CEN15LA421

NTSB accident investigation · Lerch RV6A · Deckerville, MI · September 22, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
September 22, 2015, 14:26 local (18:26 UTC)
Place
Deckerville, MI
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N215DGLerch RV6A
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 5, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration East Michigan FSDO
FAA report
20150922016889A
Case key
92049

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The in-flight loss of engine oil after the oil filter separated from the engine adapter assembly because of an incorrect modification of the oil filter adapter assembly, which resulted in a precautionary landing in a field.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance: modification/alterationPersonnel issues › Task performance · Maintenance personnelLerch Gerhard RV6A: 1 caseAll aircraft: 69 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceLerch Gerhard RV6A: 1 caseAll aircraft: 130 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelLerch Gerhard RV6A: 1 caseAll aircraft: 174 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · MalfunctionLerch Gerhard RV6A: 1 caseAll aircraft: 130 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that, while in cruise flight, he smelled an odor and subsequently confirmed that the engine had lost oil pressure. The pilot believed that the airplane would not be able to reach an airport, so he decided to shut down the engine and make a precautionary landing to a nearby dirt road. Shortly before touchdown, the pilot saw obstacles near the road, so he banked the airplane left toward an open field to avoid them. The airplane landed hard in the field and subsequently nosed over. A postaccident examination revealed that the lower fuselage and the sides of the fuselage were covered in engine oil. Further examination established that the oil filter had disengaged from the adapter assembly and was the source of the loss of engine oil during the accident flight. The oil filter adapter assembly had been modified for a spin-on oil filter; however, the modification had not been completed in accordance with the installation instructions, and, as such, an incorrect oil filter had been used. It is likely that the incorrect modification of the oil filter adapter assembly resulted in a lack of proper thread engagement with the adapter heli-coil, the subsequent separation of the oil filter, and the corresponding loss of engine oil during the accident flight. A review of the engine maintenance logbook established that the incorrect oil filter adapter assembly modification and the corresponding incorrect oil filter had likely been used since the last engine overhaul, which was completed 18 years before the accident. The engine had accumulated 627 hours since the last overhaul.

Factual narrative

On September 22, 2015, about 1426 eastern daylight time, an experimental amateur-built Lerch model RV6A single-engine airplane, N215DG, was substantially damaged during a forced landing near Deckerville, Michigan. The private pilot sustained minor injuries and his passenger sustained a serious injury. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed at the accident site. The personal flight departed Sandusky City Airport (Y83), Sandusky, Michigan, at 1345, and had the intended destination of Ray Community Airport (57D), Ray, Michigan.The pilot reported that while in cruise flight he smelled an odor and subsequently confirmed that the engine had lost oil pressure. The pilot believed that the airplane was not able to reach an airport, so he decided to shut down the engine and make a precautionary landing to a nearby dirt road. Shortly before touchdown, the pilot saw a vehicle with a trailer approaching on a crossroad and a stop sign at the road intersection. He banked the airplane to the left towards an open field to avoid the obstacles. The airplane landed hard in the field and subsequently nosed over. The airplane sustained substantial damage to the fuselage, wings, empennage, firewall and engine mounts. A postaccident examination, completed by Federal Aviation Administration (FAA) Inspectors, revealed that the lower fuselage and sides of the fuselage were covered in engine oil. Further examination established that the oil filter had separated from the adapter assembly and was hanging from the engine by safety wire. The oil filter adapter plate was observed separated from the adapter, although the adapter itself remained attached to the engine. A visual examination established that the disengaged oil-filter was the source of the loss of engine oil during the accident flight. A review of Textron Lycoming Special Service Publication No. SSP-885-1 established that the original canister-type oil filter assembly had been modified for a spin-on oil filter; however, the modification had not been completed in accordance with the installation instructions and, as such, an incorrect oil filter had been used. Although the correct heli-coil insert had been installed in the adapter, the specified converter stud was not installed. The missing converter stud was designed to engage the adapter's heli-coil and retain the oil filter adapter plate. Without the installed converter stud, the use of the specified female-threaded oil filter was not possible. As such, the use of an oil filter with a male-threaded stud had been used. A visual examination revealed that the heli-coil insert threads were damaged and pulling out of the adapter. Additionally, the oil-filter used on the accident engine, which incorporated a male-threaded stud, would have only engaged a few of the heli-coil threads. Additional examination of the heli-coilinsert revealed evidence of cross-threading of the threads. A review of the engine maintenance logbook established that the incorrect oil filter adapter modification, and corresponding incorrect oil filter, had likely been used since the last engine overhaul, which was completed in September 1997. The engine, a Lycoming O-320-H2AD, serial number L-3317-76, had accumulated 627 hours since the last overhaul. The most recent oil change was completed on June 22, 2015, during the most recent condition inspection. The engine had accumulated 12 hours since the last oil change. The pilot reported that 3.4 hours after the condition inspection he noted a minor leak from the oil filter assembly. He corrected the leak by replacing the adaptor plate gasket and reinstalling the oil filter. The engine had accumulated 8.6 hours since the oil leak was mitigated.

Aircraft

Registration
N215DG
Reported as
Lerch RV6A
Category
Airplane, amateur-built
Serial number
23218
Built
1997
Airframe hours
627
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · June 22, 2015 · 12 hours before
Departed
Y83 · Sandusky, MI
Destination
57D · Ray, MI
Equipment
Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
August 18, 2015
Seat
Left
Restraint
4-point
Flight hours
627 total · 445 in this make and model · 12 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 48 °F
Altimeter
30.21 inHg
Observed at
MBS, 14 nm away

Docket · 5

The files NTSB released with the investigation on November 5, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.