# NTSB ERA10LA100: Fpna A-22 Valor, N721FP, Hunting Island, SC, December 23, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 23, 2009, 15:32 local (20:32 UTC) - Place: Hunting Island, SC - Coordinates: 32.089168, -80.959724 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.0892&lon=-80.9597&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: No injuries - Injuries: 2 uninjured - Status: Completed, report July 18, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 75199 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA100 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75199/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75199 - Page: https://openairdocs.org/ntsb/ERA10LA100 ## Probable cause Maintenance personnel's inadequate inspection of the oil system's fittings during a routine oil servicing, which resulted in oil starvation due to a loose and/or detached oil line B-nut fitting that led to the engine seizing while in flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Eng oil sys (airframe furnish): eng oil dist (airframe furn)](https://openairdocs.org/ntsb-findings/01057920): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-findings/01057920/cases.md?model=0600044), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057920/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level; cases with it: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=0600044), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=0600044), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=0600044), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/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: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=0600044), [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: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=0600044), [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: [Fpna A-22 VALOR, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0600044), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Fpna A-22 VALOR, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=0600044), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Fpna A-22 VALOR, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=0600044), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis While maneuvering as part of a formation flight, the pilot noticed that the electronic instruments were dimming and that the oil pressure gauge indicated zero. About 10 seconds later, the engine seized and the pilot performed a forced landing on a dirt road. The airplane incurred substantial damage during landing when it veered into a ditch. A postaccident examination of the engine revealed that the No.1 cylinder's connecting rod was protruding through the top of the engine case. Upon removal of the engine cowling, the brass B-nut was found separated from the oil cooler fitting. There was no apparent damage to the threads on the inside of the nut and no damage on the outside of the fitting. Oil was present in the oil sump and on the oil dipstick. The engine had a dry sump forced lubrication system. The oil pump extracts the oil from the oil tank via the oil cooler and forces it through the oil filter to the engine. According to notations found in the airplane's maintenance logbook, the engine's oil had been changed 1.6 flight hours prior to the accident. According to the owner, maintenance personnel did not touch the oil cooler or fittings during the oil change service. The engine manufacturer’s Service Instructions manual had a warning associated with servicing and purging of the oil system. The warning stated that maintenance personnel should carefully check all lubrication system connections, lines and clamps for leaks and security. ## Factual narrative On December 23, 2009, about 1532 eastern standard time, a FPNA A-22 Valor, Special Light Sport Airplane (S-LSA), N721FP, was substantially damaged during a forced landing following a loss of engine power near Hunting Island, South Carolina, approximately 14 miles east of the Savannah/Hilton Head International Airport (SAV), Savannah, Georgia. The certificated commercial pilot and one passenger were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local formation flight which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot reported that he and his passenger were in a formation flight that departed SAV approximately 15 minutes prior to the accident. They were en route back to the departure airport when the pilot noticed that the electronic instruments were dimming and the oil pressure gauge read zero. About 10 seconds later, the engine seized and he notified Savannah Approach Control of his intended emergency landing location. The airplane's owner who was flying a second airplane in formation witnessed the accident. He observed white smoke coming from the engine area of the airplane and about 20 seconds later, the engine appeared to quit. He watched the airplane descend and land on a dirt road and as the airplane decelerated, it veered to the left into a ditch. The owner reported that on the day of the accident, the airplane had been topped off with aviation gas. Prior to the accident flight the owner had flown the airplane for 1.3 hours and reported that there were no indications of mechanical issues. Examination of the airplane by an FAA inspector revealed that the left wing was bent aft from a point approximately half way out on the wing to the tip at an approximate 45 degree angle, and the left main landing gear was found separated