# NTSB LAX91LA200: Cessna T-337-D, N2688S, Fullerton, CA, May 5, 1991

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: May 5, 1991, 12:15 local (19:15 UTC)
- Place: Fullerton, CA
- Location: 33.8720° N, 117.9798° W: Placed by OpenAirDocs at FULLERTON MUNI (FUL), within about a mile (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=33.8720&lon=-117.9798&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report July 14, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27196
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX91LA200
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27196/pdf
- Page: https://openairdocs.org/ntsb/LAX91LA200

## Probable cause

THE LOSS OF POWER IN THE FRONT ENGINE DUE TO THE IMPROPER AND INCOMPLETE INSTALLATION OF THE ENGINE IN THE AIRCRAFT BY A MECHANIC.

## Sequence of events

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

- Loss of engine power(total) - mech failure/malf, takeoff
  - 1 engine
  - engine installation - improper (cause)
  - fuel injection control/system - pressure excessive (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - maintenance,calibration - improper, other maintenance personnel (cause)
- On ground/water collision with object, landing - roll
  - object - fence
  - remedial action - not possible, pilot in command
- Forced landing, descent - emergency
- Overrun, landing - roll

## Analysis

THE AIRCRAFT WAS ON A GO AROUND AT ABOUT 30 FT AGL WHEN THE FRONT ENGINE QUIT.  THE PLT RETARDED BOTH THROTTLES AND LANDED; THE AIRCRAFT OVERRAN THE DEPARTURE END OF THE RUNWAY AND COLLIDED WITH A FENCE.  THE FRONT ENGINE WAS OVERHAULED AND INSTALLED IN THE AIRCRAFT 2 HRS PRIOR TO THE ACCIDENT.  EXAMINATION OF THE ENGINE REVEALED NUMEROUS DISCREPANCIES RELATING TO INCOMPLETE INSTALLATION OF THE ENGINE:  TOOLS LEFT IN THE ENG COMPARTMENT; LOOSE AND NOT CONNECTED OIL AND FUEL LINES; IMPROPERLY CONNECTED THROTTLE AND MIXTURE CONTROLS; ETC.  THE TURBO CONTROLLER WAS FOUND MISADJUSTED AND NOT PROPERLY CONTROLLING THE WASTE GATE VALVE.  THE FUEL PRESSURE WAS SET EXCESSIVELY HIGH, WHICH CAUSED THE ENGINE TO QUIT WHEN RUN IN A TEST CELL.  THE AIRCRAFT LOGBOOKS SHOWED THAT THE ENGINE INSTALLATION HAD BEEN SIGNED OFF BY AN AIRFRAME AND POWERPLANT MECHANIC AS COMPLETE.

## Aircraft

- Registration: [N2688S](https://openairdocs.org/deregistered/N2688S-1991-09-25), registration cancelled 1991-09-25, S/N 3370988 (OpenAirDocs)
- Reported make and model: CESSNA T-337-D
- Registry model: [Cessna T337D](https://openairdocs.org/model/cessna-t337d) (registry code 2075719) (OpenAirDocs)
- Category: Airplane
- Serial number: 337-0988
- Engines: CONTINENTAL TS10-360-A 210 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Dale W. Nix
- Registered owner: Dale W. Nix
- Last inspection: Unknown, January 2, 2000
- Airport: FUL, Fullerton, runway 24, 3,100 × 75 ft, asphalt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, valid medical--no waivers/lim.; flight hours: 197 total, 83 in this make and model, 116 as pilot in command, 3 in the last 90 days, 2 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 220° at 5 knots
- Visibility: 10 statute miles
- Lowest ceiling: none

## 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 19910505014119A](https://openairdocs.org/incident/19910505014119A), May 5, 1991: Cessna T337D, Fullerton, CA, Substantial damage. Front engine recent installed quit on go around. Aborted hit fence. Many descrepencies noted on eingine installation

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.