# NTSB ERA22LA071: Cessna 210, N5779J, Brent, AL, November 21, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: November 21, 2021, 08:26 local (14:26 UTC) - Place: Brent, AL - Coordinates: 32.927481, -87.185179 - Nearby events: https://openairdocs.org/map.md?lat=32.9275&lon=-87.1852&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Cessna, Continental Engines - NTSB case key (mKey): 104288 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104288/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104288 - Page: https://openairdocs.org/ntsb/ERA22LA071 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Not inspected (probable cause); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073446), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073446), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Cessna 210K, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=2073446), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 210K, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073446), [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: [Cessna 210K, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073446), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N5779J), registered now, S/N 21059479, built 1971 (OpenAirDocs) - Reported make and model: CESSNA 210 (K) - Registry model: [Cessna 210K](https://openairdocs.org/model/cessna-210k) (registry code 2073446) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21059479 - Year built: 1971 - Airframe hours: 3631 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: minor; 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 ## 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 20211121019729A](https://openairdocs.org/incident/20211121019729A), Nov 21, 2021: Cessna 210K, Brent, AL, Substantial damage. Aircraft departed tuscaloosa regional airport (tcl) on an IFR flight plan enroute to sky park (18FD) airport in baker Florida. Enroute at 7000 feet the pilot… ## Docket (11 files) The files NTSB released with the investigation on September 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104288. 57.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13073326&FileExtension=pdf&FileName=ERA22LA071%20Signed%206120_Redacted-Rel.pdf - Pilot statements (item 2, PDF, 2 pages, 584 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13103208&FileExtension=pdf&FileName=Pilot%20Statements_Redacted-Rel.pdf - FAA inspector's statement (item 3, PDF, 1 page, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13103325&FileExtension=pdf&FileName=ERA22LA071%20NTSB%20MFR%20FAA%20Inspector_Redacted-Rel.pdf - Maintenance log excerpts (item 4, PDF, 12 pages, 46.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13103501&FileExtension=pdf&FileName=Maintenance%20Excerpts_Redacted%20Reduced-Rel.pdf - Service bulletin SB-001 rev b oil filter adapter gaskets (item 5, PDF, 11 pages, 905 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13103936&FileExtension=pdf&FileName=Stratus-SB-001_Rev-B-Rel.pdf - Investigation photographs (item 6, PDF, 6 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13102563&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Memorandum for record a�� wreckage examination (item 7, PDF, 7 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13103099&FileExtension=pdf&FileName=ERA22LA071%20Examination%20Summary-Rel.pdf - Engine data monitor (edm) - specialist's factual report (item 8, PDF, 9 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13073080&FileExtension=pdf&FileName=ERA22LA071%20JPI%20EDM%20Factual_final-Rel.pdf - Attachment 1 to engine data monitor (edm) - specialist's factual report (item 9, CSV, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13073282&FileExtension=csv&FileName=attachment1-Rel.csv - Statement of party representatives to NTSB investigation (item 10, PDF, 10 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13102364&FileExtension=pdf&FileName=Signed%20Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 2 pages, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13114448&FileExtension=pdf&FileName=Wreckage%20Release%20Package%20Signed_Redacted-Rel.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.