# NTSB CEN15LA421: Lerch RV6A, N215DG, Deckerville, MI, September 22, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 22, 2015, 14:26 local (18:26 UTC) - Place: Deckerville, MI - Coordinates: 43.453056, -82.764999 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.4531&lon=-82.7650&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report January 5, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration East Michigan FSDO - NTSB case key (mKey): 92049 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA421 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92049/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92049 - Page: https://openairdocs.org/ntsb/CEN15LA421 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: modification/alteration](https://openairdocs.org/ntsb-findings/02062030): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-findings/02062030/cases.md?model=05604HH), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02062030/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=05604HH), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=05604HH), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=05604HH), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05604HH), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=05604HH), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05604HH), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05604HH), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Lerch Gerhard RV6A, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05604HH), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N215DG-2021-03-09), registration cancelled 2021-03-09, S/N 23218 (OpenAirDocs) - Reported make and model: Lerch RV6A - Registry model: [Lerch Gerhard RV6A](https://openairdocs.org/model/lerch-gerhard-rv6a) (registry code 05604HH) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 23218 - Year built: 1997 - Airframe hours: 627 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: serious; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20150922016889A](https://openairdocs.org/incident/20150922016889A), Sep 22, 2015: Lerch Gerhard RV6A, Deckerville, MI, Substantial damage. Approximately 45 minutes into his third flight of the day, the pilot reported smelling a strange odor. He looked at his engine instruments and noticed zero oil… ## Docket (5 files) The files NTSB released with the investigation on November 5, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92049. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 888 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433690&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement (Patrick Lusch) (item 2, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433691&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20(Patrick%20Lusch)-Master.PDF - Memorandum of Conversation (FAA Inspector Rick Anderson) (item 3, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433692&FileExtension=.PDF&FileName=Memorandum%20of%20Conversation%20(FAA%20Inspector%20Rick%20Anderson)-Master.PDF - Textron Lycoming Special Service Publication No. SSP-885-1 (Excerpts) (item 4, .PDF, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433693&FileExtension=.PDF&FileName=Textron%20Lycoming%20Special%20Service%20Publication%20No.%20SSP-885-1%20(Excerpts)-Master.PDF - Photos (item 5, .PDF, 2 photos, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40433694&FileExtension=.PDF&FileName=Photos-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.