# NTSB WPR19LA187: Beech C23, N24580, Ludlow, CA, June 30, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 30, 2019, 11:34 local (18:34 UTC) - Place: Ludlow, CA - Coordinates: 34.914722, -115.796386 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.9147&lon=-115.7964&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 99848 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99848/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99848 - Page: https://openairdocs.org/ntsb/WPR19LA187 ## Probable cause Maintenance personnel’s failure to properly tighten an oil line fitting, which resulted in a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1151242), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=1151242), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech C23, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151242), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-cruise: Emergency descent initiated](https://openairdocs.org/ntsb-events/130); cases with it: [Beech C23, 1 case](https://openairdocs.org/ntsb-events/130/sequence.md?model=1151242), [All aircraft, 42 cases](https://openairdocs.org/ntsb-events/130/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech C23, 25 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151242), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N24580-2022-07-26), registration cancelled 2022-07-26, S/N M-1410, built 1972 (OpenAirDocs) - Reported make and model: BEECH C23 - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1410 - Year built: 1972 - Airframe hours: 3889.37 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; 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 ## 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 20190630008689A](https://openairdocs.org/incident/20190630008689A), Jun 30, 2019: Beech C23, Ludlow, CA, Substantial damage. The engine of the aircraft had been zero timed just two flight hours prior to the accident flight due to reaching tbo. For break-in, the repair facility told… ## Other investigations on N24580 (2) 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. - [NTSB LAX89LA300](https://openairdocs.org/ntsb/LAX89LA300), Sep 2, 1989: Beech C23 (N24580), Selma, CA, substantial damage. Probable cause: THE PILOT'S FAILURE TO MAINTAIN PROPER CLEARANCE FROM THE POWER LINE, WHILE MANEUVERING AT LOW ALTITUDE. THE POWER LINE WAS A RELATED FACTOR. - [NTSB MKC74DCQ42](https://openairdocs.org/ntsb/MKC74DCQ42), Jun 2, 1974: Beech C23 (N24580), Marquette, KS, substantial damage ## Docket (6 files) The files NTSB released with the investigation on January 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99848. 28.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12230952&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - NTSB roc - exam (item 2, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13127629&FileExtension=pdf&FileName=RECORD%20OF%20phone%20CONVERSATION-Rel.pdf - Oil leak pictures (courtesy of mechanic p. blood) (item 3, PDF, 3 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12230388&FileExtension=pdf&FileName=Chino%20engine%20inspection%20-Rel.pdf - Oil leak video (courtesy of mechanic p. blood) (item 4, MOV, 12.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12230662&FileExtension=MOV&FileName=IMG_2156-Rel.MOV - Release of aircraft wreckage, NTSB form 6120.15 (item 5, PDF, 1 page, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13148920&FileExtension=pdf&FileName=Wreckage%20Release%20signed_Redacted-Rel.pdf - Photos (courtesy of FAA inspector) (item 6, PDF, 17 pages, 8.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12226137&FileExtension=pdf&FileName=N24580_Dilullo_Photos-Rel.pdf 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.