from airframe. The carry through structure that the main landing gear had been attached to was fractured About 21 gallons of usable fuel was drained from the tanks at the accident site.. A connecting rod from the No.1 cylinder was found protruding through the top of the engine case. Upon removal of the engine cowling the brass B-nut was found separated from the oil cooler fitting. Further inspection of the B-nut revealed that there was no apparent damage to the threads on the inside of the nut and no damage on the outside of the fitting. Oil was present in the oil sump and on the oil dipstick. The airplane was equipped with a Rotax 912 UL engine. The engine had a dry sump forced lubrication system. The oil pump extracts the motor oil from the oil tank via the oil cooler and forces it through the oil filter to the points of lubrication in the engine. On November 4, 2009, the airplane underwent a 100-hour inspection and at that time had 463.2 total hours. According to the owner, the airplane had been flown approximately 1.6 hours since its most recent oil change. He further reported that during the oil change they did not touchthe oil cooler or fittings. He further stated that "if the engine would break the suction seal it is a big ordeal to re-prime the oil system so we don't touch it." A review of the airplane maintenance logbooks revealed that the day prior to the accident, the oil and oil filter had been drained and replaced. The airplane at that time had 483.1 total hours recorded on the tachometer. The Rotax Service Instructions manual "Purging of Lubrication System For Rotax Engine Type 912 and 914," Section 3 "Accomplishment/Instructions" states in part "WARNING: Carefully check all lubrication system connections, lines and clamps for leaks and security." ## Aircraft - Registration: [N721FP](https://openairdocs.org/deregistered/N721FP-2018-01-23), registration cancelled 2018-01-23, S/N 263, built 2008 (OpenAirDocs) - Reported make and model: FPNA LLC A-22 Valor - Registry model: [Fpna A-22 VALOR](https://openairdocs.org/model/fpna-a-22-valor) (registry code 0600044) (OpenAirDocs) - Registry engine: [Rotax 912UL series](https://openairdocs.org/engine/rotax-912ul-series) (registry code 55571, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 263 - Airframe hours: 463 - Engines: Rotax 912 UL 80 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Costal Empire Flight Training Academy LLC - Registered owner: Fpna LLC - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: 100 hour, November 4, 2009, 22 hours before - Departed: SAV, Savannah, GA - Destination: SAV, Savannah, GA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: none; commercial, flight instructor; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review May 26, 2009; seat: right; flight hours: 533 total, 20 in this make and model, 517 as pilot in command, 201 in the last 90 days, 578 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 21,000 ft overcast - Temperature: 54 °F, dew point 37 °F - Altimeter: 30.20 inHg - Observed at: SAV, 12 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 20091223053079A](https://openairdocs.org/incident/20091223053079A), Dec 23, 2009: Fpna LLC A-22 VALOR, Hardeeville, SC, Substantial damage. Pilot was cruising when the oil pressure dropped to zero. Shortly thereafter, the engine stopped operating. The pilot landed on a dike next to the savannah… ## Docket (9 files) The files NTSB released with the investigation on April 29, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75199. 9.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 522 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324336&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum For Record - Airplane Owner (item 2, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341239&FileExtension=.PDF&FileName=Memorandum%20For%20Record%20-%20Airplane%20Owner-Master.PDF - Airplane Maintenance Records [Excerpts] (item 3, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341236&FileExtension=.PDF&FileName=Airplane%20Maintenance%20Records%20%5BExcerpts%5D-Redacted.PDF - Engine Manufacturer Service Instruction Manual [Excerpt] (item 4, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341237&FileExtension=.PDF&FileName=Engine%20Manufacturer%20Service%20Instruction%20Manual%20%5BExcerpt%5D-Master.PDF - Savannah Weather (item 5, .PDF, 7 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341212&FileExtension=.PDF&FileName=Savannah%20Weather-Master.PDF - Photo 1: Right Side Of Airplane At Rest (Courtesy of FAA) (item 6, .PDF, 858 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341213&FileExtension=.PDF&FileName=Photo%201%3A%20Right%20Side%20Of%20Airplane%20At%20Rest%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2: Airplane At Rest (Courtesy of FAA) (item 7, .PDF, 883 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341226&FileExtension=.PDF&FileName=Photo%202%3A%20Airplane%20At%20Rest%20(Courtesy%20of%20FAA)-Master.PDF - Photo 3: Detached B-nut As Found (Courtesy of FAA) (item 8, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341224&FileExtension=.PDF&FileName=Photo%203%3A%20Detached%20B-nut%20As%20Found%20(Courtesy%20of%20FAA)-Master.PDF - Photo 4: Connecting Rod Through Right Forward Cylinder (Courtesy of FAA) (item 9, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341214&FileExtension=.PDF&FileName=Photo%204%3A%20Connecting%20Rod%20Through%20Right%20Forward%20Cylinder%20(Courtesy%20of%20FAA)-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.