Aircraft Accident/Incident Report

Byron, California 94514
Thursday, August 19, 1999 19:05 PDT

NTSB Narrative Summary Released at Completion of Accident

The pilot said the aircraft was in level cruise at 6,500 feet msl when the engine suddenly quit without warning. The pilot switched fuel tanks and turned on the electric boost pump, which restored fuel flow on the gage, but the engine did not restart. Coincident with the loss of power, the pilot heard a 'pop' sound come from the engine compartment. The pilot selected an open field and continued to attempt a restart as he prepared for the off-airport landing. The aircraft touched down in the field and rolled some distance before the nose gear collapsed. During the teardown inspection of the engine, all cylinder bases and through bolt studs exhibited evidence of oil leakage. During removal of the cylinders, all through bolt and cylinder hold down stud nuts were loose enough to break torque with one hand using a short open-end wrench. Removal of the cylinders revealed fretted cylinder bases and pads. Separation of the case halves revealed fretting on all cylinder pads and bearing saddle-parting surfaces, with more fretting observed on the No. 2 main bearing saddle surfaces. The No. 2 main bearing was fragmented and found in the oil sump, with erosion and smearing evident to the bearing saddle. The crankshaft was fractured across the No. 3 short cheek, with heavy scoring evident to the Nos. 2 and 3 main journals. Review of the maintenance records disclosed that cylinders 1, 2, 4, 5, and 6 were replaced on March 24, 1997, 232 hours prior to the accident.

NTSB Probable Cause Narrative

The failure of the operator's maintenance personnel to properly torque the cylinder and engine case through bolts during the replacement of five cylinders, which led to the spinning of the No. 2 main bearing and the resultant oil starvation induced catastrophic internal engine failure.

Event Information

Type of Event Accident
Event Date 8/19/1999
Event Day of the Week Thursday
Time of Event 1905
Event Time Zone Pacific Daylight Time
Event City BYRON
Event State CALIFORNIA
Event Country --
Zipcode of the event site 94514
Event Date Year 1999
Event Date Month 8
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1922 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 30
Weather Observation Facility ID SCK
Elevation of weather observation facility 30
Distance of event from weather observation facility (units?) 9
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 32
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) 300
Variable Wind Indicator Unknown
Wind Speed (knots) 10
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 6
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 1446
NTSB Notification Source --
NTSB Notification Date Aug 19 1999 12:00AM
NTSB Notification Time 1940
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 12 2000 11:50AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N5378V
NTSB Number LAX99LA277
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 135: Air Taxi & Commuter
Type of Flight Plan filed Company VFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Cessna
Aircraft Model T210L
Aircraft Series Identifier T210L
Aircraft Serial Number 21060923
Certified Max Gross Weight 3800
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 6
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection 100 Hour
Date of Last Inspection Aug 11 1999 12:00AM
Airframe hours since last inspection 10
Airframe Hours 4070
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name AUBURN FLYING SERVICE
Aircraft Owner Street Address 13622 NEW AIRPORT ROAD
Aircraft Owner City AUBURN
Aircraft Owner State CA
Aircraft Owner Country
Aircraft Owner Zipcode 95602
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code AWFA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Non-scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code Q68
Departure City GROVELAND
Departure State CA
Departure Country
Departure Time 1830
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code CCR
Destination City CONCORD
Destination State CA
Destination Country
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:35AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --