# NTSB ERA15LA332: Lancair IV, N864KM, Fort Lauderdale, FL, August 30, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 30, 2015, 10:55 local (14:55 UTC) - Place: Fort Lauderdale, FL - Coordinates: 26.197221, -80.170829 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.1972&lon=-80.1708&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Serious injuries - Injuries: 1 serious, 1 uninjured - Status: Completed, report October 2, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors, FAA - NTSB case key (mKey): 91886 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA332 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91886/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91886 - Page: https://openairdocs.org/ntsb/ERA15LA332 ## Probable cause The mechanic's improper installation of the turbocharger assembly, which resulted in oil starvation and a subsequent total loss of the engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Turbocharging (recip only): turbocharger](https://openairdocs.org/ntsb-findings/01058120): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-findings/01058120/cases.md?model=056011O), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01058120/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=056011O), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=056011O), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/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: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=056011O), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=056011O), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=056011O), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=056011O), [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: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=056011O), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Mahar Michael C IVP, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056011O), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that, during the climb to cruise altitude, he noticed a loss of engine oil pressure. He declared an emergency with air traffic control (ATC) and requested to return to the airport. After ATC acknowledged, the pilot advised ATC that he lost all engine power and had to make an emergency landing. During the forced landing, the airplane collided with a ditch and was destroyed by postcrash fire. An examination of the engine revealed that it failed catastrophically, displaying signatures of lubrication distress; further, no measurable quantity of oil could be recovered from within the engine. Detailed examination of the engine's turbochargers revealed that one of the two units displayed evidence of burnt oil on the external surface and evidence of a foreign material in the unit's center housing, on the thrust bearing, and on the thrust collar. The foreign material was identified as polyethylene (plastic), similar to that used to protect the exposed orifices of the engine during shipment. Review of maintenance records revealed that the pilot/mechanic had replaced both turbochargers with overhauled units two days before the accident flight. The turbocharger overhauler provided installation instructions and warnings that, in part, stated, "Remove all protective caps and plugs BEFORE installing this turbocharger." The foreign material discovered within the turbocharger's center housing suggests that the protective plastic cap at the oil outlet was likely not removed during the installation. It is likely that the turbocharger center housing filled with oil, which then flowed out of the engine via the turbocharger housing backplate, resulting in oil starvation and the subsequent total loss of engine power. ## Factual narrative On August 30, 2015, about 1055 eastern daylight time, an experimental amateur-built Lancair IV-P, N564KM, was destroyed by collision with terrain and a postcrash fire during a forced landing after takeoff from the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The commercial pilot sustained serious injuries, and the passenger was not injured. The privately owned and operated airplane was operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual flight rules conditions were reported at the airport about the time of the accident, and an instrument flight rules flight plan had been filed for the flight destined for Lynchburg Regional Airport (LYH), Lynchburg, Virginia.According to the pilot, during a climb to cruise he noticed that the engine's oil pressure dropped to 9 psi. He declared an emergency with air traffic control (ATC) due to the low oil pressure indication and requested to return to FXE. ATC provided radar vectors and cleared the airplane for the visual approach to runway 9. Shortly thereafter, the pilot contacted the FXE tower controller and reported an "engine failure." The pilot made a forced landing on a levee located 5 miles west of the approach end of runway 9. During the landing rollout, the airplane veered off the levee, collided with a ditch, and caught fire. The airplane was recovered and the engine was retained for examination. During the examination of the engine puncture holes were discovered in both upper crankcase halves. Further examination revealed that no measurable amount oil could be drained from the engine. All of the spark plugs were removed and displayed a sooty appearance. The cylinders were removed and the cylinder attaching hardware torque and break away torque was checked and found within manufactures specifications; the No. 1, No. 2 and No. 3 pistons and cylinder skirts were damaged. The No. 1 piston exhibited signatures consistent with a valve strike on the dome. The oil sump was removed and contained pieces of connecting rod, rod bolts, rod bearing, and aluminum material in the bottom of the sump. The crankcase was separated and the main bearings were not damaged. All of the bearing tabs were intact and no fretting was noted on the thru-bolt bosses. There was no evidence of bearing shift and the crankcase mating surfaces were machined. Puncture holes were also noted on bottom right crankcase half below the No. 1 cylinder. No obstructions were found in the crankcase oil galleries. Prior to removal, the camshaft was bent forward of the rear journal. The crankshaft was removed and disassembled, the main journals had a normal operating appearance. The No. 1 connecting rod journal was found burnt and deformed. The No. 4 connecting rod journal was found burnt; the No. 2, No. 3, No. 5 and No. 6 connecting rod journals had a normal operating appearance. Examination of the connecting rod bearings revealed