# NTSB SEA04FA165: Cessna T210L, N2452S, Tulsa, OK, August 17, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 17, 2004, 17:12 local (22:12 UTC) - Place: Tulsa, OK - Coordinates: 36.027778, -95.99472 - Nearby events: https://openairdocs.org/map.md?lat=36.0278&lon=-95.9947&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report September 13, 2005 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 59924 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA04FA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59924/pdf - Page: https://openairdocs.org/ntsb/SEA04FA165 ## Probable cause The pilot's inadequate preflight inspection by his failure to secure the oil cap, which resulted in oil leakage on the windscreen, obstructing his vision, and his failure to maintain adequate airspeed. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - lubricating system,oil filler cap - not installed (contributing factor) - aircraft preflight - inadequate, pilot in command (contributing factor) - fluid,oil - leak (contributing factor) - diverted attention, pilot in command (contributing factor) - airspeed - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - open field ## Analysis The airplane was departing on runway 19R. Moments after liftoff, the pilot called tower and asked to return to the airport because he was getting oil on his windscreen. A pilot taking off immediately behind the accident airplane observed the airplane, at approximately 300 feet, turn right to return to the airport. He said that the airplane appeared very slow, and then it rotated to the ground. Postimpact examination of the wreckage revealed that the engine oil filler neck did not have a cap on it. The oil filler neck was partially compressed, and the oil cap was found (on a chain) undamaged. Pieces of windscreen Plexiglas were found outside of the wreckage zone, and they were coated with oil. The engine manufacturer's representative said that the engine could probably run for 15 to 25 minutes without a cap on the filler neck. ## Factual narrative HISTORY OF FLIGHT On August 17, 2004, at 1712 central daylight time, a Cessna T210L, N2452S, was destroyed when it impacted the ground near Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma. The instrument rated private pilot and his two passengers were fatally injured. The pilot/owner was operating the airplane under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the cross-country personal flight that was originating at the time of the accident. The pilot had not filed a flight plan; family members said that the destination of the flight was Joplin, Missouri. A Federal Aviation Administration (FAA) Air Traffic Controller (ATC; tower control) witness said that the pilot requested to taxi to the self-service refueling location on the airport approximately 30 minutes before his takeoff. He said that the self-service fueling location is visually obstructed by a large hangar, and he was unable to observe the pilot's activity. The records for the self-service fueling pump (credit card purchases only) indicate that at 1644 a purchase was made for 62.49 gallons. ATC tower recordings indicate that the pilot was cleared for takeoff at 1710 on runway 19R (right). After takeoff, he was instructed to turn to 100 degrees. Approximately 100 seconds later the pilot reported he had oil on his wind screen and would like to return to the airport. A witness-pilot of an airplane that was taking off behind the accident aircraft said that the accident aircraft leveled off at approximately 300 feet, slowed down, and made a right turn back towards the airport. He said that as the accident airplane started the right hand turn to the north, "it appeared to be moving very slow." The witness-pilot said that as the accident airplane turned through a heading of approximately 300 degrees, he noticed the right wing drop, and it rotated right 3/4 of a turn and impacted the ground. A postimpact fire ensued. PERSONAL INFORMATION The pilot had taken a Federal Aviation Administration (FAA) required flight medical on January 2, 2004; he held a third class medical certificate. The pilot's flight time log-book indicated that he took a FAA required flight review on May 1, 2003. At the time of the accident, his pilot log-book indicated that he had approximately 1,474 hours of flight experience, 794 hours of those hours were in the accident airplane, and approximately 36 hours were in the last 90 days. AIRCRAFT INFORMATION The airplane was a single engine, propeller-driven, six seat airplane, which was manufactured by Cessna Aircraft Company, in 1976. The airplane had a maximum takeoff gross weight of 3,800 pounds. It was powered by a Continental TSIO-520-H, reciprocating turbo charged, fuel injected, direct drive, air cooled, horizontally opposed, six cylinder engine, which had a maximum takeoff rating of 285 horsepower at sea level. Maintenance records indicate that the last annual inspection was completed on March 18, 2004. The airplane's maintenance records, together with the pilot's flight log-book, indicate that the airplane had 3,129 hours of total time at the time of the accident. METEOROLOGICAL INFORMATION At 1719, the weather conditions at Richard Lloyd Jones Jr. Airport (RVS; elevation 638 feet), Tulsa, Oklahoma, were as follows: wind 210 degrees for 8 knots: visibility 10 statue miles (sm); clear of clouds; temperature 91 degrees Fahrenheit; dew point 64 degrees Fahrenheit; altimeter setting 30.00 inches. WRECKAGE AND IMPACT INFORMATION The airplane was found in an open grass field surrounded by houses (N36 degrees, 01", 40"; W95 degrees, 59', 41"; elevation 638 feet), approximately 3,168 feet from the departure end of runway 19R. The airplane's longitudinal orientation was 180 degrees. There was a 1.5 feet deep crater approximately 4 feet in front of the airplane with associated ground scars to suggest that the airplane bounced backwards to its final location. The airplane was consumed by postimpact conflagration. All of the airplane's major components were accounted for at the accident site. The landing gear was retracted; the flaps were found up. Control cable continuity was confirmed for all flight controls. The engine's crankshaft rotated with "thumb" compression on all cylinders; continuity was exhibited throughout the engine. One propeller blade exhibited "S" type bending; the second blade appeared undamaged; the third blade was bent under the engine. The engine's oil neck was found without a cap. The cap was attached to the neck by a chain, and was found between cylinders number 4 and number 6; it was undamaged. The oil filler neck was partially compressed. Pieces of windscreen Plexiglas were found outside of the fire zone, and they were coated with oil. The engine manufacturer's representative said that the engine could probably run for 15 to 25 minutes without a cap on the filler neck. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Chief Medical Examiner, Tulsa, Oklahoma, performed an autopsy on the pilot on August 18, 2004. The cause of death was determined to be multiple blunt trauma. The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (#200400201001), carbon monoxide, cyanide, volatiles (ethanol), and drugs tested, found negative results. ADDITIONAL INFORMATION The airplane, including all components and logbooks, was released to a representative of the owner's insurance company on May 5, 2005. ## Aircraft - Registration: [N2452S](https://openairdocs.org/deregistered/N2452S-2015-05-15), registration cancelled 2015-05-15, S/N 21061293, built 1976 (OpenAirDocs) - Reported make and model: Cessna T210L - Registry model: [Cessna T210L](https://openairdocs.org/model/cessna-t210l) (registry code 2073449) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21061293 - Airframe hours: 3129 - Engines: Teledyne Continental TSIO-520-H 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Richard L. Dunham - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 18, 2004, 43 hours before - Departed: RVS, Tulsa, OK - Destination: JLN, Joplin, MO - Airport: RVS, Richard Lloyd Jones Jr. Arpt, runway 19R, 5,102 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; last flight review May 1, 2003; seat: left; toxicology performed; flight hours: 1,473 total, 794 in this make and model, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 66 °F - Altimeter: 30.00 inHg - Observed at: RVS, 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 20040817018449A](https://openairdocs.org/incident/20040817018449A), Aug 17, 2004: Cessna T210L, Tulsa, OK, Destroyed, 3 fatal. (-23) Pilot of N2452S departed r.l. Jones, (rvs) airport, jenks, Oklahoma, on runway 19R, VFR. Pilot contacted ATC, reported small oil leak and requested to… 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.