# NTSB SEA98FA092: Cessna T210N, N199JM, Hillsboro, OR, June 9, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 9, 1998, 12:53 local (19:53 UTC) - Place: Hillsboro, OR - Coordinates: 45.579578, -122.909973 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.5796&lon=-122.9100&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report January 11, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 42717 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA98FA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/42717/pdf - Page: https://openairdocs.org/ntsb/SEA98FA092 ## Probable cause Improper installation (bushing), mechanical binding (bushing), mechanical binding (connecting rod), and fatigue within the crankshaft. Contributing factors were inadequate major (engine) overhaul and trees. ## 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, approach - engine assembly,crankshaft - fatigue (cause) - engine assembly,connecting rod - binding(mechanical) (cause) - engine assembly,other - binding(mechanical) (cause) - maintenance,installation - improper, other maintenance personnel (cause) - maintenance,overhaul,major - inadequate, other maintenance personnel (contributing factor) - Loss of control - in flight, approach - vfr pattern - final approach - object - tree(s) (contributing factor) - object - wire,transmission - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot-in-command reported a power loss on approach to the runway. The aircraft passed through the tops of trees approximately 150 feet beyond, and entered a stall/spin maneuver, impacting a power line and the ground approximately 2,800 feet short of the runway threshold. The flaps and landing gear were in a retracted position. Post-crash examination revealed the crankshaft separated in fatigue which originated from a circumferential gouge mark on the aft face of the #2 cheek at an area located outboard of the forward radius of the #1 rod journal. The circumferential gouge mark on the crankcheek was consistent with the connecting rod shifting forward during engine operation. The rub marks on the cheek walls of the #1 connecting rod were consistent with tight piston pin bushing to piston pin clearance. Additionally, the bushings for all the connecting rods were undersize. Airframe/engine logs revealed a top overhaul of the engine approximately 23 hours prior to the crankshaft failure, during which the piston pins were replaced but the connecting rod bushings were not. No dimensional check of the bushings was made or required at that time. The engine was overhauled 515 hours previous to the top overhaul. The manufacturer's overhaul manual specifies that the new bushings should be reamed to the specified (inside) diameter. Post-crash examination of the engine revealed non-standard connecting rod cotter keys and light fretting between the engine case halves. ## Factual narrative HISTORY OF FLIGHT On June 9, 1998, at 1253 Pacific daylight time, a Cessna T210N, N199JM, registered to and being flown by a private pilot, was destroyed during an uncontrolled descent into power lines and terrain following impact with trees. The pilot had just radioed that he had lost his engine and was attempting to land at the Portland-Hillsboro Airport, Hillsboro, Oregon. The pilot and passenger sustained fatal injuries. Visual meteorological conditions existed and no flight plan had been filed. The flight, which was personal in nature, was to have been operated under 14CFR91, and had departed Sun River, Oregon, earlier on the morning of the accident. According to family members, the pilot and his wife departed Sun River, Oregon, late on the morning of the accident destined for Hillsboro, Oregon, where they planned to meet friends for lunch and then drive to the Oregon coast. There was no record of a flight plan being filed nor a weather briefing being obtained for the Sun River-Hillsboro flight. The first known radio contact with the aircraft was at 1252:19, when the pilot contacted the Federal Aviation Administration's (FAA) Hillsboro air traffic control tower (ATCT) advising "about two miles north landing Hillsboro." The tower controller acknowledged and instructed the pilot to "report right downwind runway three zero." At 1252:29, the pilot radioed "we got an emergency here, we need to land immediately," and the tower controller responded six seconds later inquiring "do you want a straight in two zero?" At 1252:37, the pilot responded "that's affirmative" and the tower controller immediately advised "roger, report on final for two zero, do you need equipment?" At 1252:42, the pilot responded "no, that's uh no equipment, we'll make it." Between 1252:50 and 1253:21, the tower controller coordinated with three other aircraft in the vicinity, and at 1253:21, the controller inquired "centurion niner juliet mike, how far north are you and what's the nature of the emergency?" The pilot responded seven seconds later advising "juliet mike we lost our engine." At 1253:31, an unknown aircraft radioed Hillsboro tower reporting "tower, he's uh coming in three zero, he's in the trees (pause) south of the airport and he's overhead, I'll go check for injuries and fire, you got fire north of the (power outage occurs)." No further radio transmission were received (refer to ATTACHMENT ATC-I). The three tower controllers on duty observed the aircraft and/or the fireball from the impact slightly southeast of the Hillsboro airport (refer to ATTACHMENTS T-I, II and III). A number of ground witnesses observed the aircraft. One witness reported observing "a thin trail of smoke coming from the plane, and the landing gear was up. The plane came from the east." Another witness also reported observing the aircraft "flying low with a faint trail of light black smoke trailing" and that "the plane then hit the trees." A third witness reported that the "motor [was] running but not running strong" and that "as he made his way through the trees, he clipped a tree." A fourth witness reported that "it sounded to me that the plane's engine was under