# NTSB CEN20LA301: Vans RV4, N54WP, Idabel, OK, July 22, 2020

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Class 3 · Limited · Final report
- Date: July 22, 2020, 17:45 local (22:45 UTC)
- Place: Idabel, OK
- Coordinates: 33.900001, -94.830001 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=33.9000&lon=-94.8300&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: FAA FSDO
- ADs cited in the narratives: [AD 90-04-06 R1](https://openairdocs.org/ad/90-04-06-R1) (OpenAirDocs)
- NTSB case key (mKey): 101655
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA301
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101655/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101655
- Page: https://openairdocs.org/ntsb/CEN20LA301

## Probable cause

The pilot’s improper installation of an oil line, resulting in the loss of oil and subsequent total loss of engine power.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Janicki Steven B RV4, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05606X9), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)
- [Eng oil sys (airframe furnish)](https://openairdocs.org/ntsb-findings/01057900): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Janicki Steven B RV4, 1 case](https://openairdocs.org/ntsb-findings/01057900/cases.md?model=05606X9), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057900/cases.md)
- [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Related maintenance info (probable cause); cases with it: [Janicki Steven B RV4, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=05606X9), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Janicki Steven B RV4, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05606X9), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)

## Analysis

After a full stop landing to refuel on a cross-country flight in the experimental airplane, the pilot noticed a chaffed oil line leading to the propellor governor. The pilot, with assistance from a local mechanic, removed the damaged oil line and replaced it with a used serviceable line. The pilot pre-flighted the airplane, took off, and continued his flight. About 70 minutes into the flight, the pilot observed oil on the windscreen. As the pilot maneuvered for a precautionary landing at a nearby airport, the engine stopped producing power. About 1/2 mile from the airport, the pilot attempted to land on a roadway. The airplane impacted power lines and the ground. The pilot stated that he could not see the power lines through the oil-covered windscreen. The airplane came to rest in a ditch adjacent to the roadway, resulting in structural damage to the fuselage and empennage. Examination of the airplane and engine after the accident revealed a crack in the oil line leading to the propeller governor from its connection at the engine case. There was no clamp installed to secure the line. A conditional airworthiness inspection had recently been completed on the experimental airplane. According to Federal Aviation Administration Airworthiness Directive (AD) 90-04-06R1, a clamp should have been installed on the oil line leading to the propeller governor. The pilot reported that when he replaced the oil line, there was no clamp present, so he did not install a clamp and was not aware of the applicable AD. He stated that had he been aware of the AD, he would have installed a new oil line and clamp. The available evidence indicates that the pilot’s improper installation of the oil line resulted in the in-flight loss of oil and subsequent total loss of engine power.

## Factual narrative

On July 22, 2020, about 1745 central daylight time, a Vans RV4, N54WP, was substantially damaged when it was involved in an accident near Idabel, Oklahoma. The airline transport pilot and a child passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was on a multi-leg cross-country flight. On a planned refueling stop at Kennett Memorial Airport (TKX), Kennett, Missouri, the pilot noticed an oil leak coming from a chaffed oil line leading to the propeller governor. The pilot, with assistance from a local fixed base operator mechanic, removed the damaged oil line and replaced the line with a used serviceable oil line. After the installation and preflight, the pilot took off and climbed to 5,500 ft mean sea level, en route to his destination. About 70 minutes later, the pilot smelled something and observed oil on the windscreen. The pilot asked air traffic control for the nearest airport, which was about 11-miles away. As the pilot was maneuvering to the airport to land, the engine stopped producing power. About 1/2 mile from the airport, about 70 ft above the ground, the pilot attempted to maneuver the airplane to land on a roadway. The airplane impacted power lines and the ground. The pilot stated that he could not see the power lines through the oil-covered windscreen. The airplane came to rest in a ditch adjacent to the roadway, resulting in structural damage to the fuselage and empennage. Both occupants exited the airplane uninjured. Examination of the engine after the accident revealed a crack in the oil line leading to the propeller governor from its connection at the engine case. There was no clamp installed to secure the line. The experimental airplane had a conditional airworthiness inspection on May 1, 2020. According to Federal Aviation Administration Airworthiness Directive (AD) 90-04-06R1, a clamp should have been installed on the oil line leading to the propeller governor. The pilot reported that when he replaced the oil line at TKX, there was no clamp present, so he did not install a clamp and was not aware of the applicable AD. He also reported that had he been aware of the AD, he would have installed a new oil line and clamp.

## Aircraft

- Registration: [N54WP](https://openairdocs.org/deregistered/N54WP-2022-01-08), registration cancelled 2022-01-08, S/N 2197, built 2009 (OpenAirDocs)
- Reported make and model: Vans RV4 (Undesignat)
- Registry model: [Janicki Steven B RV4](https://openairdocs.org/model/janicki-steven-b-rv4) (registry code 05606X9) (OpenAirDocs)
- Registry engine: [Lycoming AEIO-360-A1A](https://openairdocs.org/engine/lycoming-aeio-360-a1a) (registry code 41847, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 2197
- Year built: 2009
- Airframe hours: 670
- Engines: Lycpming IO 360 EXP 189 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Special, Experimental (Special)
- Last inspection: Condition, May 1, 2020, 26 hours before
- Departed: TKX, Kennett, MO
- Destination: T56, Midlothian, TX
- Airport: 4O4, McCurtain County Airport
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 41; injuries: minor; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review December 19, 2019; seat: front; restraint: 3-point; flight hours: 5,776 total, 332 in this make and model, 91 in the last 90 days, 44 in the last 30 days, 5 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 130° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 79 °F, dew point 70 °F
- Altimeter: 29.95 inHg
- Observed at: 4O4, 1 nm away

## Docket (5 files)

The files NTSB released with the investigation on October 13, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101655. 4.3 MB in all.

- Memorandum for the record pilot report summary CEN20LA301 (item 1, PDF, 1 page, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14510849&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Pilot%20Report%20Summary%20CEN20LA301_Redacted-Rel.pdf
- Memorandum for the record examination of cracked oil line CEN20LA301 (item 2, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14511285&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Examination%20of%20Cracked%20Oil%20Line%20CEN20LA301_Redacted-Rel.pdf
- Conditional inspection document CEN20LA301 (item 3, PDF, 1 page, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14510859&FileExtension=pdf&FileName=Conditional%20Inspection%20Document%20CEN20LA301_Redacted-Rel.pdf
- Photo array CEN20LA301 (item 4, PDF, 4 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14511329&FileExtension=pdf&FileName=Photo%20Array%20CEN20LA301-Rel.pdf
- FAA AD 90-04-06 R1 CEN20LA301 (item 5, PDF, 8 pages, 479 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14568816&FileExtension=pdf&FileName=FAA%20AD%2090-04-06%20R1%20CEN20LA301-Rel.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.