# NTSB LAX08LA292: Cessna T210N, N6278C, Oakland, CA, September 10, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 10, 2008, 13:50 local (20:50 UTC) - Place: Oakland, CA - Coordinates: 37.833332, -122.313331 - Nearby events: https://openairdocs.org/map.md?lat=37.8333&lon=-122.3133&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 29, 2009 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Adminstration - NTSB case key (mKey): 68915 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08LA292 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68915/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68915 - Page: https://openairdocs.org/ntsb/LAX08LA292 ## Probable cause A loss of engine power while maneuvering due to the disintegration of the number two main bearing, which resulted in a fracture of the crankshaft. Contributing to the accident was inadequate maintenance. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna T210N, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2073456), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Inadequate inspection (probable cause); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=2073456), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Not specified (probable cause); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=2073456), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Cessna T210N, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2073456), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna T210N, 9 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073456), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Cessna T210N, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=2073456), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## Analysis During a local photo flight at an altitude of 1,500 feet mean sea level (msl), the pilot reported a decrease in engine power followed by a complete loss of engine oil pressure. The pilot determined that due to his location and altitude, he was forced to make a landing on the water. During the landing, the airplane sustained substantial damage to the horizontal stabilizers and to the bottom of the fuselage. During the post-accident investigation, it was determined that the number two and three cylinders had been replaced 137.1 flight hours prior to the accident. During the engine examinations, thermal discoloration of the crankshaft main journals and damage to various other internal components were noted. The crankshaft was fractured just forward of the number two main bearing. The fracture surfaces of the crankshaft were mechanically damaged due to rotational forces. The number two main bearings were not found in the main bearing support diameters. Several bearing fragments were found in the oil sump and on the bearing support diameter. The crankcase itself had been compromised just above the number one cylinder. A review of the maintenance logbooks noted that the engine was beyond manufacturers' recommendations for time between overhaul. Several maintenance discrepancies and non-compliance with manufacturers' recommendations were also noted. ## Factual narrative HISTORY OF FLIGHT On September 10, 2008, about 1350 Pacific daylight time (PDT), a Cessna T210N, N6278C, ditched in the San Francisco Bay following a loss of engine power, about 1/4 mile north of the Oakland Bay Bridge, Oakland, California. Ja-Mar Industries, Inc., DBA Air Flight Services, was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and one passenger were not injured; the airplane sustained substantial damage to the tail and lower cowling area by impact forces. The local photo flight departed Reid-Hillview Airport of Santa Clara County (RHV), California, about 1320. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot reported that about 30 minutes after departing RHV, the engine started to lose power. He then noticed that there was no indicated oil pressure. He was flying about 1,500 feet mean sea level (msl) when the power loss occurred, and he decided the best place to land was on the water. Investigators examined the airplane after it was removed from the salt water. A hole was observed in the engine crankcase near the number two cylinder. The airplane was recovered for further investigation. AIRCRAFT INFORMATION The airplane was a Cessna T210N, serial number 21063853. A review of the airplane’s logbooks revealed that the airplane had a total airframe time of 8,147 hours at the last annual inspection. The logbooks contained an entry for an annual inspection dated June 1, 2008. The tachometer read 8010.7 at the last inspection; the tachometer read 8147.8 at the accident scene. The engine was a Teledyne Continental Motors TSIO-520-R, serial number 293904-R. The engine was installed on the airframe in September 1997. At the time of the accident, total time recorded since major overhaul was 2,866.8 hours. The manufacturer recommends 1,600 hours or 12 years between overhauls. The number two and three cylinders were replaced with serviceable items during the annual inspection on June 1, 2008. The total time since installation was 137.1 hours. TESTS AND RESEARCH Investigators examined the wreckage at Plain Parts, Sacramento, California, on September 17, 2008. Examination of the engine assembly revealed the following issues. The backbone area and associated hardware forward of the fuel manifold valve had a heavy coating of dark gray sealant. Fretting was found on the crankcase halves at the backbone area at the number five and six bolt attachments. The number three, five, and six cylinder bays were intact and undamaged. The number one, two, and four cylinder bays had mechanical damage. The number one cylinder bay had displaced material and a small hole from mechanical damage. All of the main bearing support mating surfaces exhibited rough surfaces and pitting from fretting. The number one main bearing support diameter had displaced material. The number two main bearing support lock-slot was elongated. The number two main bearing supportdiameter had displaced material and mechanical damage from bearing rotation and extrusion. The number two main bearings were not found in the main bearing support diameters. Several bearing fragments were found in the oil sump and on the bearing support diameter. The larger fragments had smearing of the surface babbit, exposing the copper layer. The number one and three main bearings had deformation, hard particle passage and smearing of the surface babbit, exposing the copper layer. The number four main bearing had gouges from hard particle passage, exposing the copper layer. The number five main bearing had normal wear. There were no signs of lubrication distress on any of the main bearings. The crankshaft separated into two sections between the number two connecting rod journal and the main bearing journal. The fracture surfaces of the crankshaft cheek had displaced material and thermal discoloration. ADDITIONAL INFORMATION A detailed review of the maintenance logbooks by the Federal Aviation Administration inspector participating in the investigation reported noting several discrepancies and non-compliance with manufacturers' recommendations throughout several inspections. ## Aircraft - Registration: [N6278C](https://openairdocs.org/deregistered/N6278C-2009-07-23), registration cancelled 2009-07-23, S/N 21063853, built 1979 (OpenAirDocs) - Reported make and model: CESSNA T210N - Registry model: [Cessna T210N](https://openairdocs.org/model/cessna-t210n) (registry code 2073456) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21063853 - Airframe hours: 8147 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Ja Mar Industries Inc DBA, doing business as Air Flight Service - Registered owner: Ja Mar Industries Inc DBA - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2008, 137 hours before - Departed: RHV, SAN JOSE, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review June 15, 2007; seat: left; flight hours: 2,300 total, 200 in this make and model, 2,300 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 54 °F - Altimeter: 29.84 inHg - Observed at: OAK, 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 20080910845549A](https://openairdocs.org/incident/20080910845549A), Sep 10, 2008: Cessna T210N, Oakland, CA, Substantial damage. (-23) The aircraft was flying around the bay area doing aerial photography. The pilot reported oil pressure loss and the engines suddenly went quiet at 1,500… ## Docket (6 files) The files NTSB released with the investigation on October 26, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68915. 5.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320228&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector On-Scene Accident Report (item 2, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320229&FileExtension=.PDF&FileName=FAA%20Inspector%20On-Scene%20Accident%20Report-Redacted.PDF - TCM Final Report (item 3, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320230&FileExtension=.PDF&FileName=TCM%20Final%20Report-Redacted.PDF - Annual Maintenance Entries (item 4, .PDF, 418 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320231&FileExtension=.PDF&FileName=Annual%20Maintenance%20Entries-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320545&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 807 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320233&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.