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NTSB Report

August 7, 2015 · Cessna 182F · N5738F

Montecito, CA

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
August 7, 2015
Injury Outcomes
2 injuries (2 fatalities)
Location
Montecito, CA
Aircraft
Cessna 182F (1963)
Tail Number
N5738F
Operator
Pacific Coast Flyers
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
WPR15FA236

The commercial pilot was conducting a cross-country business flight. While en route to the destination airport, the pilot reported to an air traffic controller that they were going to lose an engine. The flight was over mountainous terrain; the controller provided nearby airports to the pilot, and the pilot chose a diversionary airport. The pilot then reported that the airplane was experiencing vibrations and that he could not see anything due to oil on his windscreen, as well as smoke that had entered into the cabin. The controller told the pilot that he would report an emergency for him; no further communications were received from the pilot. The airplane was located the following morning in mountainous terrain. The airplane struck a mountain at an elevation of 3,554 ft. On-site examination of the wreckage revealed that the airplane came to rest inverted with the undercarriage covered in oil from the nose to the tail. An examination of the airframe revealed no mechanical anomalies that would have precluded normal operation. The engine teardown examination revealed a hole in the engine crankcase above the No. 6 connecting rod. The No. 5 connecting rod had fractured and separated from the crankshaft, which caused internal damage to the engine and led to the loss of engine power. The internal components exhibited signs of oil starvation; however, the cause of the oil starvation could not be determined. Although a small amount of ethanol was detected in the pilot's cavity blood, no ethanol was detected in the vitreous or urine, indicating that the detected ethanol was likely due to postmortem production and did not contribute to the accident. Although the pilot's tissue samples tested positive for small amounts of the inactive metabolite of marijuana, no active drug was detected in the pilot's blood; therefore, the pilot was likely not experiencing significant effects from his marijuana use at the time of the accident.

NTSB Probable Cause

Oil starvation that led to the failure of the No. 5 connecting rod and a subsequent loss of engine power.

