# NTSB LAX93LA325: Glassair SH-2R, N333KM, Bakersfield, CA, August 17, 1993 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 17, 1993, 16:04 local (23:04 UTC) - Place: Bakersfield, CA - Coordinates: 35.379093, -119.02098 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.3791&lon=-119.0210&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report August 1, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 28450 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA325 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/28450/pdf - Page: https://openairdocs.org/ntsb/LAX93LA325 ## Probable cause THE IMPROPER MAINTENANCE BY THE PILOT THE NIGHT BEFORE THE ACCIDENT WHICH RESULTED IN AN OIL LINE LEAK NEAR THE AIRPLANE'S EXHAUST SYSTEM. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Fire, takeoff - initial climb - fluid,fuel - leak (contributing factor) - lubricating system,oil tubing - previous damage (contributing factor) - lubricating system,oil line - fire - maintenance - improper, pilot in command (cause) - Forced landing, descent - emergency - Gear not extended, descent - emergency - wheels up landing - selected, pilot in command ## Analysis THE PILOT CHANGED THE AIRPLANE'S ENGINE OIL THE NIGHT BEFORE THE FLIGHT. AFTER TAKEOFF, AN INFLIGHT FIRE ERUPTED IN THE ENGINE COMPARTMENT. THE POST FLIGHT EXAMINATION OF THE AIRPLANE'S OIL TEMPERATURE SENDING UNIT LINE TO THE GAUGE WAS FOUND DAMAGED AT A CRIMPED FITTING. THE PILOT BELIEVES THE DAMAGE WAS CAUSED BY HIM DURING THE ENGINE OIL CHANGE. ## Factual narrative On August 17, 1993, at 1604 hours Pacific daylight time, a Glassair SH-2R, N333KM, landed gear up on Runway 12L at Meadows Field, Bakersfield, California, after experiencing an inflight fire. The pilot was conducting a local visual flight rules personal flight to Fresno, California. The airplane, registered to and operated by the pilot, sustained substantial damage. The certificated private pilot, the sole occupant, was not injured. Visual meteorological conditions prevailed. The flight originated at Meadows Field at 1600 hours. A Federal Aviation Administration inspector examined the airplane. The inspector reported that the source of the fire appeared to be from a 1/4 inch rubber hose attached to the intake side of the number 1 cylinder. The line was traced through the airplane's firewall to another manifold behind the instrument panel. The line is believed to belong to the oil gauge. The pilot reported during a telephone interview that he had changed the airplane's engine oil the night before. The pilot stated he believes that he inadvertently damaged a crimped line while changing the oil. Post flight inspection of the airplane by the pilot revealed the engine oil temperature line had disconnected at the crimped fitting near the airplane's exhaust system. The pilot reported that he landed the airplane gear up due to a loss of electrical power. ## Aircraft - Registration: [N333KM](https://openairdocs.org/aircraft/N333KM), registered now, S/N 586, built 1987 (OpenAirDocs) - Reported make and model: GLASSAIR SH-2R - Registry model: [Macdonald John A GLASAIR SH 2R](https://openairdocs.org/model/macdonald-john-a-glasair-sh-2r) (registry code 05655VA) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 586 - Airframe hours: 685 - Engines: LYCOMING O-320 160 horsepower reciprocating - Damage: Substantial damage - Fire: In-Flight - Flight: Personal, Part 91 - Registered owner: Jones, Donald D. - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, July 14, 1993, 22 hours before - Departed: BFL - Airport: BFL, Meadows Field, runway 12L, 10,857 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 1,821 total, 466 in this make and model, 41 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 12 knots - Visibility: 12 statute miles - Lowest ceiling: 25,000 ft overcast - Temperature: 90 °F, dew point 54 °F - Altimeter: 29.00 inHg - Observed at: BFL, 1 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 19930817029619A](https://openairdocs.org/incident/19930817029619A), Aug 17, 1993: Amtr GLASAIR, Bakersfield, CA, Substantial damage. Landed gear up due to engine fire and lost of electric power. Pilot reported he crimped oil gage line changing oil. 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.