# NTSB ERA10LA487: Navion Navion G, N2448T, Dublin, GA, September 19, 2010 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: September 19, 2010, 13:25 local (17:25 UTC) - Place: Dublin, GA - Coordinates: 32.564445, -82.985275 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5644&lon=-82.9853&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report June 13, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors, FAA/FSDO - NTSB case key (mKey): 77337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA487 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77337/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77337 - Page: https://openairdocs.org/ntsb/ERA10LA487 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Navion NAVION G, 3 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=6150120), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Navion NAVION G, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=6150120), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Navion NAVION G, 2 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=6150120), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Navion NAVION G, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=6150120), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Navion NAVION G, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6150120), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N2448T), registered now, S/N NAV-4-2448, built 1962 (OpenAirDocs) - Reported make and model: NAVION NAVION G - Registry model: [Navion NAVION G](https://openairdocs.org/model/navion-navion-g) (registry code 6150120) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-2448 - Airframe hours: 3357 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: minor; 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 ## 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 20100919048209A](https://openairdocs.org/incident/20100919048209A), Sep 19, 2010: Navion NAVION G, East Dublin, GA, Substantial damage. During cruise flight, the pilot heard a surge in the engine noise, and noticed engine oil pressure dropping to the redline; the engine experienced a loss of… ## Docket (9 files) The files NTSB released with the investigation on April 11, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77337. 13.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 6.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40345003&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Interview Summaries (item 2, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344418&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Excerpt From Airframe Logbook (item 3, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344420&FileExtension=.PDF&FileName=Excerpt%20From%20Airframe%20Logbook-Redacted.PDF - Excerpt From Engine Logbook (item 4, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344421&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Evidence Control Form (item 5, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344431&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344428&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1: Oil Drain Tube (Photo Courtesy of FAA) (item 7, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344423&FileExtension=.PDF&FileName=Photo%201%3A%20%20Oil%20Drain%20Tube%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2: Engine With Crack at No. 5 Cylinder Base (item 8, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344424&FileExtension=.PDF&FileName=Photo%202%3A%20%20Engine%20With%20Crack%20at%20No.%205%20Cylinder%20Base-Master.PDF - Photo 3: No. 5 Piston And Connecting Rod (item 9, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344426&FileExtension=.PDF&FileName=Photo%203%3A%20%20No.%205%20Piston%20And%20Connecting%20Rod-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. --- 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.