WPR19LA187

NTSB accident investigation · Beech C23 · Ludlow, CA · June 30, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 30, 2019, 11:34 local (18:34 UTC)
Place
Ludlow, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N24580Beech C23
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA
FAA report
20190630008689A
Case key
99848

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Maintenance personnel’s failure to properly tighten an oil line fitting, which resulted in a total loss of engine power.

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 levelBeech C23: 1 caseAll aircraft: 174 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceBeech C23: 1 caseAll aircraft: 130 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 pilot and the passenger departed on a cross-country flight. While at cruise, the pilot noted a faint smell of burning paint, followed by the oil pressure drop to zero and eventually experienced a complete loss of engine power. The pilot performed an emergency landing during which the airplane sustained substantial damage. A postaccident examination revealed there was no oil remaining in the engine, the AN hose fitting on the oil cooler was loose, and there was evidence of an oil leak in the area of the loose fitting. No other pre-impact mechanical anomalies were detected that could have precluded normal operations. The engine had been overhauled about 4 operating hours prior to the accident. The accident is consistent with maintenance personnel failing to properly tighten the oil hose fitting, which resulted in a total loss of engine power.

Factual narrative

On June 30, 2019, about 1134 Pacific daylight time, a Beechcraft C23 airplane, N24580, was substantially damaged when it was involved in an accident near Ludlow, California. The pilot and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated no anomalies were found during the preflight and 1 quart (qt) of oil was added for a total of 7.5+ qts.The pilot further stated that he was at cruise flight at 6,000 ft above ground level when he noted a faint smell of burning paint. Within 10 seconds, he observed the oil pressure drop to zero and the engine RPM decay to about 2,100. A couple of seconds later, the engine lost all power. The pilot subsequently performed an emergency landing. Upon impact with the terrain, the three-landing gear separated, the engine cowling was forced aft, and the firewall suffered deformation at the mounting points. Evidence of oil loss was visible on the lower left side of the fuselage. No oil appeared on the dipstick, which was properly secured. The engine was recently overhauled and had accumulated about 4 hours of operating time since returning to service. The engine was examined by a certified mechanic with oversight by a Federal Aviation Administration inspector at Chino, CA. The examination revealed that the AN hose fitting on the oil cooler was loose, and oil residue was present in the area of the fitting. No other pre-impact mechanical anomalies were detected that could have precluded normal operation.

Aircraft

Registration
N24580
Reported as
Beech C23
Category
Airplane
Serial number
M-1410
Built
1972
Airframe hours
3,889.37
Engine
Lycoming O&VO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Tiger Capital, LLC
Registered owner
Tiger Capital, LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 27, 2019
Departed
EED · Needles, CA
Destination
cno · Chino, CA
Equipment
Stall warning system, Electronic flight bag or handheld device, ADS-B, Video recording device

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
55
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine sea
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 1, 2019
Seat
Left
Restraint
4-point
Flight hours
18,000 total · 150 in this make and model · 17,800 as pilot in command · 100 in the last 90 days · 35 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
105 °F
Altimeter
30.00 inHg
Turbulence
Unknown
Observed at
EED, 75 nm away

Docket · 6

The files NTSB released with the investigation on January 25, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 28.3 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.

Other investigations on N24580 · 2

Matched to the same aircraft by N-number and date.