# NTSB SEA95FA213: Cessna P210N, N3674P, Black Diamond, WA, September 10, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 10, 1995, 11:55 local (18:55 UTC) - Place: Black Diamond, WA - Coordinates: 47.32003, -121.990425 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.3200&lon=-121.9904&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 25, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 42066 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA95FA213 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42066/pdf - Page: https://openairdocs.org/ntsb/SEA95FA213 ## Probable cause improper maintenance which led to oil starvation due to a inadequately tightened B-nut in an oil line. A factor was the lack of suitable terrain for a forced landing. ## 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 part/bolt/nut/clamp/etc (cause) - maintenance - improper, company maintenance personnel (cause) - fluid,oil - starvation (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency descent/landing - terrain condition - none suitable (contributing factor) ## Analysis The pilot advised Air Traffic Control that his aircraft had sustained a loss of power while he was engaged in aerial photography operations over mountainous terrain near Mt. Rainier. He elected to attempt to glide from over 10,500 feet above sea level to an airstrip suggested by ATC as a possible forced landing site. During the descent the engine lost total power. The aircraft crashed into trees on the north side of a river with a paved road along its south shore, and within about a mile of an abandoned airstrip. Disassembly and inspection of the engine revealed internal failure due to oil starvation. A B-nut on an oil line to the turbocharger was found to be loose. Maintenance records showed that this oil line had been subject to recent maintenance by company personnel. ## Factual narrative HISTORY OF FLIGHT On September 10, 1995, approximately 1155 Pacific daylight time, a Cessna P210N, N3674P, was destroyed when it collided with terrain during an emergency descent after the loss of engine power. The commercial pilot, who was the sole occupant of the aircraft, was fatally injured. Visual meteorological conditions prevailed at the time of the flight, which was an aerial photography flight conducted under 14 CFR 91. The aircraft had departed Eugene, Oregon, about 0930, with a company flight plan, and was expected to return to Harrisburg, Oregon, at the end of the aerial photography flight. The aircraft and ELT were consumed by post-crash fire. Approximately 1141, the pilot called Seattle Air Route Traffic Control Center (ARTCC) declaring an emergency, advising that he had a power loss and was descending, 20 miles north of Mount Rainier. At 1143, N3674P was given a discrete transponder code by Seattle ARTCC. Radar contact was established, and the controller inquired if the pilot was familiar with Bandera airport. The pilot of N3674P stated that he was not. Radar data shows that the aircraft overflew the site of a former airstrip, Lester State Airport, which had been washed away by floods ("A" on attached depiction). The following communications are extracted from an FAA transcript of Seattle Approach communications with N3674P. The entirety of the transcript is attached. A depiction of the flight path, overlaid upon quad maps, was generated by investigators and is attached, showing the aircraft's radar position at the time of several communications exchanges which include the aircraft's altitude at the approximate time of communication. At 1144:12, Seattle ARTCC advised Seattle Approach control of N3674P's position near Bandera, 35 miles out of Seattle. Seattle Approach established radar contact at 1144:31. At 1145:01, N3674P, which had been handed off to Seattle Approach from Seattle ARTCC, came up on frequency with Seattle Approach. At 1145:07, the pilot stated that his altitude was 10,500 and descending, and moments later advised that he was going down "about fifteen hundred per minute." (See "B" on depiction.) At 1145:55, the pilot stated "...let go ah negative oil pressure for seven four papa," and--a few seconds later--acknowledged that he had completely lost his engine. At 1146:48, Seattle Approach advised N3674P of Enumclaw airport at eleven o'clock and 15 miles, and Bandera airport, about ten miles north, but advised of 5400 feet terrain north of his position. At 1147:01, the pilot said that he would "go for Enumclaw." At 1148:02, N3674P's altitude was 7500 feet. (See "C" on depiction.) At 1148:40, the pilot stated that his altitude was 6200 feet ("D" on depiction). At 1150:31, the pilot stated "and there goes the power." His altitude was 4500 feet at 1150:39 ("E" on depiction). At 1151:55, Seattle Approach provided a suggested heading of 260 for Black Diamond. The pilot noted that he had a hill ahead on that heading. At 1152:13, his altitude was 3100 feet ("F" on depiction). Seattle Approach asked if any roads were visible, and suggested that the pilot try for one if he was unable to glide to an airstrip. At 1153:17, the pilot stated "seven four papa's one thousand seven hundred ["G" on depiction]. I'm going to try this road over here." At 1153:48, there was an unintelligible communication to Seattle Approach. There were no further direct communications with Seattle Approach from N3674P. At 1154:48, another aircraft in the vicinity advised Seattle Approach that N3674P's pilot made a last transmission saying