# NTSB CHI04LA280: Cessna T210L, N2027S, Kingman, KS, September 27, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 27, 2004, 11:33 local (16:33 UTC) - Place: Kingman, KS - Coordinates: 37.668888, -98.123886 - Nearby events: https://openairdocs.org/map.md?lat=37.6689&lon=-98.1239&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Inc., Cessna Aircraft Company, Federal Aviation Administration - NTSB case key (mKey): 60226 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI04LA280 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60226/pdf - Page: https://openairdocs.org/ntsb/CHI04LA280 ## Probable cause The lack of engine oil due to the mechanic's improper maintenance in not securing the loose "B" nut for the oil pressure line to the turbocharger leading to the loss of engine power while maneuvering. An additional cause was the unsuitable terrain the pilot encountered during the forced landing. A factor was the terrace the nose wheel impacted and subsequently nosed over. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, maneuvering - maintenance - improper, other maintenance personnel (cause) - lubricating system,oil line - loose part/bolt/nut/clamp/etc (cause) - fluid,oil - lack of (cause) - Forced landing, descent - emergency - On ground/water encounter with terrain/water, emergency landing - unsuitable terrain or takeoff/landing/taxi area - encountered, pilot in command (cause) - terrain condition - dirt bank/rising embankment (contributing factor) - Nose over, emergency landing ## Analysis The airplane sustained substantial damage when it nosed over during a forced landing following an in-flight loss of engine power. The certified flight instructor (CFI) and the private pilot sustained serious injuries. According to the CFI, the flight's purpose was to meet the dual instruction requirements of the Wings Program. The CFI's accident report stated, "Upon the completion of the turn the engine lost about 50 [percent] of its power. We thought that we could make it to Kingman Airport and started a course for it. [Approximately three and a half] miles from the airport the engine stopped [abruptly] the prop continued to windmill we made an approach to a wheat field. The pilot made a very good approach and a smooth landing. After approximately 400 ft of ground roll we encountered a terrace. It appears that this caused the nose wheel to shear off. With nothing to support the nose it caused the airplane to flip over on its back." The last annual inspection of the airframe and engine was on September 2, 2004, and the tachometer read 3,191.7 hours at the time of that inspection. That annual inspection's endorsement indicated that the number two and four cylinders were removed during that inspection. The number two cylinder was found with an eroded exhaust. That number two cylinder was replaced with an overhauled cylinder. On-scene examination of the bottom of the fuselage revealed a trail of oil on its left side. Examination of the engine revealed a hole in the top of the crankcase near the number two cylinder. Examination of the oil pressure line from the engine to the turbocharger revealed a loose "B" nut. The tachometer read 3,192.1 hours on-scene. The engine was disassembled and internal examination revealed that the rod ends for the number one and number two cylinders were discolored, deformed, and separated from the crankshaft. The crankshaft was discolored. The discoloration present was consistent with the heat produced by a lack of lubrication. The examination revealed silver colored and copper colored debris in the oil sump. That debris was consistent with bearing material. The tee fitting and pressure line with the loose "B" nut were removed from the engine case. The line's end and tee fitting's end were capped off and a fluid under pressure was supplied to the tee fitting. That fluid was observed leaking from the loose "B" nut. ## Factual narrative HISTORY OF FLIGHT On September 27, 2004, about 1133 central daylight time, a Cessna T210L, N2027S, piloted by a private pilot with a certified flight instructor (CFI) aboard, sustained substantial damage when it nosed over during a forced landing following an in-flight loss of engine power while maneuvering near Kingman, Kansas. The instructional flight was operating under 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The instructor and the private pilot sustained serious injuries. The local flight departed from Wichita Mid-Continent Airport, near Wichita, Kansas, about 1116. According to the CFI, the flight's purpose was to meet the requirements of the Wings Program. The CFI's accident report stated: After reaching the west practice area we made one 360 [degree] turn. We were at 4,500 [feet above mean sea level]. Upon the completion of the turn the engine lost about 50 [percent] of its power. We thought that we could make it to Kingman Airport and started a course for it. [Approximately three and a half] miles from the airport the engine stopped [abruptly] the prop continued to windmill we made an approach to a wheat field. The pilot made a very good approach and a smooth landing. After approximately 400 ft of ground roll we encountered a terrace. It appears that this caused the nose wheel to shear off. With nothing to support the nose it caused the airplane to flip over on its back. The pilot, who was receiving dual instruction, sustained injuries and as a result was not able to complete an accident report. PERSONNEL INFORMATION The CFI held an airline transport pilot certificate with