the No. 1 rod bearing was located in oil sump andfound burnt and wiped. The No. 4 rod bearing was found burnt and wiped but was still contained within the rod and cap; No.2, No. 3, No. 5, and No.6 rod bearings indicated signs of lubrication distress. The oil pump was disassembled and scoring was present in the internal oil pump housing and oil pump gear facing. Metal contamination was present in the oil relief valve. The oil filter was removed and opened for examination. The filter element exhibited metal contamination (aluminum & steel). A visual examination of both turbochargers revealed one turbocharger had a normal grayish coloration on the internal turbine blades, while the other turbocharger was found blackend and oily on the turbine and compressor impeller blades. The turbochargers were sent to Hartzell Engine Technologies for further examination and identified as urbo A (serial No. tKL01420), and turbo B (serial No. KFN00434). Examination of the turbo A revealed the turbocharger was overhauled by Main Turbo Systems. The turbocharger rotating assembly spun freely with no indication of compressor or turbine rub. Both the axial and radial end play was within specification. The turbocharger assembly was consistent with the design data and there was no evidence of mechanical malfunction. The internal lubrication passages were present with no indications of concern. The turbocharger was dry and displayed evidence of internal and external corrosion. Examination of turbo B revealed that it was also overhauled by Main Turbo Systems. The turbocharger rotating assembly spun freely with no indication of compressor or turbine rub. Both the axial and radial end play was within specification. The turbocharger assembly was consistent with the design data and there was no evidence of mechanical malfunction. The internal lubrication passages were present with no indications of concern. There was evidence of foreign material in the center housing, on the thrust bearing, and on the thrust collar. Evidence of "burnt" oil was discovered on the external surfaces of turbocharger. The turbo was dissembled and it was revealed that oil residue was evident on the backside of the compressor wheel. Further examination also revealed oil residue on the turbo backplate. A review of the engine logbook entries revealed that both turbochargers were removed and replaced by the pilot/mechanic with overhauled units two days prior to the accident flight. The entry in the logbook noted, "three engine test runs/operational checks and conducted leak check in accordance with SB no. 23, dated Feb 8, 2006. No leak/discrepancies noted at this time." An examination of the foreign material located in the center housing of the turbo was conducted. The unknown material was examined using a Fourier Transform Infrared (FTIR) spectrometer with a diamond attenuated total reflectance (ATR) accessory in accordance to ASTM E1252-98 (American Society for Testing Materials E1252- 98). The spectrum was consistent with a straight-chainedaliphatic hydrocarbon. A spectral library search found a very strong spectral match to polyethylene. During the shipment of the turbochargers, polyethylene protective caps and plugs were used to plug the oil line openings. These protective caps and plugs must be removed before installation. The turbocharger overhauler provided instruction and warning tags with the units, one of which stated, "Remove all protective caps and plugs BEFORE installing this turbocharger." ## Aircraft - Registration: [N864KM](https://openairdocs.org/deregistered/N864KM-2018-04-24), registration cancelled 2018-04-24, S/N LIV-166, built 1997 (OpenAirDocs) - Reported make and model: LANCAIR IV (P) - Registry model: [Mahar Michael C IVP](https://openairdocs.org/model/mahar-michael-c-ivp) (registry code 056011O) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: LIV-166 - Year built: 1997 - Airframe hours: 1617 - Engines: Continental TSIO-550-E1B 350 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, April 10, 2015, 167 hours before - Departed: FXE, Fort Lauderdale, FL - Destination: LYH, Lynchburg, VA - Flight plan: IFR - Equipment: Airframe parachute, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Electronic multifunction display, Video recording device, Stall warning system, Satellite tracking device, Onboard weather, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: serious; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review March 12, 2015; seat: left; restraint: 3-point; flight hours: 6,954 total, 114 in this make and model, 4,399 as pilot in command, 77 in the last 90 days, 31 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 17 knots, gusting 24 - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft broken - Temperature: 82 °F, dew point 75 °F - Altimeter: 30.01 inHg - Observed at: FXE, 10 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 20150830015769A](https://openairdocs.org/incident/20150830015769A), Aug 30, 2015: Mahar Michael C IVP, Parkland, FL, Destroyed. The aircraft departed fxe (fort lauderdale executive airport) at 1435(UTC)/1035(local). At 1438(UTC) the pilot declared an emergency due to low oil pressure… ## Docket (8 files) The files NTSB released with the investigation on August 11, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91886. 19.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455230&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455231&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Engine Maintenance Logbook Excerpts (item 3, .PDF, 8.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455232&FileExtension=.PDF&FileName=Engine%20Maintenance%20Logbook%20Excerpts-Master.PDF - FAA Inspector Statement - Engine Examination (item 4, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455233&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20-%20Engine%20Examination-Master.PDF - Turbocharger Teardown Inspection (item 5, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455234&FileExtension=.PDF&FileName=Turbocharger%20Teardown%20Inspection%20-Master.PDF - NTSB Materials Laboratory FTIR Results (item 6, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455235&FileExtension=.PDF&FileName=NTSB%20Materials%20Laboratory%20FTIR%20Results-Master.PDF - Turbocharger Installation Instruction Tags (item 7, .PDF, 699 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455236&FileExtension=.PDF&FileName=Turbocharger%20Installation%20Instruction%20Tags-Master.PDF - Photos (item 8, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455237&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.