that "he...wasn't gonna make the road and he was going to...go down in the trees." Witnesses fishing near the Green River Headworks control gate saw the airplane and heard what sounded like engine problems. They then saw the aircraft make a course reversal eastbound and then crash and burn on the north side of the river. The wreckage was found about 6 miles east of Black Diamond, Washington, in a willow or aspen grove at "G" on the attached depiction. According to a GPS receiver, approximate latitude and longitude of the accident site was N 48 degrees 18.5 minutes and W 121 degrees 51 minutes, about 800 feet above sea level. The wreckage was on the opposite side of the shoreline from the SE Green River Headworks access road to the Howard Hansen Reservoir, about 2 miles east of the intersection of Cumberland-Kanaskat RD SE and the SE Green River Headworks roads. When the wreckage site was overflown by investigators, it was noted that an abandoned airstrip, of approximately 1500-2000 feet length and marked with white "X"s, was on the opposite side of the river, within about a mile of the crash site. AIRCRAFT INFORMATION The aircraft had undergone an annual inspection March 1, 1995. Since that date, it had accumulated approximately 290 hours flight time, and the engine had approximately 900 hours since factory remanufacture. The engine had been installed about January or February of 1993. In July of 1995, six overhauled cylinders from ECI were installed, which had approximately 120 hours since installation at the time of the accident. Pilots had observed that the oil pressure had dropped on at least three occasions, but that it had remained in the green oil pressure range. Each time, oil screens were checked and no metal was found. The aircraft was not consuming oil. During the 30 days preceding the accident, the oil relief check valve had been checked for condition, the oil cooler thermal control valve had been replaced, and at least two oil filters had been opened and checked for contamination. On the Saturday previous to the accident, the oil pressure was reported to have been back up to the expected range. The aircraft had 16.5 gallon auxiliary fuel tanks installed in the outboard portions of the wings. WRECKAGE AND IMPACT INFORMATION Terrain in the vicinity of the accident was hilly or mountainous, and heavily forested, in brush or willowy growth, near the riverbed. Broken limbs in trees, about 20 feet above the surface, were noted about 39 feet to the west of the left hand wing tip. The propeller was about 15 feet east of the left wing tip. A crater was about eighteen feet east and ten feet south of the propeller. The main wreckage was southeast of the crater, with its remaining fuselage oriented on a centerline of about 125 degrees, nose to tail. The wreckage sustained extensive fire damage. The right wing was extensively melted in the fuel tank area near the root, and at the wing tip area, where the auxiliary tank was installed. The left wing also had extensive impact and fire damage. The wing flaps were determined to have been in the extended position. The main fuselage area was mostly consumed by fire. The instrument panel was burned away, and the remaining instruments and radios provided no usable information. The tachometer was found and the rpm indication was off scale at the 6 'clock position. The throttle was in idle position; the mixture was in rich position, and the propeller control was full forward. A large camera was mounted where the pilot's seat is normally located. The copilot's seat was installed. A large oxygen bottle was installed behind the copilot's seat. The engine remained attached to the firewall. The cowling remained attached, and was partially consumed by fire. The cowling was removed for inspection. The throttle butterfly was at idle; the mixture control was in a mid-range position, and the propeller lever was at full aft position. The top of the engine and accessory section exhibited fire damage. The left magneto was separated from its mount. Three holes were noted in the crankcase, with one above cylinder #4, with the connecting rod visible; one above cylinder #3; and another under the left magneto above cylinder #2. Many of the tube ## Aircraft - Registration: [N3674P](https://openairdocs.org/deregistered/N3674P-1997-03-24), registration cancelled 1997-03-24, S/N P21000047 (OpenAirDocs) - Reported make and model: CESSNA P210N - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Category: Airplane - Serial number: P21000047 - Airframe hours: 4500 - Engines: CONTINENTAL TSIO-520-P 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Other work use, Part 91 - Registered owner: Wac Corporation - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 1, 1995, 290 hours before - Departed: EUG, EUGENE, OR - Destination: OR78, HARRISBURG, OR - Flight plan: Company VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 8,600 total, 3,000 in this make and model, 8,600 as pilot in command, 169 in the last 90 days, 40 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 59 °F - Altimeter: 30.00 inHg - Observed at: SEA ## 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 19950910028099A](https://openairdocs.org/incident/19950910028099A), Sep 10, 1995: Cessna P210N, Black Diamond, WA, Destroyed, 1 fatal. Lost power on photo flight. 20MI north mt rainier. Crashed into trees. Had thrown 4 connecting rods. Oil line broke 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.