Full Narrative

HISTORY OF FLIGHT On August 6, 2015, about 2210 Pacific daylight time, a Cessna 182F airplane, N5738F, impacted mountainous terrain about 15 miles northeast of Montecito, California. The pilot and passenger were fatally injured, and the airplane sustained substantial damage. The airplane was registered to a private individual and operated by Pacific Coast Flyers as a 14 Code of Federal Regulations Part 91 cross-country business flight. Night visual meteorological conditions existed near the accident site about the time of the accident, and no flight plan had been filed. The flight had departed from the San Luis County Regional Airport, San Luis Obispo, California, at an undetermined time, and was destined for Mc Clellan-Palomar Airport, Carlsbad, California. The pilot checked in with Point Mugu Approach Control at 2147:31. Less than 1 minute later, the pilot reported that there was a problem, and reported that he wasn't sure where they were going from here, and asked for directions. At 2148:26, the pilot reported that they were going to lose an engine, and then stated, "here something just happened." The controller and the pilot then discussed nearby diversionary airports, they chose Santa Barbara. At 2149:27, the pilot reported vibrations and that he couldn't see anything. He then reported an oil problem, "I think… we lost something." At 2150:21, the pilot reported that smoke was coming into the cabin; the controller told the pilot he was going to declare an emergency for him. No further communications were received from the pilot after 2150:58. At 2151:34, the approach controller reported to the Los Angeles Air Route Traffic Control Center that the accident airplane had blown something, that the windshield was covered with oil, that there was smoke in the cockpit, and that the pilot was attempting to get to Santa Barbara. The Ventura County Sheriff's Department located the airplane wreckage the next morning at 0430 in mountainous terrain. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with a rotorcraft-helicopter rating, and private pilot privileges for airplane single- and multiengine land. The pilot's personal flight records were not located. A review of the Federal Aviation Administration (FAA) airmen medical records revealed that the pilot was issued a time-limited, special issuance, second-class on March 7, 2015. On his medical certificate application, the pilot reported 6,250 total flight hours and 50 hours in the previous 6 months. The Aerospace Medical Certification Division withdrew the special issuance and issued a general denial on April 27, 2015, for alcohol dependence and failure to report a 2013 DUI. On July 29, 2015, the pilot requested a reconsideration because he had completed alcohol treatment and was in aftercare, but a decision was pending at the time of the accident. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number 18254796, was manufactured in 1963. It was powered by a Continental Motors O-470-R 230-horsepower reciprocating engine. The airplane was purchased by a private owner on November 22, 2014, and was leased to Pacific Coast Flyers as a rental airplane. A review of the airplane's maintenance logbook revealed that an annual/100-hour inspection was completed on May 1, 2015, at which time the airframe total time was 6,050.25 hours, and the engine time since major overhaul was 250.4 hours. The engine was overhauled by Corona Aircraft Engines, Corona, California; test run, and returned to service on September 10, 2009, as a zero hours-SMOH engine. The engine was installed on the accident airplane on September 18, 2009, at an airframe total time of 5,529.85 hours. A March 18, 2011, Blackstone Laboratories oil sample report noted that there was an excessive amount of metal in an oil sample; that had been submitted for testing, and suggested a thorough inspection of the engine before operating the airplane. An April 29, 2013, oil sample report noted that there was some improvement, but that an excessive amount of metal was still present in the oil sample, and that "this engine could have some serious issues in the works." The report suggested that the operator look for cylinder issues and/or exhaust valve guide problems, change the oil every 30 hours, and proceed with caution. A December 9, 2013, Blackstone Laboratories oil sample report indicated that the amount of wear metals in the sample were "coming down" from previous samples, but recommended that the operator try a shorter oil run to wash out the excess metals and then resample the oil in about 30 hours. An April 15, 2014, oil sample report showed that the amount of wear metals in the oil sample were much lower, and that the improvements were promising. The laboratory suggested using another shorter oil run, and submitting another sample. A February 19, 2015, oil sample report stated that the oil sample was better than past samples, and that the wear metals were in the average range. There was no contamination identified at this time; engine total time was 486 hours since major overhaul. METEOROLOGICAL INFORMATION The nearest weather reporting station from the accident site was located 23 nautical miles southwest of the accident site at the Santa Barbara Municipal airport (SBA), Santa Barbara, California. At 2153, the weather was reported as clear sky, visibility 10 statute miles. The temperature was 21 degrees C, dew point was 17 degrees C. The wind was from 100 degrees at 6 knots. The altimeter setting was 29.83 Hg. The end of civil twilight occurred at 2023. WRECKAGE AND IMPACT INFORMATION The airplane impacted a mountain at an elevation of 3,554 ft. The airplane came to rest inverted on a near-vertical slope about 300 feet below the top of the ridgeline; the airplane came to rest about 50 ft below the impact point. The airframe examination revealed no mechanical anomalies that would have precluded normal operation. Oil was observed on the airplane's undercarriage from the nose to the tail cone. A visual examination of the engine revealed a hole in the top of the engine case near the No. 6 cylinder. The engine was shipped to the manufacturer for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The Santa Barbara County Sheriff-Coroner, Coroner's Bureau, conducted an autopsy on the pilot. The cause of death was reported as "multiple traumatic injuries." The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The testing detected 0.0431 and 0.002 (ug/ml, ug/g) tetrahydrocannabinol carboxylic acid, the inactive metabolite of marijuana in the liver and cavity blood respectively; no tetrahydrocannabinol (marijuana) was detected in the cavity blood. No ethanol was detected in the urine or vitreous; 67 (mg/dL, mg/hg) ethanol was detected in cavity blood. TEST AND RESEARCH An engine teardown examination was performed, and it revealed that the No. 5 connecting rod had fractured and separated from the crankshaft, which caused internal damage to the engine. The engine's internal components exhibited signs of oil starvation. Residual oil was found in the top and front of the engine crankcase.

Flight

Event TypeAccident
Event Time22:10 PDT
Nearest Airport0nm
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna 182F
Tail NumberN5738F
Aircraft CategoryAir
DamageSubstantial
OperatorPacific Coast Flyers
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsCont Motor · O-470-R · Reciprocating · 0
Seats4

People & Injuries

Injury Summary2 injuries (2 fatalities)
Fatal2
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 58 · None · Fatal

Conditions

ConditionsVMC
LightDark Night
Wind100° @ 6 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point70 F / 63 F
Altimeter29.82 inHg
Observation Time04:53
Weather SourceWFAC

Appendix: Source Data