C210 pilot lost oil pressure and oil quantity and had the engine seize. He made a successful dead st...

Attributes
ACN	583155
Time
Date	200305
Day	Fri
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Light	Night
Aircraft 1
Operator	general aviation : personal
Make Model Name	Cessna 210 Centurion / Turbo Centurion 210C, 210D
Operating Under FAR Part	Part 91
Flight Phase	ground : maintenance
Person 1
Affiliation	other
Function	maintenance : technician
Qualification	technician : airframe technician : inspection authority technician : powerplant
Experience	maintenance technician : 5
ASRS Report	583155
Person 2
Affiliation	other
Function	maintenance : inspector
Qualification	technician : airframe technician : powerplant technician : inspection authority
Experience	maintenance lead technician : 14 maintenance technician : 20
ASRS Report	583377
Events
Anomaly	aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure other anomaly other
Independent Detector	other flight crewa
Resolutory Action	flight crew : landed in emergency condition flight crew : declared emergency flight crew : diverted to another airport none taken : detected after the fact other
Consequence	other other
Factors
Maintenance	contributing factor : work cards contributing factor : schedule pressure performance deficiency : repair performance deficiency : testing performance deficiency : installation performance deficiency : inspection
Supplementary
Problem Areas	Company Maintenance Human Performance Aircraft
Primary Problem	Maintenance Human Performance

Narrative:

The pilot reported loss of engine power, at which time, the pilot noticed the loss of oil pressure. An emergency was declared. The engine shut down by itself short of the airport, where the pilot made a successful engine out landing. No further damage to the aircraft was sustained and no injuries to the pilot or passenger were sustained. My chief inspector made a visual inspection of the engine after the incident and noticed a loose b-nut on an oil pressure line below the #4 cylinder area. This location appears to be the area where the oil left the engine. Also the #4 connecting rod was found broken with damage to the crank case. The #1 and #4 cylinders were replaced prior to this flight. The loose oil line was removed and reinstalled during the #4 cylinder replacement. The engine was run on the ground for 40 mins performing leak and operational checks as well as other checks to the aircraft. A leak was noticed coming from an adjacent oil line from the loose one. The leak was corrected and further engine ground runs showed no more leaks. A flight test was not performed due to an urgent need for the aircraft. After reviewing what I did as well as what my inspector did, in performing the final checks on the aircraft before releasing it for flight, I can only think that a test flight may have shown a problem which could have been corrected before further flight. As well as a second check of the line that was found to be loose with a wrench when the line that was found to be loose during ground run-up was tightened. Supplemental information from acn 583377: the line had either failed or vibrated loose. Work was just completed changing #1 and #4 cylinder. The oil line was removed during the maintenance on the engine, but the technician was sure he had tightened the b-nut. It is possible the line was damaged during the removal and installation of #4 cylinder. Engine had been run on the ground for at least 40 mins doing other checks. 1 oil leak had been corrected and no other leaks were found.

Original NASA ASRS Text

Title: C210 PLT LOST OIL PRESSURE AND OIL QUANTITY AND HAD THE ENG SEIZE. HE MADE A SUCCESSFUL DEAD STICK LNDG. MAINT HAD JUST REPAIRED THE ENG AND LEFT AN OIL LINE LOOSE.

Narrative: THE PLT RPTED LOSS OF ENG PWR, AT WHICH TIME, THE PLT NOTICED THE LOSS OF OIL PRESSURE. AN EMER WAS DECLARED. THE ENG SHUT DOWN BY ITSELF SHORT OF THE ARPT, WHERE THE PLT MADE A SUCCESSFUL ENG OUT LNDG. NO FURTHER DAMAGE TO THE ACFT WAS SUSTAINED AND NO INJURIES TO THE PLT OR PAX WERE SUSTAINED. MY CHIEF INSPECTOR MADE A VISUAL INSPECTION OF THE ENG AFTER THE INCIDENT AND NOTICED A LOOSE B-NUT ON AN OIL PRESSURE LINE BELOW THE #4 CYLINDER AREA. THIS LOCATION APPEARS TO BE THE AREA WHERE THE OIL LEFT THE ENG. ALSO THE #4 CONNECTING ROD WAS FOUND BROKEN WITH DAMAGE TO THE CRANK CASE. THE #1 AND #4 CYLINDERS WERE REPLACED PRIOR TO THIS FLT. THE LOOSE OIL LINE WAS REMOVED AND REINSTALLED DURING THE #4 CYLINDER REPLACEMENT. THE ENG WAS RUN ON THE GND FOR 40 MINS PERFORMING LEAK AND OPERATIONAL CHKS AS WELL AS OTHER CHKS TO THE ACFT. A LEAK WAS NOTICED COMING FROM AN ADJACENT OIL LINE FROM THE LOOSE ONE. THE LEAK WAS CORRECTED AND FURTHER ENG GND RUNS SHOWED NO MORE LEAKS. A FLT TEST WAS NOT PERFORMED DUE TO AN URGENT NEED FOR THE ACFT. AFTER REVIEWING WHAT I DID AS WELL AS WHAT MY INSPECTOR DID, IN PERFORMING THE FINAL CHKS ON THE ACFT BEFORE RELEASING IT FOR FLT, I CAN ONLY THINK THAT A TEST FLT MAY HAVE SHOWN A PROB WHICH COULD HAVE BEEN CORRECTED BEFORE FURTHER FLT. AS WELL AS A SECOND CHK OF THE LINE THAT WAS FOUND TO BE LOOSE WITH A WRENCH WHEN THE LINE THAT WAS FOUND TO BE LOOSE DURING GND RUN-UP WAS TIGHTENED. SUPPLEMENTAL INFO FROM ACN 583377: THE LINE HAD EITHER FAILED OR VIBRATED LOOSE. WORK WAS JUST COMPLETED CHANGING #1 AND #4 CYLINDER. THE OIL LINE WAS REMOVED DURING THE MAINT ON THE ENG, BUT THE TECHNICIAN WAS SURE HE HAD TIGHTENED THE B-NUT. IT IS POSSIBLE THE LINE WAS DAMAGED DURING THE REMOVAL AND INSTALLATION OF #4 CYLINDER. ENG HAD BEEN RUN ON THE GND FOR AT LEAST 40 MINS DOING OTHER CHKS. 1 OIL LEAK HAD BEEN CORRECTED AND NO OTHER LEAKS WERE FOUND.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.

C210 pilot lost oil pressure and oil quantity and had the engine seize. He made a successful dead stick landing. Maintenance had just repaired the engine and left an oil line loose.