FTW04FA057

NTSB accident investigation · Cessna 182RG · El Dorado, AR · January 6, 2004

Accident · FatalField investigationFinal report
Date
January 5, 2004, 18:25 local (Jan 6, 2004, 00:25 UTC)
Place
El Dorado, AR
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9318RCessna 182RG
Weather
Visual (VMC) · Night
Status
Completed · report September 1, 2004
Report
Approved by Office Director
Parties
Cessna Aircraft Company, FAA Flight Standards District Office, Teledyne Continental Motors, Inc., Lycoming Engines
FAA report
20040105001179A
Case key
58579

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The loss of engine power as a result of loss of engine oil due to the failure of the oil filter converter plate gasket and the noncompliance to an airworthiness directive. Contributing factors were the lack of suitable terrain for the forced landing and the dark night lighting conditions.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise - normal
Lubricating system,oil gasket - failure,partialCause
Maintenance,compliance with ad - not complied withCause
Lubricating system,oil gasket - leakCause
Engine assembly,connecting rod - failure,total
Forced landingDescent - emergency
In flight collision with objectEmergency descent/landing
Object - tree(s)
Object - fence
Object - fence post
Terrain condition - none suitableFactor
Light condition - dark nightFactor

Analysis

The 1,643.4-hour pilot reported that during cruise flight on a dark night, he saw "sparks under the cowling in front, and lost cylinders one, two, and three, according to the engine monitoring unit installed in the airplane." The pilot attempted to return to the airport, but the engine lost power, and he initiated a forced landing to a field with the flaps and gear retracted. Examination of the airplane revealed visible signs of oil streaks were observed throughout the entire length of the bottom of the fuselage. Flight control continuity was established throughout the airplane at the accident site. Examination of the engine revealed that the oil filter converter plate gasket was extruded in multiple locations. An Emergency Airworthiness Directive (AD) had previously been issued requiring the replacement of the oil filter converter plate gasket, but no entries were found in the airplane maintenance log books pertaining to its compliance.

Factual narrative

History of flight

On January 5, 2004, approximately 1825 central standard time, a Cessna 182RG, single-engine airplane, N9318R, sustained substantial damage during a forced landing following a loss of engine power near El Dorado, Arkansas. The non-instrument rated private pilot sustained serious injuries, and the passenger was fatally injured. The airplane was registered to and operated by the pilot. Night visual meteorological conditions prevailed, and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The cross-country flight originated from South Arkansas Regional Airport at Goodwin Field (ELD) near El Dorado, Arkansas, approximately 1815, and was destined for the Memphis International Airport (MEM), near Memphis, Tennessee.

According to local authorities, the pilot reported that during cruise flight at 3,000 feet mean sea level (msl), he saw "sparks under the cowling in front, and lost cylinders one, two, and three, according to the engine monitoring unit installed in the airplane." The pilot added that he attempted to return to ELD, but the engine lost total power, and he initiated a forced landing to a field with landing gear retracted.

During a telephone interview with the NTSB investigator-in-charge (IIC), the pilot stated that on the day of the accident, approximately 1630, he attempted to start the airplane's engine, but was unable to get it started. The pilot then plugged-in an engine heater, and went away for more than a hour. After he returned, the engine started without any problems; however, by the time the pilot departed ELD, it was getting very dark.

After departure and approximately 19 miles from the airport, while at a cruise altitude of 3,000 feet msl, he heard "a very loud bang, followed by another loud bang." When he was attempting to look for a place to land, the engine "seized up." He saw sparks from the engine, and smoke had filled the cabin area. The cockpit doors were partially opened to ventilate the smoke, and with the evening darkness, the pilot could barely see the landing area. He further stated that he was unable to see any of the obstacles that the airplane struck before impacting the ground.

A witness located near the accident site reported to local authorities that she observed an airplane circling above her house until it descended below a tree line. Moments later, she heard a boom, and what she thought was the airplane crash.

Personel information

A review of Federal Aviation Administration (FAA) airmen records revealed the pilot held a private pilot certificate with an airplane single-engine land rating, issued on April 10, 1995, and was issued a third-class medical certificate on April 22, 2002, with two restrictions: "Must have available glasses for near vision. Not valid for any class after April 30, 2004."

A review of the pilot's logbook indicated a total flight time of 1,643.4 hours, as of the last entry on November 5, 2003. A "Daily Flight Record" was found inside the airplane, which included flights between November 5, 2003 and December 31, 2003, that amounted to an additional 41.9 hours.

Aircraft information

The 1979-model Cessna 182RG airplane, serial number R18200688, was a high wing, semimonocoque design airplane, with a retractable landing gear, configured to carry a maximum of four occupants. The airplane was powered by a normally aspirated, direct drive, air-cooled, horizontally opposed, carbureted, six-cylinder Textron-Lycoming O-540-J3C5D engine, serial number L-23505-40A, rated at 235 horsepower.

