SEA91LA217

NTSB accident investigation · Beech B24R · Shady Cove, OR · August 21, 1991

Accident · Serious injuriesLimited investigationFinal report
Date
August 20, 1991, 17:15 local (Aug 21, 1991, 00:15 UTC)
Place
Shady Cove, OR
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2528WBeech B24R
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 1993
Report
Approved by Office Director
FAA report
19910820035139A
Case key
41520

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

Improper re-installation of an oil line by maintenance personnel, which resulted in an oil leak from a loose line and subsequent seizure of the engine. Uneven terrain in the emergency landing area was a related factor.

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.

Loss of engine power(total) - mech failure/malfCruise
Lubricating system,oil line - looseCause
Maintenance,installation - improperOther maintenance personnelCause
Fluid,oil - leakCause
Powerplant - seizedCause
Forced landingDescent - emergency
In flight collision with terrain/waterLanding
Wheels up landing
Terrain condition - rough/unevenFactor

Analysis

On the first flight after an annual inspection, the pilot was returning his Beech B24R to its home base. He noted that the engine was not developing normal RPM, and he elected to return to the maintenance facility. Shortly thereafter, the engine seized. The pilot made a wheels-up landing on uneven grassy terrain, and the aircraft was damaged. An investigation revealed that an oil line, which had been removed for maintenance, was loose and oil had been pumped overboard.

Aircraft

Registration
N2528W
Reported as
Beech B24R
Category
Airplane
Serial number
MC201
Engine
Lycoming IO-360-A1B6, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
John G. Purdy
Registered owner
John G. Purdy
Departed
MFR · Medford, OR
Destination
Shady Grove, OR

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
69
Certificate
Commercial
Airplane ratings
Multi-engine sea, Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Flight hours
3,660 total · 1,392 in this make and model · 3,179 as pilot in command · 13 in the last 90 days · 1 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 7 knots
Visibility
10 statute miles
Lowest ceiling
6,500 ft overcast
Temperature
-0 °F, dew point -0 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.