throttled or under powered." Two additional witnesses reported seeing the "single engine plane with landing gear up heading for (north) the PGE 115 KV line," and that "the plane's rt. wing clipped a tree" (refer to ATTACHMENTS W-I THROUGH W-V). PERSONNEL INFORMATION No pilot flight logs were found at the accident site. The pilot's flight time was estimated on the basis of the time indicated at his last FAA medical examination. This time was reported as 1,025 total flight hours (20 within the previous 6 months), and was recorded on the pilot's third class medical dated June 2, 1988. FAA records showed no later medical certificate for the pilot. It was not determined if the pilot had a current flight review and what date the review may have been conducted. AIRCRAFT INFORMATION FAA records showed that N199JM was registered to the pilot and his wife May 21, 1985. Subsequent to the accident, no insurance carrier for the aircraft could be identified, and the aircraft was presumed to be uninsured. The aircraft's most recent airframe and engine log were recovered from the wreckage. Although heavily fire damaged, the logbooks contained some readable information. The Teledyne Continental Motors (TCM) Gold Medallion Aircraft Engine log showed the TSIO-520R engine as being rebuilt by the manufacturer on March 25, 1988. The logbook was opened on May 4, 1988, at an aircraft tach time of 1,782.5 hours (zero engine time), and was installed on N199JM at that time (refer to ATTACHMENTS EL-I,II, and III). The aircraft's logbooks showed that on January 10, 1995, the engine was again overhauled and zero timed at a tach time of 2,880.1 hours. This major overhaul was carried out by Regal Air, Snohomish County Airport, Everett, Washington, 98204, (refer to ATTACHMENTS EL-IV and AL-I through IV). The last entry of the aircraft's engine logbook was a 100 hour inspection which was signed off on May 13, 1998, at a total tach time of 3,394.8 hours and 514.72 hours since the last major overhaul (refer to ATTACHMENTS EL-V and AL-V). Additionally, this entry showed 0.0 hours since a top overhaul and contained an entry reading "removed all cylinders and installed Cermihil exch. units." The last entry of the aircraft's airframe logbook was an annual inspection which was signed off on May 13, 1998, at a total tach time of 3,394.8 hours (refer to ATTACHMENT AL-V). An envelope containing a two page invoice from Performance Air, PO BOX 1786, Ramona, California, 92065, was found ejected from the aircraft and displaying no fire damage. This invoice, dated May 9, 1998, contained an itemization of parts and labor applied to N199JM at tach time of 3894.8 hours and included six Cermihil cylinders, six piston pins and a reference to a "top overhaul of engine" (refer to ATTACHMENT INV-I). An inspector from the FAA's San Diego Flight Standards District Office (FSDO) examined the records provided by Performance Air related to N199JM. The documents included billing for parts and labor signed off on May 10, 1998, a three page Performance Air discrepancy list, a four page Performance Air 100 hour/annual inspection form, and a two page invoice identical to the invoice ejected from the aircraft at the site (as described above). The last entry on the Discrepancy List was "Cylinder Top O/H, C/W top O/H ECI Inst. & TSIO 520 manual." The airframe & powerplant (A&P) mechanic who performed the top overhaul at Performance Air was interviewed telephonically and recalled that new piston pins did not come with the replacement cylinders. He reported that he intentionally changed the piston pins, rather than leave the old pins in place, based upon his evaluation of the condition of the old pins, which he described as being somewhat discolored with possible corrosion. He also reported that he was fairly certain he did not replace the connecting rod bushings or dimensionally check the inner diameter of the bushings. Additionally, the mechanic related that he had flown the aircraft approximately two hours during/following the top overhaul and inspection, and that the pilot/owner flew the aircraft on a test flight of about one hour following the overhaul. He also reported that the pilot took the aircraft on a round trip flight from Ramona, California, into central/northern California and return for an estimated total flight time of five hours. He also reported that the pilot flew the aircraft from Ramona into the Pacific Northwest and return for an estimated total flight time of ten hours. The remaining flights were those associated with the departure from Ramona through Winnemucca, Nevada, Sun River, Oregon, and into Hillsboro, estimated at another five hours of flight time. Based on these flight time ## Aircraft - Registration: [N199JM](https://openairdocs.org/deregistered/N199JM-2017-04-13), registration cancelled 2017-04-13, S/N 21064010, built 1980 (OpenAirDocs) - Reported make and model: Cessna T210N - Registry model: [Cessna T210N](https://openairdocs.org/model/cessna-t210n) (registry code 2073456) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 21064010 - Airframe hours: 3418 - Engines: Continental TSIO-520-R(9) 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Burtla, Joseph, R. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 13, 1998, 23 hours before - Departed: SUN RIVER, OR - Destination: HIO, HILLSBORO, OR - Airport: HIO, Portland-Hillsboro, runway 30, 6,600 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, expired; seat: left; toxicology performed; flight hours: 1,025 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 25,000 ft broken - Temperature: 70 °F, dew point 52 °F - Altimeter: 30.00 inHg - Observed at: HIO, 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 19980609012829A](https://openairdocs.org/incident/19980609012829A), Jun 9, 1998: Cessna T210N, Portland, OR, Destroyed, 2 fatal. Pilot declared emerg, cleared to land on rwy 20, acft lost engine, struck power lines and crashed. (.4)the pilot-in-command reported a power loss on approach… 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.