# NTSB CEN21LA034: Cessna 182, N3537C, Lebanon, OH, October 28, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 28, 2020, 11:40 local (15:40 UTC) - Place: Lebanon, OH - Coordinates: 39.431359, -84.256329 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4314&lon=-84.2563&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 102207 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA034 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102207/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102207 - Page: https://openairdocs.org/ntsb/CEN21LA034 ## Probable cause Improper maintenance that resulted in a blocked crankcase breather port and a subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 182T, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=2072703), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) - [Eng oil sys (airframe furnish): eng oil dist (airframe furn)](https://openairdocs.org/ntsb-findings/01057920): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 182T, 1 case](https://openairdocs.org/ntsb-findings/01057920/cases.md?model=2072703), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057920/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 182T, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2072703), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Failure; cases with it: [Cessna 182T, 2 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=2072703), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible; cases with it: [Cessna 182T, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2072703), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/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 182T, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072703), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 182T, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072703), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## 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](https://openairdocs.org/deregistered/N3537C-2021-01-25), registration cancelled 2021-01-25, S/N 18280966 (OpenAirDocs) - Reported make and model: CESSNA 182 (T) - Registry model: [Cessna 182T](https://openairdocs.org/model/cessna-182t) (registry code 2072703) (OpenAirDocs) - Category: Airplane - Serial number: 18280966 - Year built: 2001 - Airframe hours: 5114 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: none; 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 ## 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 20201028018609A](https://openairdocs.org/incident/20201028018609A), Oct 28, 2020: Cessna 182T, Lebanon, OH, Substantial damage. On Wednesday, October 28, 2020, at approximately 1130 EDT, a Cessna CE-182 aircraft, registration n-number N3537C, was involved in an accident when it crashed… ## Docket (5 files) The files NTSB released with the investigation on April 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102207. 12.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11888523&FileExtension=pdf&FileName=6120.1_Redacted-Rel.pdf - Memorandum of record - FAA repair station findings (item 2, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11898490&FileExtension=pdf&FileName=Memorandum%20of%20Record%20-%20FAA%20Findings-Rel.pdf - Oils system description email (item 3, PDF, 2 pages, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11898480&FileExtension=pdf&FileName=Oil%20System%20Description%20Email_Redacted-Rel.pdf - Photos (item 4, PDF, 3 pages, 446 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11916319&FileExtension=pdf&FileName=Photo%20Array%20CEN21LA034-Rel.pdf - Maintenance records (item 5, PDF, 5 pages, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11901995&FileExtension=pdf&FileName=MX%20Logbooks_Redacted-Rel.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.