Aircraft Accident/Incident Report

Los Angeles, California 90064
Sunday, July 9, 1989 11:33 PDT

NTSB Narrative Summary Released at Completion of Accident

ON THE FIRST FLT AFTER THE ACFT'S ANNUAL INSPECTION FOLLOWING REPLACEMENT OF ALL OIL LINES, THE CFI PLANNED TO GIVE THE ACFT'S OWNER/PLT A BFR. FIVE MIN AFTER TAKEOFF, THE CREW OBSERVED THAT THE OIL PRESSURE GAGE INDICATED NEAR ZERO LBS OF PRESSURE. THE CFI MONITORED THE OIL TEMP GAGE & THE TEMP WAS IN THE GREEN ARC. THE CREW ALERTED ATC OF THE SITUATION & REC'D AN IFR CLEARANCE BACK TO THE ARPT. DURING THE NEXT 14 MIN, THE OIL PRESSURE NEEDLE REMAINED SLIGHTLY ABOVE RED LINE, THE OIL TEMP REMAINED STABLE & IN THE GREEN ARC. THE ACFT PASSED THE FINAL APPROACH FIX & CONTINUED TO OPERATE NORMALLY. SUDDENLY, ALL ENG PWR WAS LOST. THE CFI MADE A FORCED LDG ON A GOLF COURSE 3 MI FM THE ARPT. EXAM OF THE ENG REVEALED INTERNAL HEAT DISTRESS & BROKEN CONN RODS. FURTHER EXAM REVEALED A 'B' NUT ON A NEWLY INSTALLED OIL LINE HAD NOT BEEN SECURELY TORQUED & HAD COME LOOSE AT ITS ENG CASE ATTACHMENT FITTING. THE OIL LINE WAS FOUND SATURATED WITH OIL.

NTSB Probable Cause Narrative

AN UNDERTORQUED OIL LINE FITTING, DUE TO ITS IMPROPER INSTALLATION BY MAINTENANCE PERSONNEL, WHICH RESULTED IN A LOOSE OIL LINE FITTING, AN OIL LINE LEAK, OIL EXHAUSTION, AND SUBSEQUENT FAILURE OF THE ENGINE.

Event Information

Type of Event Accident
Event Date 7/9/1989
Event Day of the Week Sunday
Time of Event 1133
Event Time Zone Pacific Daylight Time
Event City LOS ANGELES
Event State CALIFORNIA
Event Country --
Zipcode of the event site 90064
Event Date Year 1989
Event Date Month 7
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 0
Degrees magnetic from airport 0
Airport Elevation 175
Weather Briefing Completeness Unknown
Investigator's weather source Pilot
Time of the weather observation 1132 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 30
Weather Observation Facility ID SMO
Elevation of weather observation facility 175
Distance of event from weather observation facility (units?) 3
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 1200
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 7
Air Temperature at event time (in degrees celsius) 23
Dew Point at event time (in degress fahrenheit) 17
Wind Direction (degrees magnetic) 240
Variable Wind Indicator Unknown
Wind Speed (knots) 5
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 Serious
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor 1
Injury Total None --
Injury Total Serious 1
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 2299
NTSB Notification Source --
NTSB Notification Date Jul 9 1989 12:00AM
NTSB Notification Time 1155
Fiche Number and/or location -used to find docket information 42371
Date of most recent change to record Dec 13 2000 12:52PM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N609AC
NTSB Number LAX89LA233
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model P210N
Aircraft Series Identifier P210N
Aircraft Serial Number P21000609
Certified Max Gross Weight 4000
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 Annual
Date of Last Inspection Jul 1 1989 12:00AM
Airframe hours since last inspection 1
Airframe Hours 1058
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name PARVEZ GONDAL, M.D.
Aircraft Owner Street Address 4604 GLENCO #3
Aircraft Owner City ,AROAM DE; REY
Aircraft Owner State CA
Aircraft Owner Country
Aircraft Owner Zipcode 90292
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
Owner has at least one certificate None
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 --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Instructional
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code SMO
Departure City SANTA MONICA
Departure State CA
Departure Country
Departure Time 1109
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code
Destination City
Destination State
Destination Country
Specific Phase of Flight Landing
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:30AM
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 --