Temperature
60 °F
Altimeter
30.12 inHg
Observed at
I68

Docket · 5

The files NTSB released with the investigation on April 26, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.9 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.