The private pilot and his two passengers departed on a local pleasure flight in the Cessna 210 near Pagosa Springs, Colo. Right after takeoff, engine oil covered the windscreen and the engine began to lose power.
According to a video of the accident, the pilot made a tear-drop turn in an attempt to land on the opposite runway. The airplane lost altitude during the turn and the pilot overshot the runway.
He said that as he crossed over the runway, he reduced power to idle. As he attempted to turn back toward the runway, he turned off the master switch.
The plane descended quickly and landed adjacent to the runway in packed snow. The airplane landed hard on the main landing gear and with the right wing low before it slid for about 300 feet, resulting in substantial damage to the fuselage and right wing, and causing minor injuries to two of the plane’s occupants.
The landing gear, right flap, left wing tip, and all three propeller blades were also damaged.
Post-accident examination of the engine revealed the oil filler cap was not secured to the oil filler neck. The pilot said this was the first flight after the oil had been changed by a maintenance facility. He did not check the oil filler cap before the flight because it was not required by the FAA approved preflight inspection checklist.
The NTSB determined the probable cause as the pilot’s inadequate preflight inspection which led to a loss of oil pressure and partial loss of engine power on takeoff. Contributing to the accident was the pilot’s failure to check the security of the oil filler cap prior to the flight.
NTSB Identification: CEN14CA106
This January 2014 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.
The pilot is a moron? Really? The maintenance shop set the chain of events in motion.
The NTSB and FAA shift legal causation to the pilot despite the clear fact that the oil change facility created this nightmare and set up a ‘gotcha’ trap for the pilot who trusted his maintenance facility with a simple routine task.
Ok, so we all make mistakes, but no enforcement action against them? Just the pilot? Pretty lame really. I’m so tired of systematic blame assigned against pilots all day long for everything in connection with a flight. Here, that’s just wrong.
If I was the pilot I would be pretty upset. FAR 91.103 does not dictate removal and reinstallation of an engine oil cap during a preflight. (“Each pilot in command shall, before beginning a flight, become familiar with all available information concerning that flight.”)
A pilot is not required under any preflight procedure to remove any oil cap on that type aircraft and reinstall it except when addition oil. You find me a manual or regulation that says otherwise. The pilot was correct in his analysis.
What about other things that might have been messed up during the maintenance? What if the oil drain plug had come off? Blame the pilot?
Get real people. Do you commenters own your aircraft and pay for maintenance?
Pilot takes the airplane for maintenance, is told its performed, gets a bill and pays it. Is she now required to go behind the facility and check every conceivable area that might have been touched, or the entire aircraft? Apparently so.
What about avionics? Wiring hidden from view? What about gaskets that may appear to be installed but are actually upside down – it happens.
The oil cap scenario may seem not worthy of discussion for some of you, but the same logic of the NTSB and FAA would blame the pilot for things she can’t even get to or begin to see or test, or have the knowledge to evaluate or test as well. And should not have to. A&Ps have a license for a reason. Are we not entitled to trust that work? Do we not in fact trust it with our lives?
Get ready. Better check your aircraft well. Watch that landing gear and make sure its not about to collapse on you. Better hope everything is 100%. Guess who’s fault it will be.
Insane, where do you stop with this craziness. Any pilot checking things like the oil filler cap would be going above and beyond what would be consider normal preflight procedures.
Just remember, everyone who touches your plane, is trying to KILL you.
Mining the NTSB Docket usually turns up interesting information, and for this accident it paid off again. Here’s a copy of an email exchange between the aircraft owner/pilot and the maintenance facility prior to the accident. It looks like the maintenance facility may own a wrecked C210, though the pilot failed to make an effort to discover the fault…:
‐‐‐‐‐Original Message‐‐‐‐‐
From: J T Alfred
Sent: Friday, December 27, 2013 7:13 AM
To: Pat Artis
Subject: Re: Have you run up the P210 after the oil change
Yes
On Dec 26, 2013, at 9:01 PM, Pat Artis wrote:
> I may fly this week
>
> Pat Artis
> Sent from my iPad
I was the aircraft commander taking an SH-3D (Navy antisubmarine warfare version of the Sikorsky S-61) on its maiden post-maintenance check flight after complete overhaul at the Naval Air Rework Facility. As usual, we nit-picked everything we could find on the helo and finally launched from Quonset Point (RI) Naval Air Station. Everything about the airframe and engines checked out perfectly, to our surprise and delight. When we came to a 40-foot hover over Narraganset Bay to check out the dipping sonar, all 400 feet of the cable and the VERY expensive sonar dome came flying out of the underside of the aircraft. Seems the rework facility had “preserved” the emergency hydraulic buttons with Paralketone, ensuring that the emergency control for the “down” direction was locked open as soon as the reeling machine brake was released. Note to self: even a perfect preflight can miss the unexpected, as Grampaw Pettibone would have said.
Thanks for posting this
I can use this example in my ground school classes….
This could fall into situational awareness or maybe decision making or.., never mind
I see the problem after reading the article again ( there was snow everywhere and it was cold outside so that meant taking off gloves and opening a cold cowl ). Yeh I know those are not in the preflight
Sorry to hear the damage to aircraft and perhaps the snow saved lives
Always sad to hear about a plane going down and passengers’ minor injuries. Not a surprise to read the NTSB’s probable cause is inadequate preflight and contributing cause was failure to check the oil cap… No mention of the shop shows the buck stops with the PIC for the flight…
I was taught to check extensively after a trip to the maintenance shop especially around parts that could have been touched (and I found cowl flaps not reconnected, failed elevator trim, cowl not attached properly etc). And Mike Busch’s Maintenance Induced Failures columns only reinforced me to pay extra attention.
I was also taught to do a test flight (VFR day) and log it before taking any passenger or doing night/IMC… Maybe overkill after a simple oil change but again if we are carrying pax, probably loved ones, no reason to expose them to additional risks.
The reference to FAA check lists sounds a bit off since the buck stops with PIC responsibilities. But since he has brought up this topic, I believe the FAA is clearly passing the buck to the PIC in numerous entries like
§91.7 Civil aircraft airworthiness and §91.407 Operation after maintenance, preventive maintenance, rebuilding, or alteration.
Doesn’t hurt to go and regularly practice Impossible Turns before doing one in an emergency. These maneuvers aren’t as easy as they seem but feasible.
I guess this guy is better at being a lawyer then a pilot.
Not required by FAA?! Who in his right mind will jump into an airplane without a proper pre flight?
Buddy, do us all a favor, switch to boating, this airplane “stuff” is not for you.
The oil level was not checked?
He checked the oil with the “dip” stick. I’m assuming he did so because it WAS on the FAA approved preflight inspection checklist? Because, “He did not check the oil filler cap before the flight because it was not required by the FAA approved preflight inspection checklist.”
PARTIAL blame on the facility? Are you kidding me?
BUT FOR the failure of the maintenance personnel on this accident airplane (the lack of the maintenance shop checking the work) this would not have happened. That is crystal clear. The mechanic’s mishap was as basic as they come. Indeed, not applying the basics are where most accidents find their root cause.
Nevertheless, this one offends my sense of right and wrong because the NTSB and FAA place blame squarely on the shoulders of the pilot for EVERYTHING in connection with a flight. If it was the investigator’s aircraft that maintenance did not secure the oil filler cap on I just bet she would have thought differently. What do you think?
Let’s get real. Let’s get in that left seat of that accident airplane for a few minutes and rewind the
tape.
I take my bird for maintenance –and let’s say any kind of maintenance – it doesn’t matter. It is performed I am told, I am provided an invoice, and I pay. Am I now required to go behind and check everything single thing that was alleged to have been done? Am I required to check areas that I do not have ready access to? For example, what about avionics wiring? Or some wiring improperly performed hidden from view that might cause a fire? What about an improper spark plug? A line with a pin hole, a part that may not have been safety wired correctly? A flight control cable that was stretched by a tired mechanic or helper and is soon to snap? An incorrect gasket or seal, or one installed upside down? It happens. An oil filter not tightened properly, but to our eyes looked perfectly in place. The oil cap may look fine, but its gasket seal may not have been reinstalled. Even though I ‘check’ all these things with my trained or untrained eyes as the case may be, this brings us to another issue. Suppose that I see something that does not look right, what authority do I have, as pilot, to override the maintenance procedures of a licensed A&P? What authority do I have to change it as performed? But because responsibility for an accident is likely to be placed on my shoulders, am I required to go behind him and undo his work on a preflight? Under what authority? I am not an A&P, nor do I have to be to have to hold a PPL in the U.S.
Yet, under this C210 accident report the fault is transferred to me as Pilot in Command.
Yes, the pilot COULD have found it. The question is, was it his DUTY to find it. The current regulation says YES. Although we all can come up with many creative examples where we would have no way to know of a mechanical or electrical problem about to smack us in the face during a preflight, we all know what FAR 91.103 says: “Each pilot in command shall, BEFORE beginning a flight, become familiar with ALL available information concerning that flight.” [Emphasis added]. That seems to say it all. The question is where is the limitation of that duty. How long do I spend on preflight? And how far do I have to go behind my dear friends, the A&Ps and their helpers, and check items that I entrusted to their care?
