LAX89LA233

NTSB accident investigation · Cessna P210N · Los Angeles, CA · July 9, 1989

Accident · Serious injuriesLimited investigationFinal report
Date
July 9, 1989, 11:33 local (18:33 UTC)
Place
Los Angeles, CA
Injuries
1 serious, 1 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N609ACCessna P210N
Weather
Visual (VMC) · Day
Status
Completed · report July 22, 1992
Report
Approved by Office Director
FAA report
19890709020999A
Case key
26442

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

An undertorqued oil line fitting, due to its improper installation by maintenance personnel, which resulted in a loose oil line fitting, an oil line leak, oil exhaustion, and subsequent failure of the engine.

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 - normal
Maintenance,installation - improperPilot in command(cfi)Cause
Lubricating system,oil line - undertorquedCause
Lubricating system,oil line - looseCause
Fluid,oil - leakCause
Loss of engine power(total) - mech failure/malfApproach - faf/outer marker to threshold (ifr)
Fluid,oil - exhaustionCause
Powerplant - failure,totalCause
Forced landingDescent - emergency
In flight collision with terrain/waterLanding

Analysis

On the first flt after the acft's annual inspection following replacement of all oil lines, the CFI planned to give the acft's owner/plt a bfr. Five min after takeoff, the crew observed that the oil pressure gage indicated near zero lbs of pressure. The CFI monitored the oil temp gage & the temp was in the green arc. The crew alerted ATC of the situation & rec'd an IFR clearance back to the arpt. During the next 14 min, the oil pressure needle remained slightly above red line, the oil temp remained stable & in the green arc. The acft passed the final approach fix & continued to operate normally. Suddenly, all eng pwr was lost. The CFI made a forced ldg on a golf course 3 mi fm the arpt. Exam of the eng revealed internal heat distress & broken conn rods. Further exam revealed a 'b' nut on a newly installed oil line had not been securely torqued & had come loose at its eng case attachment fitting. The oil line was found saturated with oil.

Aircraft

Registration
N609AC
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000609
Airframe hours
1,058
Engine
Continental TSIO-520-P, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
Parvez Gondal, M.D.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 1989 · 1 hours before
Departed
SMO · Santa Monica, CA
Flight plan
IFR

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
43
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
5,700 total · 500 in this make and model · 10 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 5 knots
Visibility
7 statute miles
Lowest ceiling
1,200 ft broken
Temperature
73 °F, dew point 63 °F
Altimeter
29.00 inHg
Observed at
SMO, 3 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.