ERA10LA487

NTSB accident investigation · Navion Navion G · Dublin, GA · September 19, 2010

Accident · Minor injuriesLimited investigationFinal report
Date
September 19, 2010, 13:25 local (17:25 UTC)
Place
Dublin, GA
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2448TNavion Navion G
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 13, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors, FAA/FSDO
FAA report
20100919048209A
Case key
77337

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 pilot's failure to properly secure the oil drain plug after changing the engine oil, which resulted in oil starvation and an engine failure during cruise flight.

Findings · 2

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: scheduled/routine maintenancePersonnel issues › Task performance · PilotNavion NAVION G: 3 casesAll aircraft: 320 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Incorrect service/maintenanceNavion NAVION G: 1 caseAll aircraft: 174 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 airplane was in cruise flight at 7,000 feet mean sea level, when the engine began to run rough and the oil pressure decreased. The pilot was unable to fly the airplane to the nearest airport and performed a forced landing to a field. During the landing, the airplane struck a ditch and came to rest upright, which resulted in substantial damage to the empennage. An annual inspection was completed on the airplane about 5 months, or 25 flight hours, prior to the accident; however, the pilot had recently changed the engine oil himself. Initial examination of the engine revealed that the oil drain tube remained attached to the oil quick-release drain plug, and oil was leaking down the side of the oil drain tube likely as a result of the quick-release oil drain plug not being properly secured. A subsequent teardown examination of the engine revealed that the No. 5 connecting rod failed due to lack of lubrication.

Factual narrative

On September 19, 2010, about 1325 eastern daylight time, a Navion G, N2448T, owned and operated by an airline transport pilot (ATP), was substantially damaged during a forced landing to a field, following a loss of engine power in cruise flight near Dublin, Georgia. The certificated ATP incurred minor injuries and the passenger was not injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the planned flight to Cannon Creek Airpark (15FL), Lake City, Florida. The flight originated from Evansville Regional Airport (EVV), Evansville, Indiana. The pilot reported that the airplane was in cruise flight at 7,000 feet mean sea level, when the engine began to run rough and the oil pressure decreased. He informed air traffic control, and the controller provided a vector for the nearest suitable airport, W H "Bud" Barron Airport (DBN), Dublin, Georgia; however, the pilot was unable to fly the airplane to the airport. He subsequently performed a gear-up forced landing to a field, located about 6 miles southeast of DBN. During the landing, the airplane struck a ditch and came to rest upright, which resulted in substantial damage to the empennage. The pilot, age 78, held an ATP certificate with type ratings in multiple transport category airplanes. The pilot also held a mechanic certificate. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on July 1, 2009. The pilot reported a total flight experience of 18,763 hours; of which, 720 hours were in the same make and model as the accident airplane. The airplane was equipped with a Teledyne Continental Motors IO-520-BA, 285-horsepower engine. The airplane's most recent annual inspection was completed on April 8, 2010. At that time, the engine had accumulated about 469 hours since major overhaul. The airplane had flown about 25 hours from the time of the most recent annual inspection, until the accident. The pilot further stated that sometime after the annual inspection in April, but before a recent trip to Pennsylvania, he changed the oil in the accident airplane. He could not remember what date he changed the oil, and he forgot to record the oil change in the aircraft logbooks. An FAA inspector noted that the No. 5 cylinder was cracked at the base. He also observed no oil on the dipstick, but significant amounts of oil on the engine cowling. When the engine was recovered from the field, an oil drain tube remained attached to the oil quick-release drain plug, and oil was leaking down the side of the oil drain tube. The engine subsequently underwent a teardown examination at the manufacturer's facility, under the supervision of an NTSB investigator. The examination revealed several cracks in the engine case at the No. 5 cylinder base. The case was pushed out, consistent with impact from a loose connecting rod.Disassembly of the engine revealed evidence of thermal distress on the crankshaft at the No. 4 and No. 5 connecting rods, and evidence of lack of lubrication. Less than 2 quarts of oil were recovered from the 12-quart-capacity engine. The No. 5 connecting rod was fractured at the crankshaft attachment points and the attachment fittings were loose in the oil pan.

Aircraft

Registration
N2448T
Reported as
Navion Navion G
Category
Airplane
Serial number
NAV-4-2448
Airframe hours
3,357
Engine
Cont Motor IO-520, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
John B Gordon
Registered owner
John B Gordon
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 8, 2010 · 25 hours before
Departed
EVV · Evansville, IN
Destination
15FL · Lake City, FL
Flight plan
IFR

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
78
Injuries
Minor
Certificates
Commercial, Flight engineer, Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
October 12, 2009
Seat
Left
Flight hours
18,660 total · 721 in this make and model · 20 in the last 90 days · 14 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 64 °F
Altimeter
30.09 inHg
Observed at
DBN, 6 nm away

Docket · 9

The files NTSB released with the investigation on April 11, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.0 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.