WPR14LA207

NTSB accident investigation · Cessna 182 · Arvin, CA · May 24, 2014

Accident · Minor injuriesLimited investigationFinal report
Date
May 24, 2014, 12:11 local (19:11 UTC)
Place
Arvin, CA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N97038Cessna 182
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 20, 2017
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA, Continental Motors
FAA report
20140524013359A
Case key
89263

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

The pilot’s failure to reconnect the air-oil separator return line after completing an oil change, which resulted in a total loss of engine power due to oil starvation.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna 182: 1 caseAll aircraft: 174 casesProbable cause
Eng oil sys (airframe furnish): eng oil dist (airframe furn)Aircraft › Aircraft power plant · Incorrect service/maintenanceCessna 182: 1 caseAll aircraft: 18 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot reported that, while in cruise flight, he noticed that the engine oil pressure had dropped. He declared an emergency and was initially given a heading to the closest airport. About 2-3 minutes later, he heard rattling noises from the engine, then the cabin filled with black smoke. He identified an open field and maneuvered for a forced landing. The airplane hit a berm and bounced, hitting several more berms, until it came to rest inverted. On-scene photographs showed that the belly of the airplane was coated with engine oil aft of the engine firewall. An engine examination identified that the air-oil separator return line was not connected to the return port located on a cylinder rocker cover. Maintenance records showed that the pilot had performed an oil change 4.3 hours before the accident. Since the oil filter is located behind the air-oil separator return line, it is likely that the pilot removed the air-oil separator return line to access the oil filter and failed to reconnect the line after replacing the filter. While in flight, oil slowly drained out of the air-oil separator return line and open return port, coating the belly of the airplane, until the engine experienced catastrophic failure due to oil starvation.

Factual narrative

On May 24, 2014, at 1211 Pacific daylight time, a Cessna 182Q, N97038, experienced a total loss of engine power and force landed in a field one mile south of Arvin, California. During the off airport landing the airplane nosed over, substantially damaging the tail and left lift strut. The airplane was registered to, and operated by, the commercial pilot under the provisions of 14 Code of Federal Regulations, Part 91, as a personal flight. Both the pilot and his single passenger received minor injuries. Visual meteorological conditions prevailed during the flight, and a visual flight plan was not filed. The flight originated at Corona Municipal Airport, Corona, California.The pilot stated that an hour into the flight, while over the Tehachapi Mountains, he noticed that the engine oil pressure had dropped, but the oil temperature and cylinder temperatures were normal. He declared an emergency to Bakersfield Approach and was initially given vectors to Bakersfield Municipal Airport. About 2-3 minutes later he started hearing rattling noises coming from the engine and then the cockpit filled with black smoke. He identified an open field on his left and maneuvered to make that field but didn't realize it had crop furrows. The airplane hit the first berm hard, bounced 3-4 times hitting berms along the way, then the nose wheel hit a berm and flipped the airplane over onto its back. On scene photos showed that the belly of the airplane was coated with engine oil aft of the engine fire wall. An examination of the airplane and engine by the NTSB Investigator-in-Charge (IIC) and a technical representative from Continental Motors Incorporated was performed on September 30, 2014. The engine time indicated on the tachometer was 2,861.6 (hours). Investigators found the air-oil separator return line disconnected from the oil return port located on the rocker cover of the engine's number 1 cylinder. Oil staining was evident on the lower engine cowling below the number 1 cylinder. It was noted that the engine oil filter was located behind the air-oil separator return line. The left engine case half, upper section above the No 4 cylinder, exhibited a 6 x 4 inch hole just aft of the oil filler neck. The cylinders were removed and the case was separated into its halves. The crankshaft main bearings exhibited normal wear with no heat discoloration. The number 3 crankshaft throw bearing was shiny & polished showing very little heat discoloration. The number 4 crankshaft throw was dark black with a few gouges and exhibited extreme heat distress. The number 5 crankshaft throw was black and exhibited extreme heat distress. The number 6 connecting rod attached to the crankshaft throw was discolored dark gray, consistent with heat distress. The internal section of the engine case in line with the number 3 & 4 crankshaft throws exhibited internal repeated impact marks, metal removal, and damage to the oil galleries on both sides of the engine case. Examination of the enginelogbook revealed that the most recent annual inspection was performed on April 10, 2013, 2,828.2 hours total time, and 309.5 hours since major overhaul (SMOH). The last entry in the logbook was dated April 18, 2014, where the pilot/owner had performed an oil change, 2,857.3 hours total time

Aircraft

Registration
N97038
Reported as
Cessna 182 (Q)
Category
Airplane
Serial number
18266947
Airframe hours
2,861.6
Engine
Teledyne Continental O-470U(4), 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 10, 2013 · 33 hours before
Departed
KAJO · Corona, CA
Destination
KPVT · Porterville, CA
Flight plan
VFR/IFR
Equipment
Unknown

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
80
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
November 11, 2012
Seat
Left
Flight hours
3,687 total · 18 in the last 90 days · 3.5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 192 °F
Altimeter
29.89 inHg
Observed at
KBFL, 22 nm away

Docket · 11

The files NTSB released with the investigation on April 20, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.3 MB in all.

FAA reports on this event · 1

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