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NTSB Report
July 9, 1989 · Cessna P210N · N609AC
Los Angeles, CA
Overview
Report Status
Probable Cause
Event Type
Accident
Date
July 9, 1989
Injury Outcomes
2 injuries (1 serious injury, 1 minor injury)
Location
Los Angeles, CA
Aircraft
Cessna P210N
Tail Number
N609AC
Injuries
Serious
Aircraft Damage
Destroyed
NTSB Number
LAX89LA233
ON THE FIRST FLT AFTER THE ACFT'S ANNUAL INSPECTION FOLLOWING REPLACEMENT OF ALL OIL LINES, THE CFI PLANNED TO GIVE THE ACFT'S OWNER/PLT A BFR. FIVE MIN AFTER TAKEOFF, THE CREW OBSERVED THAT THE OIL PRESSURE GAGE INDICATED NEAR ZERO LBS OF PRESSURE. THE CFI MONITORED THE OIL TEMP GAGE & THE TEMP WAS IN THE GREEN ARC. THE CREW ALERTED ATC OF THE SITUATION & REC'D AN IFR CLEARANCE BACK TO THE ARPT. DURING THE NEXT 14 MIN, THE OIL PRESSURE NEEDLE REMAINED SLIGHTLY ABOVE RED LINE, THE OIL TEMP REMAINED STABLE & IN THE GREEN ARC. THE ACFT PASSED THE FINAL APPROACH FIX & CONTINUED TO OPERATE NORMALLY. SUDDENLY, ALL ENG PWR WAS LOST. THE CFI MADE A FORCED LDG ON A GOLF COURSE 3 MI FM THE ARPT. EXAM OF THE ENG REVEALED INTERNAL HEAT DISTRESS & BROKEN CONN RODS. FURTHER EXAM REVEALED A 'B' NUT ON A NEWLY INSTALLED OIL LINE HAD NOT BEEN SECURELY TORQUED & HAD COME LOOSE AT ITS ENG CASE ATTACHMENT FITTING. THE OIL LINE WAS FOUND SATURATED WITH OIL.
NTSB Probable Cause
AN UNDERTORQUED OIL LINE FITTING, DUE TO ITS IMPROPER INSTALLATION BY MAINTENANCE PERSONNEL, WHICH RESULTED IN A LOOSE OIL LINE FITTING, AN OIL LINE LEAK, OIL EXHAUSTION, AND SUBSEQUENT FAILURE OF THE ENGINE.
Full Narrative
ON THE FIRST FLT AFTER THE ACFT'S ANNUAL INSPECTION FOLLOWING REPLACEMENT OF ALL OIL LINES, THE CFI PLANNED TO GIVE THE ACFT'S OWNER/PLT A BFR. FIVE MIN AFTER TAKEOFF, THE CREW OBSERVED THAT THE OIL PRESSURE GAGE INDICATED NEAR ZERO LBS OF PRESSURE. THE CFI MONITORED THE OIL TEMP GAGE & THE TEMP WAS IN THE GREEN ARC. THE CREW ALERTED ATC OF THE SITUATION & REC'D AN IFR CLEARANCE BACK TO THE ARPT. DURING THE NEXT 14 MIN, THE OIL PRESSURE NEEDLE REMAINED SLIGHTLY ABOVE RED LINE, THE OIL TEMP REMAINED STABLE & IN THE GREEN ARC. THE ACFT PASSED THE FINAL APPROACH FIX & CONTINUED TO OPERATE NORMALLY. SUDDENLY, ALL ENG PWR WAS LOST. THE CFI MADE A FORCED LDG ON A GOLF COURSE 3 MI FM THE ARPT. EXAM OF THE ENG REVEALED INTERNAL HEAT DISTRESS & BROKEN CONN RODS. FURTHER EXAM REVEALED A 'B' NUT ON A NEWLY INSTALLED OIL LINE HAD NOT BEEN SECURELY TORQUED & HAD COME LOOSE AT ITS ENG CASE ATTACHMENT FITTING. THE OIL LINE WAS FOUND SATURATED WITH OIL.
Flight
Event TypeAccident
Event Time11:33 PDT
Nearest Airport0nm N
Runway0
Flight Plan FiledIFR
Aircraft FireGrd
Aircraft ExplosionNo
Aircraft
AircraftCessna P210N
Tail NumberN609AC
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · TSIO-520-P · Reciprocating · 285
Seats6
People & Injuries
Injury Summary2 injuries (1 serious injury, 1 minor injury)
Fatal0
Serious1
Minor1
Uninjured0
Total2
Crew 1Age 43 · First Class
Conditions
ConditionsVMC
LightDaylight
Wind240° @ 5 kt
Visibility7 sm
CeilingBroken clouds 1200 ft
Temperature / Dew Point63 F
Altimeter29.00 inHg
Observation Time18:32
Weather SourcePILO