ERA22LA071

NTSB accident investigation · Cessna 210 · Brent, AL · November 21, 2021

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
November 21, 2021, 08:26 local (14:26 UTC)
Place
Brent, AL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5779JCessna 210
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Cessna, Continental Engines
FAA report
20211121019729A
Case key
104288

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 inadequate maintenance of the oil filter adapter, which resulted in in an engine oil leak and subsequent loss engine oil pressure, and the subsequent off-airport landing.

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.

Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Not inspectedCessna 210K: 1 caseAll aircraft: 130 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Not serviced/maintainedCessna 210K: 1 caseAll aircraft: 130 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

During cruise flight, the pilot noticed a drop in engine oil pressure and turned toward the closest airport. The pilot subsequently elected to perform a precautionary off-airport landing during which the airplane sustained substantial damage. A postaccident examination of the engine revealed that it was equipped with a screw-on oil filter adapter. Oil seepage was found on the area surrounding the oil filter adapter attachment point, in the engine compartment, and on the underside of the fuselage. Examination of the adapter found its tightening torque to be 38.5 ft-lbs, which was below the prescribed installation torque of 65 ft-lbs. Additionally, the adapter was found installed with the originally specified fiber gasket, which the manufacturer had subsequently advised to remove and replace with a copper gasket in a mandatory service bulletin. The fiber gasket was found torn and indented. It is likely that the loose adapter and the torn fiber gasket allowed the engine oil to be pumped overboard. This ultimately resulted in the loss of oil pressure and the pilot’s decision to perform the precautionary off-airport landing. It is likely that had the mandatory service bulletin been complied with, the loss of oil pressure would not have occurred.

Factual narrative

On November 21, 2021, at 0826 central standard time, a Cessna 210 airplane, N5779J, was substantially damaged when it was involved in an accident near Brent, Alabama. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. While on an instrument flight rules flight plan, and during cruise flight about 14 minutes after takeoff from Tuscaloosa Regional Airport (TCL), Tuscaloosa, Alabama, the airplane’s flight system monitor annunciated “check oil pressure.” The pilot checked his instruments and noted that the oil pressure indicated 0 psi. The pilot declared an emergency and established best glide speed, then navigated toward the closest airport. The pilot was cleared to descend and air traffic control inquired whether the plot would be able to reach the diversion airport. Given the circumstances, the pilot decided it was prudent to land immediately. During the descent the pilot descended out of the cloud cover and selected a road for a forced landing site. After touchdown, the airplane’s right wing collided with several road signs before the airplane impacted a ditch and several trees, coming to rest upright in a nose-down attitude. Postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the fuselage, firewall, and both wings sustained substantial damage and the tail cone exhibited compression wrinkling forward of the vertical stabilizer. The front windscreen was broken. The left-wing fuel tank was breached with no fuel remaining. The right-wing fuel tank remained intact and contained fuel. Data downloaded from the JPI EDM-830 engine data monitoring device revealed normal engine operation until 0818 when the oil pressure began to drop. Shortly thereafter the manifold pressure decreased and there was a corresponding reduction in recorded values for most other engine parameters. Around this time, recorded GPS data showed the aircraft began to descend from 7,000 ft mean sea level. The data ended at 0826. Examination of the engine revealed that it was equipped with an F&M screw-on oil filter adapter. Oil was observed on the lower area of the oil adapter fiber gasket seal (see figure 1), in the engine compartment and on the underside of the fuselage. The oil filter adapter installation was tested using a digital torque wrench. The tightening torque was measured at 38.5 ft-lbs. The loosening torque (breakaway torque) measured was 34.0 ft-lbs. Per the Stratus Tools Technologies mandatory service bulletin (SB) SB-001Rev B, revised June 17, 2021(originally issued October 25, 2019), the oil adapter transfer cylinder was to be tightened to 65 ft-lbs during installation. Upon removal of the oil filter adapter, examination revealed a fiber gasket between the airplane’s engine oil pump assembly and the oil filter adapter was torn and indented (see figure 2). Figure 1: Oil around oil adapter fiber gasket seal. Figure 2: Torn, indentedfiber gasket. The revised SB also required the removal of the fiber gasket (if installed) and replacement with a copper gasket, as well as inspection of the adapter for security, leaks, seepage, or gasket damage “within the next 10 flight hours, annual inspection, or 100-hour inspection, whichever occurs first.” The SB further stated that the use of fiber gaskets had been discontinued and that “only copper gaskets are approved for initial installation or reinstallation of F&M or Stratus Tool Technologies oil filter adapters.” A review of the airplane’s maintenance records found no entries that specifically addressed the SB. The most recent entry related to the adapter was in May 2015 when the adapter was removed, and the “gasket and crush washer” were replaced. During a postaccident interview, the pilot stated that he had not experienced any anomalies or malfunctions of the airplane prior to the loss of oil pressure. He also stated that he had read about the issue with the oil filter adapter a few weeks before the accident. Given that, “it had lasted this long,” he did not believe his installation was at issue.

Aircraft

Registration
N5779J
Reported as
Cessna 210 (K)
Category
Airplane
Serial number
21059479
Built
1971
Airframe hours
3,631
Engine
Cont Motor IO 520 L14B, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Beavers Air LLC
Registered owner
Beavers Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 3, 2021 · 9.5 hours before
Departed
TCL · Tuscaloosa, AL
Destination
18FD · Baker, FL
Flight plan
IFR
Equipment
Onboard weather, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Electronic primary flight display

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
74
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
May 7, 2020
Seat
Left
Restraint
3-point
Flight hours
2,560 total · 1,092 in this make and model · 2,474 as pilot in command · 32 in the last 90 days · 16 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
3,200 ft broken
Temperature
52 °F, dew point 45 °F
Altimeter
30.27 inHg
Turbulence
Unknown
Observed at
TCL, 25 nm away
METAR
KTCL 211353Z 00000KT 10SM BKN032 11/07 A3027 RMK AO2 SLP249 T01060067

Docket · 11

The files NTSB released with the investigation on September 7, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 57.6 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.