# NTSB ERA14LA436: Bellanca 17-30A, N6648V, Monroe, GA, September 14, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 13, 2014, 21:30 local (Sep 14, 2014, 01:30 UTC) - Place: Monroe, GA - Coordinates: 33.783332, -83.690002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.7833&lon=-83.6900&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report March 26, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors - NTSB case key (mKey): 90072 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA436 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90072/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90072 - Page: https://openairdocs.org/ntsb/ERA14LA436 ## Probable cause The improper installation of the oil filter adapter at an unknown time, which resulted in an oil leak and subsequent oil starvation to the engine. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Bellanca 17-30A, 3 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1220433), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/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: [Bellanca 17-30A, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=1220433), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot; cases with it: [Bellanca 17-30A, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1220433), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid type; cases with it: [Bellanca 17-30A, 12 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=1220433), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Record-keeping: aircraft/maintenance logs](https://openairdocs.org/ntsb-findings/02062515): Personnel issues › Task performance · Pilot; cases with it: [Bellanca 17-30A, 1 case](https://openairdocs.org/ntsb-findings/02062515/cases.md?model=1220433), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/02062515/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Bellanca 17-30A, 2 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1220433), [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. - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Bellanca 17-30A, 15 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1220433), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Bellanca 17-30A, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1220433), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bellanca 17-30A, 21 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1220433), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During the approach at night, the airplane experienced a total loss of engine power, and the pilot performed a forced landing into trees. Subsequent examination of the engine revealed that the oil filter adapter was loose and that it was installed incorrectly with two copper crush gaskets rather than with one copper crush gasket and one fiber gasket per the manufacturer's installation instructions. The fiber gasket would have held the required torque for the fitting; however, the copper crush gasket did not hold the required torque. Because the oil filter adapter was loose, oil leaked from the engine, which led to the failure of the Nos. 4 and 5 connecting rods due to a lack of oil lubrication. The oil filter adapter was not original equipment on the engine. Although it could be installed under a supplemental type certificate, a review of maintenance and aircraft records did not reveal any entry or record pertaining to the installation of the oil filter adapter. The airplane had been operated for about 70 hours since its most recent annual inspection, which was performed about 1 year before the accident. It could not be determined when the oil filter adapter was incorrectly installed. Although the pilot stated that he had fueled the airplane with 100 low-lead aviation gasoline, automobile gasoline was recovered from the fuel tanks. The higher-compression ratio engine was not designed or approved to operate on automobile gasoline, and engine examinations revealed that it had been operating at higher temperatures due to the use of automobile gasoline. If the engine had not failed due to oil starvation, it is likely that it would have soon begun to detonate due to the use of the improper fuel. ## Factual narrative On September 13, 2014, about 2130 eastern daylight time, a Bellanca 17-30A, N6648V, operated by a private individual, was substantially damaged during a forced landing into trees, following a total loss of engine power during approach near Monroe, Georgia. The private pilot and passenger were seriously injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Night visual meteorological conditions prevailed for the flight that departed Dallas Bay Sky Park (1A0), Chattanooga, Tennessee, about 1940. No flight plan was filed for the planned flight to Greene County Airport (3J7), Greensboro, Georgia. The pilot reported that prior to the accident flight, he completed a preflight inspection of the airplane, which included adding 100 low-lead aviation gasoline to the left and right wing fuel tanks. He had anticipated fog at his destination airport and planned for a potential diversion to several alternate airports. He subsequently diverted to Monroe-Walton County Airport (D73), Monroe, Georgia. About 3 miles from D73, the pilot heard a "bang" as the engine began to run rough and catch fire. He then pulled the mixture lever back and moved the fuel selector to off. He also dove the airplane until the fire was out. The pilot set up for a forced landing and attempted to glide to D73, but the airplane impacted trees about 1 mile from the airport. The four-seat, low-wing, retractable-gear airplane, serial number 30301, was manufactured in 1970. It was powered by Continental Motors IO-520, 300-horsepower engine with a compression ratio of 8.5 to 1. The engine was equipped with a McCauley three-blade, constant-speed propeller. According to the aircraft logbooks, the airplane's most recent annual inspection was completed on September 21, 2013. At that time, the airplane had accumulated 2,969 total hours of operation. The engine had accumulated 1,798 hours since it was remanufactured in 1974. The airplane had flown about 68 hours from the time of the most recent annual inspection, until the accident. The pilot purchased the airplane on November 20, 2013. The engine was equipped with an F&M Enterprises Inc. (model C6LC) oil filter adapter. The oil filter adapter was not original equipment, but could be installed on the engine under Federal Aviation Administration (FAA) Supplemental Type Certificate (STC) number DE09356SC; however, review of the engine logbook did not reveal any record of the oil filter adapter installation. Further review of FAA airworthiness records for the accident airplane did not reveal any record of the installation being filed with the FAA. Review of the oil filter adapter manufacturer's installation instructions revealed that one fiber gasket and one copper crush gasket were to be used in the installation. Initial examination of the engine revealed a hole near the top front of the case. The wreckage was recovered to a salvage facility for further examination by a representative from theengine manufacturer, under the supervision of an FAA inspector. The examination revealed that the Nos. 4 and 5 connecting rods had separated and exhibited heat damage due to a lack of lubrication. Further examination revealed that the oil filter adapter was loose and had been installed using two copper crush gaskets, rather than one copper crush gasket and one fiber gasket per the installation instructions. Additionally, automobile gasoline was recovered from the fuel tanks, which was not approved for that model engine. Examination of the Nos. 1 and 2 cylinders revealed little to no combustion deposits, consistent with higher operating temperatures of automobile gasoline in that engine. ## Aircraft - Registration: [N6648V](https://openairdocs.org/deregistered/N6648V-2018-03-15), registration cancelled 2018-03-15, S/N 30301, built 1970 (OpenAirDocs) - Reported make and model: BELLANCA 17-30A - Registry model: [Bellanca 17-30A](https://openairdocs.org/model/bellanca-17-30a) (registry code 1220433) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 30301 - Year built: 1970 - Airframe hours: 2969 - Engines: CONT MOTOR IO-520 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Bailey Jason L - Registered owner: Bailey Jason L - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 21, 2013, 68 hours before - Departed: 1A0, Chattanooga, TN - Destination: 3J7, Greensboro, GA - Equipment: Handheld GPS, Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 30; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 487 total, 68 in this make and model, 308 as pilot in command, 25 in the last 90 days, 9 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Temperature: 75 °F, dew point 75 °F - Altimeter: 30.12 inHg - Observed at: CVC, 8 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 20140913021689A](https://openairdocs.org/incident/20140913021689A), Sep 13, 2014: Bellanca 17-30A, Monroe, GA, Substantial damage. On September 13, 2014 at about 1945, N6648V,a Bellanca viking 17-30A, piloted by [privacy data omitted], with one female passenger, [privacy data omitted] and… ## Docket (7 files) The files NTSB released with the investigation on February 25, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90072. 6.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422833&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Excerpt From Engine Logbook (item 2, .PDF, 608 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422834&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Manufacturer Report of Engine Examination (item 3, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422835&FileExtension=.PDF&FileName=Manufacturer%20Report%20of%20Engine%20Examination-Redacted.PDF - Oil Filter Adapter Installation Instructions (item 4, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422836&FileExtension=.PDF&FileName=Oil%20Filter%20Adapter%20Installation%20Instructions-Master.PDF - FAA STC # SE09356SC (item 5, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422837&FileExtension=.PDF&FileName=FAA%20STC%20%23%20SE09356SC-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422838&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1 – Main Wreckage (Photo Courtesy of FAA) (item 7, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40422839&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-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.