So, as we sit in the left set of the accident airplane, looking forward to the flight (not reviewing the accident) what are we thinking? We are thinking that I just had the oil changed and all is good. The engine will be happy. Less wear. Less stress. I’m glad I did it. I’m glad they changed the oil. I’m taking care of my aircraft. That’s what we think. But the accident report cautions us to do just the opposite.
This accident report has another sinister implication. It seems to shift legal causation to the Pilot.
Does that provide the maintenance facility a ‘free pass’ to be negligent? Let’s hope not. How often do we see an aircraft returned to service after maintenance only to have a problem shortly thereafter.
I reviewed the December, 2105 NTSB Aviation Monthly Accident Reports. Out of 82 reports, 5 were within days or weeks after their annual inspection. See, N88F Piper Comanche accident on 12-4-15, Annual: 11-13-15; N8777T, Cessna 182 accident 12-6-15, annual just completed; N39AY L39 jet accident 12-6-15, annual 11-23-15;
2 more reports in December, 2015 are suspicious. One of those reports makes me wonder whether avionics work or some other maintenance may have been performed by one of the facilities at the accident airport, (because of the pilot’s reported comment – See, N145JR Piper Meridian 12-10-15 ) and one poor soul was departing with his newly repainted Mooney from the paint shop. M20E N5863Q on 12-14-15.
The NTSB’s ‘new’ design for the Monthly Accident database makes browsing a difficult job, taking twice as long to complete simple tasks as it did before, by the way. It took me a good three hours to go through the reports just for December, reading as quickly as I could. Frustrating.
Even more frustrating, is the lack of information in some preliminary reports, and when I say ‘lack’ I mean there is NOTHING. 26 of the 82 reports in December had only the phrase: “NTSB investigators will use data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator, and will not travel in support of this investigation to prepare this aircraft accident report.”
No help at all.
And the remaining reports were silent about maintenance or annual inspections, even in some of the catastrophic engine failures cases, e.g., December 01, 2015 Opa Locka, FL Piper PA-32, N5568J; December 15, 2015 Brunswick, GA Piper PA-32, N8675N; December 27, 2015 Watertown, WI, Cirrus SR22, N5PF.
Am I intending to slam the A&P and maintenance personnel here? No. Without these guys, many of whom are some of the smartest people I’ve ever met, we don’t fly, and we certainly wouldn’t fly safe. Even the best of us can and will make mistakes. It is a human condition. We try to prevent mistakes.
There are risks in every flight, indeed in every pursuit you can imagine, but some risks are worth taking. That’s why we are pilots.
Conclusion in the case of the C210 here:
The truth is always that there are a number of causes in any accident, but whether the pilot was adjudged at fault or not in this one, let’s get real folks: BUT FOR the oil change personnel mess up, this sequence of events would not have happened. (“But for” is a form of legal analysis in causation).
The pilot had the last clear opportunity to check the oil cap. Should he? What else should he or she have checked? The viscosity of the oil? Undone the cowling and checked the oil drain plug? Looked that filter with a flashlight and a mirror? Looked to see if all the hoses and lines were still connected in the engine compartment? What do you think? I’m going to guess there will be different views, which is precisely one of the points I am trying to spotlight.
If you read the accident reports over the years, you will see a practice of systematic blame-laying by authorities against the Pilot. My conclusion is the historic rush to find pilot error, almost a presumption if you will, should be tempered with reality and fair judgment.
— By the way: I can’t wait to see how the drone pilots are dealt with! I can only imagine the License Revocation proceeding. Will they be in the accident reports? It’s coming, folks. It’s here.
hksawyer@gmail.com
Attorney
Stupid is, as stupid does. Forget the FAA, anyone who preflights an airplane using an FAA approved checklist is asking for problems, a preflight should include a general inspection of the entire engine compartment, not only checking oil fill caps, but exhaust system, spark plug wires , bafflrs, cylinder bases and many other items, pilots today are too well trained in operating avionics and auto pilots but not at all trained in the workings of the powerplant and other systems.
Exactly what it says. Checking the engine oil quantity is on the preflight list. Doesn’t say anything about the oil cap, only fuel caps. I would put at least partial blame on the maintenance facility.
“He did not check the oil filler cap before the flight because it was not required by the FAA approved preflight inspection checklist.”
I’m confused. Could someone clarify?
Clarification: The guy’s a moron.
John Wesley’s comment above is spot on.