CEN13FA044

The pilot's failure to maintain airplane 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. Contributing to the accident was 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.

The pilot and the pilot-rated passenger originally planned to make several circuits in the traffic pattern to test the right engine, which recently underwent extensive maintenance, before repositioning the airplane to a nearby airport. However, the flight was delayed to make an adjustment to the propeller lever friction lock. Because of the delay, the pilots departed after the sun had set and decided to fly directly to the other airport, which did not have runway lights. While en route, the right engine began to lose oil pressure and lost total power, so the pilot shut the engine down and feathered the propeller. The pilot elected to return to the departure airport, but was unable to maintain altitude. The airplane impacted trees and a postimpact fire consumed most of the airplane. 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. Witnesses who saw the airplane just before impact confirmed the landing gear was extended. Postaccident 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, which resulted 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. Although the airplane did not have a current annual inspection, no mechanical malfunctions or failures were noted with the airplane or the left engine that would have precluded normal operation.

A review of the 1956 Cessna 310 Owner's Manual revealed the single-engine climb-data chart only calculated single-engine climb rates with the flaps and gear retracted. The chart also assumed the inoperative propeller was feathered, and the wing was banked 5 degrees toward the operating engine, which would have to be at full throttle (2600 RPM) and leaned for best power. When the chart was interpolated for these and other conditions that existed at the time of the accident, the accident airplane would have had an approximate rate of climb of 566 feet per minute (ft/min). According to Cessna, the single-engine climb rate penalty if the gear was extended would have been about 400 ft/min. Based on this data, the accident airplane would have had a single-engine climb rate of about 166 ft/min at the time of the accident assuming the airplane was properly configured and the operating engine was producing full power. An autopsy was conducted on the pilot by Southwest Missouri Forensics, Nixa, Missouri, on November 6, 2013. The cause of death was determined to be, "Exsanguination secondary to aortic laceration induced by blunt force trauma to the chest in an airplane crash." Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The results were positive for the following: >34 (ug/ml, ug/g) Acetaminophen detected in urine >0.013 (ug/ml. ug/g) Chlorpheniramine detected in blood (cavity) >Chlorpheniramine detected in urine >Salicylate detected in urine Although Chlorpheniramine can be impairing, a review of the toxicology results by the NTSB Medical Officer found that the low level of Chlorpheniramine identified in post mortem cavity blood was unlikely to have contributed to the accident. An autopsy was conducted on the pilot rated passenger by Southwest Missouri Forensics, Nixa, Missouri, on November 6, 2013. The cause of death was determined to be, "Cardiac arrhythmia secondary to myocardial hypoxia caused by hypoxemia due to the combined effects of multiple bilateral rib fractures (flail chest) and cardiac lacerations induced by blunt force trauma to the chest in an airplane crash." Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The results were negative for drugs and alcohol. At 1753, the automated weather report at Joplin Regional Airport (JLN), Joplin, Missouri, about 24 miles west of the accident site, was reported as wind from 120 degrees at 3 knots, clear skies, temperature 13 degrees Celsius, dewpoint 3 degrees Celsius, and a barometric pressure setting of 30.08 inches of mercury. A review of the airplane's maintenance logbooks revealed the accident airplane did not have a current annual inspection as required by Federal Aviation Regulation (FAR) 91.409. The last annual inspection was completed on August 10, 2010, at a total time of 4,549.7 hours. In September 2011, the airplane's previous owner hired a mechanic based in Arkansas to perform an annual inspection. According to the mechanic, the airplane was unairworthy because the nose-jack point had collapsed into the belly of the airplane and "a lot" of corrosion was found in the forward cabin bulkhead. Two Federal Aviation Administration (FAA) inspectors from the Little Rock Flight Standards District Office also examined the airplane and concurred that the airplane was unairworthy. The mechanic entered the unairworthy items in the aircraft logbook and made an endorsement that the airplane was "safe" to be ferried back to Missouri with the "gear down only." The FAA issued the owner a "Special Flight Permit" for this flight on November 10, 2011. The passenger purchased the airplane in January 2012 and according to FAA records, was registered on April 2, 2012. At some point, the airplane was flown to Miami, Oklahoma, for an annual inspection. According to the aircraft logbook, on February 12, 2012, the mechanic that was hired to perform the inspection wrote, "No corrosion of significant airworthy found," but did observe "buckling caused by improper jacking not airworthy condition." According to the FAA, there were no records that a ferry permit was issued for the flight to or from Miami, Oklahoma. A review of both pilot's logbooks revealed the airplane was flown a total of 8 times after the last "Special Flight Permit" was issued in 2011. The mechanic, who was hired to overhaul the engine, said he talked to the pilot on November 2nd, before the first planned test flight regarding the work he had performed on the engine. The mechanic said he had the right engine logbook, yellow tags and the engine data plate spread out on the horizontal stabilizer for the pilot to review, since he was also a mechanic. However, he said the pilot never looked at the logbook. He told the pilot that he had not "signed off" on the overhaul and was waiting for some older components to be replaced in addition to the flight test. At that time, he planned to sign off the work as a repair only. The mechanic said that after they talked, he gave the pilot the logbook along with the yellow tags and engine data plate because the pilot said the pilot rated passenger, who owned the airplane, wanted to review them. After the accident, the mechanic turned over the airplane's remaining maintenance logbooks that he had in his possession. The right engine logbook was never located. The pilot held a commercial pilot certificate for airplane single and multi-engine land, and instrument airplane. He was also a certified flight instructor for airplane single and multi-engine land, and instrument airplane. In addition, he held an airframe and power plant (A&P) certificate. A review of his logbook revealed that as of October 6, 2012, he had a total of 3,299 flight hours; 411 hours in multi-engine airplanes, of which, 102 hours were in a Cessna 310. The pilot rated passenger held a private pilot certificate for airplane single-engine land, and instrument airplane. A review of his logbook revealed that as of September 28, 2012, he had a total of 1,621.8 hours; of which, all 10.6 hours of multi-engine time were in the accident airplane. The airplane collided with a stand of tall trees and traveled approximately 100 feet on a heading of 182 degrees before it came to rest on a pile of wooden planks and other debris. A post-impact fire consumed most of the cockpit, fuselage, and portions of both wings and the tail section. Impact marks on the trees were progressively lower along the wreckage path. Examination of the airplane revealed the flaps were in the retracted position and the landing gear were extended out of their respective wheel wells. Each of the wing mounted landing lights were found retracted. Both engines had separated from the airplane. The right propeller assembly had separated from the engine and was partially buried in the ground. The propeller blades were found in the feathered position. The left propeller assembly remained on the left engine. Both blades exhibited aft bending and leading edge damage. Both engines were examined at Continental Motors Incorporated, Mobile, Alabama, on December 11-12, 2012, under the supervision of the National Transportation Safety Board Investigator-in-Charge (NTSB IIC). External examination of the right engine revealed impact and thermal damage. The oil cooler; magnetos, vacuum pump, starter adapter, oil pump, and pressurized carburetor remained attached to the engine. The oil filter adapter was not properly attached to the engine and was not properly secured. There was also a thin coating of oil on the crankcase around the fitting. Approximately 2 quarts of dark oil were drained from the oil sump. There was a small breach in the sump from impact damage near the drain plug. The breach was on the seam of a weld point. The adapter was not original to the engine and wasinstalled on the engine per supplemental type certificat