# NTSB LAX89LA233: Cessna P210N, N609AC, Los Angeles, CA, July 9, 1989

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: July 9, 1989, 11:33 local (18:33 UTC)
- Place: Los Angeles, CA
- Coordinates: 34.029121, -118.430541 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.0291&lon=-118.4305&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious, 1 minor
- Status: Completed, report July 22, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 26442
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX89LA233
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/26442/pdf
- Page: https://openairdocs.org/ntsb/LAX89LA233

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, cruise - normal
  - maintenance,installation - improper, pilot in command(cfi) (cause)
  - lubricating system,oil line - undertorqued (cause)
  - lubricating system,oil line - loose (cause)
  - fluid,oil - leak (cause)
- Loss of engine power(total) - mech failure/malf, approach - faf/outer marker to threshold (ifr)
  - fluid,oil - exhaustion (cause)
  - powerplant - failure,total (cause)
- Forced landing, descent - emergency
- In flight collision with terrain/water, landing

## 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](https://openairdocs.org/deregistered/N609AC-2013-08-08), registration cancelled 2013-08-08, S/N P21000609, built 1980 (OpenAirDocs)
- Reported make and model: CESSNA P210N
- Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs)
- Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: P21000609
- Airframe hours: 1058
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 43; 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 (OpenAirDocs).

- [Accident 19890709020999A](https://openairdocs.org/incident/19890709020999A), Jul 9, 1989: Cessna P210N, Santa Monica, CA, Destroyed. Lost oil pressure on dual IFR flight. Found oil cooler line b nuts loose.

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.

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