# NTSB SEA91LA217: Beech B24R, N2528W, Shady Cove, OR, August 21, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: August 20, 1991, 17:15 local (Aug 21, 1991, 00:15 UTC)
- Place: Shady Cove, OR
- Coordinates: 42.609828, -122.800643 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.6098&lon=-122.8006&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 1 serious
- Status: Completed, report May 28, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 41520
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA91LA217
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41520/pdf
- Page: https://openairdocs.org/ntsb/SEA91LA217

## 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

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

- Loss of engine power(total) - mech failure/malf, cruise
  - lubricating system,oil line - loose (cause)
  - maintenance,installation - improper, other maintenance personnel (cause)
  - fluid,oil - leak (cause)
  - powerplant - seized (cause)
- Forced landing, descent - emergency
- In flight collision with terrain/water, landing
  - wheels up landing
  - terrain condition - rough/uneven (contributing factor)

## 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](https://openairdocs.org/deregistered/N2528W-2012-08-21), registration cancelled 2012-08-21, S/N MC-201, built 1973 (OpenAirDocs)
- Reported make and model: BEECH B24R
- Registry model: [Beech B24R](https://openairdocs.org/model/beech-b24r) (registry code 1151253) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: MC201
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 69; 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 (OpenAirDocs).

- [Accident 19910820035139A](https://openairdocs.org/incident/19910820035139A), Aug 20, 1991: Beech B24R, Shady Cove, OR, Substantial damage. Lost oil pressure. Engine seized. Crash landed rough field. Oil line to governor loose. First flight from annual.

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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