# NTSB CEN19LA159: Lancair LC41, N2514F, Cleburne, TX, May 30, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: May 30, 2019, 11:00 local (16:00 UTC) - Place: Cleburne, TX - Coordinates: 32.390277, -97.433609 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.3903&lon=-97.4336&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, Textron Aviation, Inc, Van Bortel Aircraft, Inc, Continental Aerospace Technologies - NTSB case key (mKey): 99516 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA159 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99516/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99516 - Page: https://openairdocs.org/ntsb/CEN19LA159 ## Probable cause A total loss of engine power due to oil starvation as the result of the oil pressure switch failure due to a manufacturing defect. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Manufacture/production](https://openairdocs.org/ntsb-findings/04013000): Organizational issues › Development · Manufacturer (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/04013000/cases.md?model=5150001), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/04013000/cases.md) - [Eng oil sys (airframe furnish): engine oil indicating system](https://openairdocs.org/ntsb-findings/01057930): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/01057930/cases.md?model=5150001), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057930/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=5150001), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Eng oil sys (airframe furnish): pressure](https://openairdocs.org/ntsb-findings/01057931): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/01057931/cases.md?model=5150001), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01057931/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Lancair LC41-550FG, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=5150001), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Lancair LC41-550FG, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=5150001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The pilot departed on a maintenance test flight in the airplane to break in an engine cylinder, which had just been replaced. During the flight, the pilot noticed an oil pressure warning light illuminate, followed by a low oil temperature indication. The pilot attempted to divert to a nearby airport; however, the engine experienced a total loss of power, and he conducted a forced landing, during which the wings sustained substantial damage. Examination of the airplane revealed a hole in the engine case above the No. 4 cylinder. Further examination revealed that the engine oil pressure switch had separated into two pieces . A detailed examination of the switch found that it had failed at a manufacturing swaged joint between its threaded section and cap piece. Therefore, it is likely that the swaging process was insufficient during manufacture. The broken switch allowed engine oil to escape the system, resulting in oil starvation and failure of the No. 4 cylinder. ## Factual narrative On May 30, 2019, about 1100 central daylight time, a Lancair LC41 airplane, N2514F, conducted a forced landing near the Cleburne Regional Airport (CPT), Cleburne, Texas. The pilot was not injured, and the airplane sustained substantial damage. The airplane was registered to and operated by Van Bortel Aircraft, Inc under the provisions of Title 14 Code of Federal Regulations Part 91 as a maintenance test flight. Visual meteorological conditions prevailed for the local flight at the time of the accident. The flight was conducted to break-in the engine's No. 5 cylinder, which had just been replaced. During the flight, the pilot noticed the oil pressure warning light illuminate, followed by a low oil temperature indication. The pilot attempted to divert to CPT; however, the engine experienced a loss of power and he conducted a forced landing. During the landing, the airplane collided with trees and came to rest upright and partly submerged in a small pond about one mile from CPT. Inspection of the airplane revealed substantial damage to the wings, and water submersion damage to the airplane. The airplane's Hobbs meter read 1,090.1 hours. The airplane was recovered to a secure facility for further examination. The examination was conducted by the NTSB Investigator-in-Charge, a representative from Van Bortel Aircraft, and technical representatives from the engine and airframe manufacturers. The examination noted the engine case had a hole above the No. 4 cylinder, and when the propeller was rotated by hand, the engine had limited rotation and internal binding was noted. A light, oil film was noted on the bottom of the airplane. The exam also found an oil pressure switch separated in two pieces. The threaded section remained to its mating joint; the other section rested on an exhaust tube and attached by its wire connector as seen in Figure 1. Figure 1: Oil Pressure Switch Photo Continental A visual inspection of the switch noted that the switch had separated at a manufacturing joint between the body and threaded section. The switch was removed and sent to Textron Aviation, Inc, Materials Laboratory for a detailed examination of the switch. Textron's examination noted the switch failed at the swaged joint between the threaded section and the base cap section of the switch. The examination was not able to determine how the joint failed, since there were no physical indications as to how the swaged joint failed. ## Aircraft - Registration: [N2514F](https://openairdocs.org/aircraft/N2514F), registered now, S/N 41093, built 2005 (OpenAirDocs) - Reported make and model: Lancair LC41 (550FG) - Registry model: [Lancair LC41-550FG](https://openairdocs.org/model/lancair-lc41-550fg) (registry code 5150001) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 41093 - Year built: 2005 - Airframe hours: 1090.1 - Engines: Continental TSIO-550-C(5) 310 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Operator: Van Bortel Aircraft, Inc - Registered owner: Van Bortel Aircraft, Inc - Airworthiness certificate: Standard, Normal - Departed: GKY, Arlington, TX - Destination: GKY, Arlington, TX - Equipment: Electronic primary flight display, Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; airline transport, flight engineer, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 5, 2019; seat: left; restraint: 3-point; flight hours: 20,019 total, 165 in this make and model, 233 in the last 90 days, 73 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 350° at 7 knots - Visibility: 10 statute miles - Temperature: 79 °F, dew point 63 °F - Altimeter: 30.01 inHg - Observed at: KCPT ## 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 20190530017719A](https://openairdocs.org/incident/20190530017719A), May 30, 2019: Lancair Company LC41-550FG, Cleburn, TX, Substantial damage. The pilot was making a maintenance check flight due to maintenance change of a number 5 engine cylinder. The pilot did not participate in a post maintenance… ## Docket (5 files) The files NTSB released with the investigation on February 28, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99516. 6.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480918&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memo Lab (item 2, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480919&FileExtension=.PDF&FileName=Memo%20Lab-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 365 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480920&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photos (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480921&FileExtension=.PDF&FileName=Photos-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480922&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.