LAX01LA045

NTSB accident investigation · Collette Glassair III · Guistine, CA · November 19, 2000

Accident · Serious injuriesLimited investigationFinal report
Date
November 19, 2000, 12:00 local (20:00 UTC)
Place
Guistine, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N540AKCollette Glassair III
Weather
Visual (VMC) · Day
Status
Completed · report October 24, 2002
Report
Approved by Office Director
Parties
FAA-WP-FSDO, TEXTRON LYCOMING
FAA report
20001119032839A
Case key
50654

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

Maintenance personnel misrouted the crankcase breather hose so that it was pinched when the cowling was installed. This pressurized the crankcase displacing the oil seal and forcing oil out of the engine. A factor was the unsuitable terrain encountered during the forced landing.

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.

Airframe/component/system failure/malfunctionCruise
Maintenance,installation - improperOther maintenance personnelCause
Engine assembly,other - misroutedCause
Engine assembly,other - flow restrictedCause
Engine assembly,crankcase - pressure excessive
Lubricating system,oil seal - disengaged
Forced landingEmergency descent/landing
Emergency procedure - initiatedPilot in command
OverrunLanding - roll
Unsuitable terrain or takeoff/landing/taxi area - encounteredPilot in commandFactor
Terrain condition - grass
Nose overLanding - roll
Terrain condition - ravine

Analysis

The airplane nosed over during a forced landing after the pilot encountered smoke in the cockpit. Oil was spewing onto the windshield, the engine was losing oil pressure, and smoke was filling the cockpit. The pilot made an emergency landing on an abandoned dirt strip that was about 1,400 feet long. However, the airplane overran the runway into a ravine and overturned. Maintenance that had been completed the day before the accident included an oil change and replacement of the crankshaft nose seal; a run-up had revealed no oil leaks. The engine sustained no visible damage resulting from the forced landing, and visual examination revealed no evidence of catastrophic mechanical malfunction or fire. A significant amount of engine oil emanated from the nose cowling where the engine and propeller flange protruded. The oil film proceeded aft onto the windscreen as well as the horizontal and vertical stabilizers. The spark plugs, cylinder walls, valves, and pistons exhibited no mechanical damage. Oil lines within the engine compartment were secure on their fittings. The propeller governor was secure and not leaking. The oil filter and oil filter converter plate were properly installed and secure. There were no visible contaminates in the oil filter or suction screen. The propeller was removed, but there was no evidence of oil leakage at the propeller seal. The crankshaft oil seal was out of its bore and resting on the crankshaft. One oil ring was cracked, but no compression rings were broken. There was evidence of overheating from running lean. The breather hose had been mounted over the motor mount rather than under it. In this location the hose was pinched when the cowling was installed. This plugged the breather hose and pressurized the case, forcing oil out through the front seal.

Factual narrative

On November 19, 2000, about 1200 Pacific standard time, a Collette Glassair III, N540AK, nosed over about 13 miles west of Guistine, California, during a forced landing after the pilot encountered smoke in the cockpit. The private pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The pilot, the sole occupant, sustained serious injuries; the airplane sustained substantial damage. The personal flight departed Guistine about 1135 en route to the Reid-Hillview Airport in San Jose, California. Visual meteorological conditions prevailed and no flight plan had been filed. The accident site was an abandoned grass strip at 31 degrees 13.73 minutes north latitude and 121 degrees 22.45 minutes west longitude.

The pilot and a friend in another airplane departed Reid-Hillview earlier in the morning and flew to Guistine. The pilot stated they refueled at Guistine and the friend was the first to depart. The accident pilot said that oil was spewing onto his windshield, he was losing oil pressure, and smoke was filling the cockpit. He made an emergency landing on an abandoned dirt strip that was about 1,400 feet long. However, the airplane overran the runway into a ravine and overturned.

The witness reversed course and saw smoke in the distance, but could not keep sight of the airplane all the way to the ground because of haze.

The pilot said a mechanic completed maintenance the day before the accident, which included an oil change and replacement of the crankshaft nose seal. A post maintenance run-up revealed no oil leaks.

A representative from Textron Lycoming examined the engine under the supervision of the Federal Aviation Administration and submitted a written report. The engine sustained no visible damage resulting from the forced landing. Visual examination revealed no evidence of catastrophic mechanical malfunction or fire. He observed a significant amount of engine oil emanating from the nose cowling where the engine and propeller flange protruded. The oil film proceeded aft onto the windscreen as well as the horizontal and vertical stabilizers.

The Lycoming representative examined the spark plugs. He did not observe any mechanical damage, and their color indicated normal operation according to the Champion Spark Plugs Check-A-Plug chart AV-27. He examined the cylinders' combustion chambers with a lighted borescope. The cylinder walls, valves, and pistons exhibited no mechanical damage. Oil lines within the engine compartment were secure on their fittings. The propeller governor was secure and not leaking. The oil filter and oil filter converter plate were properly installed and secure. There were no visible contaminates in the oil filter or suction screen.

The crankshaft oil seal was out of its bore and resting on the crankshaft. The Lycoming investigator removed the propeller, but did not observe evidence of oil leakage at the propeller seal. Further investigation was terminated until the owner disassembled the engine to comply with a sudden stoppage inspection.

The owner had the engine overhauled. He reported that one oil ring was cracked, but no compression rings were broken. There was evidence of overheating from running lean. He discovered that the breather hose had been mounted over the motor mount rather than under it. In this location the hose was pinched when the cowling was installed. The owner said this plugged the breather hose and pressurized the case. He thought this pressure would force the oil out through the front seal.

Aircraft

Registration
N540AK
Reported as
Collette Glassair III (GLASSAIR I)
Category
Airplane, amateur-built
Serial number
3077
Airframe hours
700
Engine
Lycoming IO540-K1G5D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Michael K. Snow
Airworthiness certificate
Special, Experimental (Special)
Last inspection
100 hour · November 18, 2000 · 2 hours before
Departed
3O1 · Guistine, CA
Destination
RHV · San Jose, CA

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
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
June 18, 2000
Seat
Left
Flight hours
2,300 total · 700 in this make and model · 2,300 as pilot in command · 30 in the last 90 days · 10 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
RHV, 22 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.