The airplane's maintenance records that were provided to the FAA and reviewed by the NTSB IIC, revealed the engine was overhauled by a factory authorized repair station to manufacturer's new part limits, including all applicable airworthiness directives, on April 25, 2000. The engine was then installed on the accident airplane on June 1, 2000, during an annual inspection that included an oil change, with 2,835.4 hours time-in-service and 0 hours since major overhaul (SMOH). On November 11, 2000, the engine oil was changed at time since overhaul (TSOH) of 29.9 hours. On February 10, 2001, the engine oil was changed at TSOH of 59.1 hours. An annual inspection was performed including an oil change on July 18, 2001, at TSOH of 64.1 hours, with time-in-service of 2,916.2 hours and tachometer meter time of 2,916.2 hours. An annual inspection was performed including an oil change on January 21, 2002, at TSOH of 128.9 hours, with time-in-service of 2,981.0 hours and tachometer meter time of 2,981.0 hours. On February 15, 2003, the airplane underwent its most recent annual inspection including an oil change at TSOH of 225.6 hours, with time-in-service of 3,077.7 hours and tachometer meter time of 3,077.7 hours. On June 10, 2003, the engine oil was changed at tachometer meter time of 3,118.9 hours. On September 29, 2003, the engine oil was changed at tachometer meter time of 3,196.7 hours. On November 4, 2003, the engine oil was changed at tachometer meter time of 3,246.5 hours. The most recent engine oil change was on December 23, 2003, at tachometer meter time of 3,277.6 hours. At the time of the accident, records indicated the engine had accumulated 438.6 hours SMOH.

On July 24, 2000, Mandatory Service Bulletin (SB) 543 was issued by the engine manufacturer for engine models TIO-540-J2BD and LTIO-540-J2BD for an oil filter base seal inspection because of "reports indicating that the seal on the oil filter base can become extruded from its seat, allowing oil to leak out between the base and the accessory housing." This SB was not applicable to model O-540-J3C5D.

On August 30, 2000, Mandatory Service Bulletin 543A was issued by the engine manufacturer that required the replacement of the oil filter converter plate gasket before further flight and at each 50 hour oil change thereafter. The SB was issued because of "reports indicating that operation at high temperatures can cause the converter plate gasket on the oil filter base to become extruded from its seat, allowing oil to leak out between the plate and the accessory housing." This bulletin listed many affected engine models, including model O-540-J3C5D.

On September 5, 2000, Emergency Airworthiness Directive (AD) 2000-18-53 was issued by the FAA. Differences between the AD and SB543A being "only engines with more than 50 hours time since new (TSN), time since overhaul (TSO), or time since last replacement of the oil filter converter plate or gasket must have the gasket replaced before further flight." This AD was "to prevent complete loss of engine oil and subsequent seizing of the engine, and possibility of fire." The AD also included the model O-540-J3C5D engine.

On October 4, 2000, Supplement Number 1 to Mandatory Service Bulletin 543A was issued by the engine manufacturer that provided an alternate means of compliance to the affective engine models only if:

1. They were shipped from the factory between April 1, 1999, and October 4, 2000.

2. They have had the oil filter converter plate gasket field replaced after April 1, 1999, with part number (P/N) LW-13388.

3. They have had the oil filter converter plate field replaced after April 1, 1999, with P/N LW-13904.

The FAA published a Notice of Proposed Rulemaking (NPRM) for Airworthiness Directive (AD) 2002-12-07, as an amendment to supersede AD 2000-18-53. The amendment required "the same replacements and inspections, and introduced the installation of an improved design gasket or converter plate kit as terminating action for the repetitive gasket replacements." The effective date was July 3, 2002, with comments for inclusion in the Rules Docket being received on or before August 19, 2002.

On July 1, 2003, Mandatory Service Bulletin 543B (Supersedes SB 543A and Supplement No. 1 to SB 543A) was issued by the engine manufacturer for the replacement of the oi

Aircraft

Registration
N9318R
Reported as
Cessna 182RG
Category
Airplane
Serial number
R18200688
Airframe hours
3,290.7
Engine
Lycoming O-540-J3C5B, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 15, 2003 · 438.6 hours before
Departed
ELD · El Dorado, AR
Destination
MEM · Memphis, TN
Airport
ELD · South Arkansas Regional

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
49
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
1,643 total

Weather

Conditions
Visual (VMC) · Night
Wind
20° at 7 knots
Visibility
10 statute miles
Lowest ceiling
3,300 ft
Temperature
36 °F, dew point 25 °F
Altimeter
30.38 inHg
Observed at
ELD, 11 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.