NTSB CAROL · Event
Event SEA04FA165
Aircraft involved
Probable cause & findings
The pilot's inadequate preflight inspection by his failure to secure the oil cap, which resulted in oil leakage on the windscreen, obstructing his vision, and his failure to maintain adequate airspeed.
Factual narrative
HISTORY OF FLIGHT
On August 17, 2004, at 1712 central daylight time, a Cessna T210L, N2452S, was destroyed when it impacted the ground near Richard Lloyd Jones Jr. Airport (RVS), Tulsa, Oklahoma. The instrument rated private pilot and his two passengers were fatally injured. The pilot/owner was operating the airplane under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the cross-country personal flight that was originating at the time of the accident. The pilot had not filed a flight plan; family members said that the destination of the flight was Joplin, Missouri. A Federal Aviation Administration (FAA) Air Traffic Controller (ATC; tower control) witness said that the pilot requested to taxi to the self-service refueling location on the airport approximately 30 minutes before his takeoff. He said that the self-service fueling location is visually obstructed by a large hangar, and he was unable to observe the pilot's activity. The records for the self-service fueling pump (credit card purchases only) indicate that at 1644 a purchase was made for 62.49 gallons. ATC tower recordings indicate that the pilot was cleared for takeoff at 1710 on runway 19R (right). After takeoff, he was instructed to turn to 100 degrees. Approximately 100 seconds later the pilot reported he had oil on his wind screen and would like to return to the airport. A witness-pilot of an airplane that was taking off behind the accident aircraft said that the accident aircraft leveled off at approximately 300 feet, slowed down, and made a right turn back towards the airport. He said that as the accident airplane started the right hand turn to the north, "it appeared to be moving very slow." The witness-pilot said that as the accident airplane turned through a heading of approximately 300 degrees, he noticed the right wing drop, and it rotated right 3/4 of a turn and impacted the ground. A postimpact fire ensued.
PERSONAL INFORMATION
The pilot had taken a Federal Aviation Administration (FAA) required flight medical on January 2, 2004; he held a third class medical certificate. The pilot's flight time log-book indicated that he took a FAA required flight review on May 1, 2003. At the time of the accident, his pilot log-book indicated that he had approximately 1,474 hours of flight experience, 794 hours of those hours were in the accident airplane, and approximately 36 hours were in the last 90 days.
AIRCRAFT INFORMATION
The airplane was a single engine, propeller-driven, six seat airplane, which was manufactured by Cessna Aircraft Company, in 1976. The airplane had a maximum takeoff gross weight of 3,800 pounds. It was powered by a Continental TSIO-520-H, reciprocating turbo charged, fuel injected, direct drive, air cooled, horizontally opposed, six cylinder engine, which had a maximum takeoff rating of 285 horsepower at sea level. Maintenance records indicate that the last annual inspection was completed on March 18, 2004. The airplane's maintenance records, together with the pilot's flight log-book, indicate that the airplane had 3,129 hours of total time at the time of the accident.
METEOROLOGICAL INFORMATION
At 1719, the weather conditions at Richard Lloyd Jones Jr. Airport (RVS; elevation 638 feet), Tulsa, Oklahoma, were as follows: wind 210 degrees for 8 knots: visibility 10 statue miles (sm); clear of clouds; temperature 91 degrees Fahrenheit; dew point 64 degrees Fahrenheit; altimeter setting 30.00 inches.
WRECKAGE AND IMPACT INFORMATION
The airplane was found in an open grass field surrounded by houses (N36 degrees, 01", 40"; W95 degrees, 59', 41"; elevation 638 feet), approximately 3,168 feet from the departure end of runway 19R. The airplane's longitudinal orientation was 180 degrees. There was a 1.5 feet deep crater approximately 4 feet in front of the airplane with associated ground scars to suggest that the airplane bounced backwards to its final location. The airplane was consumed by postimpact conflagration. All of the airplane's major components were accounted for at the accident site. The landing gear was retracted; the flaps were found up. Control cable continuity was confirmed for all flight controls. The engine's crankshaft rotated with "thumb" compression on all cylinders; continuity was exhibited throughout the engine. One propeller blade exhibited "S" type bending; the second blade appeared undamaged; the third blade was bent under the engine. The engine's oil neck was found without a cap. The cap was attached to the neck by a chain, and was found between cylinders number 4 and number 6; it was undamaged. The oil filler neck was partially compressed. Pieces of windscreen Plexiglas were found outside of the fire zone, and they were coated with oil. The engine manufacturer's representative said that the engine could probably run for 15 to 25 minutes without a cap on the filler neck. No preimpact engine or airframe anomalies, which might have affected the airplane's performance, were identified.
MEDICAL AND PATHOLOGICAL INFORMATION
The Office of the Chief Medical Examiner, Tulsa, Oklahoma, performed an autopsy on the pilot on August 18, 2004. The cause of death was determined to be multiple blunt trauma. The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report (#200400201001), carbon monoxide, cyanide, volatiles (ethanol), and drugs tested, found negative results.
ADDITIONAL INFORMATION
The airplane, including all components and logbooks, was released to a representative of the owner's insurance company on May 5, 2005. The airplane was departing on runway 19R. Moments after liftoff, the pilot called tower and asked to return to the airport because he was getting oil on his windscreen. A pilot taking off immediately behind the accident airplane observed the airplane, at approximately 300 feet, turn right to return to the airport. He said that the airplane appeared very slow, and then it rotated to the ground. Postimpact examination of the wreckage revealed that the engine oil filler neck did not have a cap on it. The oil filler neck was partially compressed, and the oil cap was found (on a chain) undamaged. Pieces of windscreen Plexiglas were found outside of the wreckage zone, and they were coated with oil. The engine manufacturer's representative said that the engine could probably run for 15 to 25 minutes without a cap on the filler neck. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_2004_SEA04FA165.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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