airplane single and multiengine land, glider, and single-engine sea ratings. The CFI also held a CFI certificate with single-engine airplane, multiengine airplane, and instrument airplane ratings. He reported that he had accumulated 26,407.4 hours of total time, of which 23,345.5 hours were in single-engine airplanes, and 16,431.0 hours were as an instructor. The CFI's last medical examination was completed on March 25, 2002. He stated that his medical certificate limitations and waivers indicated that he must wear corrective lenses and that the certificate was not valid for any class after March 31, 2004. The pilot-in-command (PIC), who was receiving dual instruction, held a private pilot certificate with airplane single-engine land and instrument ratings. The CFI stated that the PIC's last flight review was on October 16, 2003. The pilot's last medical examination was completed on December 4, 2002, and he indicated that he had accumulated 4,000 hours of total time and 60 hours in the last six months prior to that medical. AIRCRAFT INFORMATION N2027S, a Cessna T210L, Centurion, serial number 21060995, was a full cantilever high-wing, all-metal, propeller-driven, retractable landing gear, semi-monocoque construction, six-seat airplane. A 285 horsepower, six-cylinder, air cooled, turbocharged, direct drive, fuel-injected, horizontally opposed, Teledyne Continental Motors TSIO-520-H, serial number 506468, engine powered the airplane. Its propeller was a three-bladed McCauley D3A34C402-C, serial number 962095, which was installed under a supplemental type certificate number SA2582NM. Review of the aircraft maintenance records revealed its engine was overhauled on February 26, 1998. The tachometer read 2,723.4 at the time of that overhaul. The last annual inspection of the airframe and engine was on September 2, 2004, and the tachometer read 3,191.7 hours at the time of that inspection. That annual inspection's endorsement indicated that the number two and four cylinders were removed during that inspection. The number two cylinder was found with an eroded exhaust. That number two cylinder was replaced with an overhauled cylinder. METEOROLOGICAL INFORMATION At 1151, the recorded weather at Hutchinson Municipal Airport, near Hutchinson, Kansas, was: Wind variable at 3 knots; visibility 10 statute miles; sky condition clear; temperature 25 degrees C; dew point 11 degrees C; altimeter 30.15 inches of mercury. WRECKAGE AND IMPACT INFORMATION Federal Aviation Administration Inspectors performed an on-scene examination of the wreckage. The start of tire marks was found at latitude 37 degrees 41.007 minutes north and longitude 98 degrees 04.258 minutes west. The airplane was found resting inverted at latitude 37 degrees north 41.081 minutes north and longitude 98 degrees 04.206 minutes west. Examination of the bottom of the fuselage revealed a trail of oil on its left side. Examination of the engine revealed a hole in the top of the crankcase near the number two cylinder. Examination of the oil pressure line from the engine to the turbocharger revealed a loose "B" nut. The tachometer read 3,192.1 hours on-scene. TESTS AND RESEARCH The engine was shipped to Teledyne Continental Motors in Mobile, Alabama for examination. The engine was disassembled and internal examination revealed that the rod ends for the number one and number two cylinders were discolored, deformed, and separated from the crankshaft. The crankshaft was discolored. The discoloration present was consistent with the heat produced by a lack of lubrication. The examination revealed silver colored and copper colored debris in the oil sump. That debris was consistent with bearing material. The tee fitting and pressure line with the loose "B" nut were removed from the engine case. The line's end and tee fitting's end were capped off and a fluid under pressure at 20 psi was supplied to the tee fitting. That fluid was observed leaking from the loose "B" nut. ADDITIONAL INFORMATION The FAA, Teledyne Continental Motors, and the Cessna Aircraft Company were parties to the investigation. ## Aircraft - Registration: [N2027S](https://openairdocs.org/deregistered/N2027S-2006-09-18), registration cancelled 2006-09-18, S/N 21060995 (OpenAirDocs) - Reported make and model: Cessna T210L - Registry model: [Cessna T210L](https://openairdocs.org/model/cessna-t210l) (registry code 2073449) (OpenAirDocs) - Category: Airplane - Serial number: 21060995 - Airframe hours: 3192.1 - Engines: Continental TSIO-520-H 285 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Joe H. Yeager - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 2, 2004, 0.4 hours before - Departed: ICT, WICHITA, KS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review October 26, 2003; seat: left; flight hours: 4,000 total - Flight instructor; age 87; injuries: serious; airline transport, flight instructor; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; last flight review June 17, 2003; seat: rear ## Weather - Conditions: Visual (VMC), Day - Wind: 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 52 °F - Altimeter: 30.14 inHg - Observed at: HUT, 25 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 20040927024099A](https://openairdocs.org/incident/20040927024099A), Sep 27, 2004: Cessna T210L, Kingman, KS, Substantial damage. (-23) Aircraft departed wichita, KS airport (ict) to maneuver in the west practice area. Controller observed loss of radio and radar contact on the aircraft… 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.