Aircraft: Cessna 310. Injuries: 2 Fatal. Location: Stotts City, Mo. Aircraft damage: Destroyed.
What reportedly happened: The right engine of the twin Cessna had recently undergone extensive maintenance. The pilot and the pilot-rated passenger originally planned to make several circuits in the traffic pattern to test the right engine, then fly the airplane to a nearby airport. However, the test flight was delayed to make an adjustment to the propeller lever friction lock. Because of the delay, the test flight did not happen until after sunset.
According to witnesses, the airplane’s nose gear landing strut was flat before departure and the pilots agreed they would leave the landing gear extended for the flight.
Instead of doing circuits in the pattern, the pilots decided to fly directly to the other airport. While en route, the right engine lost oil pressure, then lost power.
The pilot flying shut down the right engine, feathered the propeller and attempted to return to the departure airport. The Cessna 310 was not able to maintain altitude. The airplane crashed into trees and caught fire.
The post-accident examination of the right engine revealed the oil filter adapter was not properly assembled or adequately secured to the engine. The mechanic who performed maintenance to the oil adapter admitted that he did not follow the manufacturer’s instructions when reassembling the adapter and when installing it on the engine. As a result, the adapter came loose during flight, resulting in a loss of oil.
Based on the single-engine performance data provided by the airplane manufacturer, the airplane should have had a single-engine climb rate of about 166 feet per minute with the landing gear extended, assuming the airplane was properly configured and the operating engine was producing full power.
Probable cause: The pilot’s failure to maintain control after he shut down the right engine in flight due a loss of oil pressure. Contributing to the accident was the pilot’s decision to reposition the unairworthy airplane during twilight after extensive maintenance had been done to the right engine along with a known mechanical deficiency with the landing gear and the mechanic’s improper assembly and installation of the right engine’s oil filter adapter, which resulted in a loss of oil to that engine.
NTSB Identification: CEN13FA044
This November 2012 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
With extensive maintenance on an aircraft engine, the aircraft’s owner should NEVER use an A&P mechanic who would not pre-agree to accompany the first post-maintenance flight at the field where the engine maintenance was done. Would an extensive pre-flight (necessary by the owner/pilot) have seen the incorrect reassembly/ safety wiring of the oil filter?
If they had retracted the landing gear they might have made it…………..
If they had not taken off with a known mechanical deficiency, they may have survived it. Heavy maintenance, two known problems on the ground, (prop. control and flat nose strut) and two people in the airplane,then they left at night to a distant airport. That is quite the chain of events waiting for a bad out come.Poor maintenance,( at least two items identified before the flight), was one thing that cased a problem, the pilot’s decisions got them killed.
Tom, I agree, retract the gear could have made all the difference. I suspect the mechanic is taking a refresher course.
Taking a refresher course? Why? He probably won’t keep his A&P after admitting to being the primary cause of a double fatality accident though the deceased PIC will be a close secondary cause for lack of judgement and failure to fly what should have a flyable airplane on a single engine with or without the gear retracted but definitely with it retracted. Once again that ole sage proves to be true: “The second engine on many light twins is there to ensure you as the PIC are the first one at the scene of the accident” not for lack of performance capability for the airplane but for the PIC.
After reading the documents in the NTSB docket, failure of the engine was a distinct possibility. The A&P didn’t torque the oil filter adapter when he reassembled it (he just tightened it until it “felt” like the required torque value). he was unaware of the assembly instructions in the oil filter adapter STC. He didn’t use the STC required gasket, and instead used a copper crush which he didn’t crush because of inadequate torque. He didn’t follow the manual for threading the adapter to the engine casing, nor did he correctly safety wire the filter.
The mechanic’s defense was that he’d not signed off the airplane for flight and the plane didn’t undergo a recommended post maintenance test flight. He argues the pilot bore full responsibility for knowingly operating an unairworthy plane without signoffs or a ferry permit. I hate to admit it, but I have to agree that the mechanic’s culpability wasn’t yet conclusive, given there were no operational test flights that could have exposed the mechanic’s failure to follow procedures.
The pilot/owner departed an airport environment at night for an UNLIGHTED destination airport following major engine maintenance, without conducting even a token few laps around the pattern. That plus known gear issues, plus, plus, plus. While not directly cited by NTSB as causal, the pilot’s use of drugs with known cognitive effects, “gotta go-itis”… The pilot and passenger had no margins when flying that unairworthy plane. Sad that the CFI rated passenger didn’t want to go, but gave in at the insistence of the owner pilot. I wonder if there was an employer-contractor/employee relationship where the CFI rated passenger felt he had no option to decline the pilot/owner’s demand to go?