ERA16LA333

NTSB accident investigation · Ryan Navion · Hurt, VA · September 27, 2016

Accident · No injuriesLimited investigationFinal report
Date
September 27, 2016, 17:45 local (21:45 UTC)
Place
Hurt, VA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5327KRyan Navion
Defining event
Enroute-cruise: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report June 25, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors, Inc., FAA/FSDO
FAA report
20160927018099A
Case key
94212

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

Incorrect installation of the oil temperature probe and an inadequate annual inspection that failed to detect leaking oil around the loose probe, which resulted in a catastrophic engine failure due to oil starvation.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelRyan NAVION B: 1 caseAll aircraft: 371 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelRyan NAVION B: 1 caseAll aircraft: 167 casesProbable cause
Power plantAircraft › Aircraft power plant · FailureRyan NAVION B: 1 caseAll aircraft: 198 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelRyan NAVION B: 1 caseAll aircraft: 174 casesProbable cause
Object/animal/substance: fence/fence postEnvironmental issues › Physical environment · Contributed to outcomeRyan NAVION B: 1 caseAll aircraft: 313 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

During cruise flight, the private pilot felt the engine suddenly begin to vibrate. He then heard a loud bang; the engine vibration increased, smoke and oil emanated from the engine compartment, and the engine lost total power. The pilot was unable to glide the airplane to a nearby airport and performed a forced landing in a field, during which the airplane struck and rolled through a fence, which resulted in substantial damage to the right wing. Examination of the engine revealed that its crankcase was absent of oil, and there were holes in the crankcase near cylinder Nos. 2, 4, and 6. Subsequent teardown examination revealed that the internal engine components exhibited heat distress consistent with a lack of lubrication. Further examination revealed that the oil temperature probe port was safety wired but could be moved by hand and that the crush washer between the probe and the cooler was installed backwards. This evidence is likely indicative that the probe had not been properly installed, although it could not be determined when that may have occurred. Air pressure applied to the oil cooler showed a leak between the oil temperature probe and the cooler. Oil residue noted on the exterior of the cooler indicated that the oil leak had likely been present for some time and that it was likely where the engine's oil had leaked out, ultimately resulting in the engine failure due to oil starvation. Had the leak been noted and addressed, by correctly installing the oil temperature probe, during the airplane's most recent annual inspection, which was completed 11 days before the accident, it is likely that the engine would not have been starved of oil.

Factual narrative

On September 27, 2016, about 1745 eastern daylight time, a Ryan Navion B, N5327K, was substantially damaged during a forced landing, following a total loss of engine power while in cruise flight near Hurt, Virginia. The private pilot was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Culpeper Regional Airport (CJR), Culpeper, Virginia, about 1700, destined for Long Island Airport (NC26), Long Island, North Carolina.According to the pilot, about 45 minutes into the flight, at an altitude of 3,000 feet mean sea level, the engine suddenly began to vibrate. He informed Roanoke Approach air traffic control (ATC) of his intent to try to land at the nearest airport, which was New London Airport (W90), Forest, Virginia. A few seconds later he heard a loud bang, the vibration worsened, smoke and oil emanated from the engine compartment, and the engine lost power as the propeller continued to windmill. The pilot then advised ATC that he would not be able to make the airport, and he then performed an emergency landing to a mowed hay field. During the landing rollout, the airplane struck and rolled through a post-and-wire fence resulting in substantial damage to the right wing. Examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing leading edge sustained substantial damage, and fence wire was wrapped around the propeller flange. The top left side of the engine crankcase was damaged, and there were holes in the crankcase near cylinder Nos. 6, 4 and 2. A connecting rod protruded through the hole near cylinder No. 4. No oil was present in the crankcase. A teardown examination of the engine was subsequently performed at the manufacturer's facility, under the supervision of a National Transportation Safety Board investigator. The examination revealed that the internal engine components exhibited heat distress consistent with a lack of lubrication. Further examination revealed that the oil temperature probe was safety wired, however it could be moved by hand. An air pressure hose was attached to the oil cooler and when 30 psi was applied, bubbles were noted around the crush washer seal of the oil temperature probe. Oil residue was also noted all over the oil cooler and surrounding area of the engine. See Figure 1. The oil temperature probe was removed, and the crush washer was found installed backwards. Figure 1. Oil Temperature Probe The temperature probe was considered an airframe item and was not installed by the engine manufacturer. The engine was delivered with a plug in the oil temperature probe port, and the installer could remove the plug and replace it with an oil temperature probe. A review of the 1951 Navion B Service Manual revealed no specific torque values for tightening the oil temperature probe. The maintenance manual for the accidentengine provided a torque range for the oil temperature port plug (with crush washer), as 190 in/lbs to 210 in/lbs. The version of the manual in effect at the time of the accident did not specify the orientation of crush washers. Maintenance records revealed that the airplane's most recent annual inspection occurred on September 16, 2016. At that time, the airplane had accrued a total of 4,488 flight hours, and the engine had accrued a total of 832 hours since overhaul.

Aircraft

Registration
N5327K
Reported as
Ryan Navion (B)
Category
Airplane
Serial number
NAV-4-2227-B
Built
1950
Airframe hours
4,488
Engine
Continental IO-550B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 16, 2016 · 1 hours before
Departed
CJR · Culpeper, VA
Destination
NC26 · Long Island, NC
Equipment
Onboard weather, Electronic multifunction display, Electronic flight bag or handheld device, Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
July 19, 2016
Seat
Left
Restraint
3-point
Flight hours
1,014 total · 708 in this make and model · 964 as pilot in command · 23 in the last 90 days · 1 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 6 knots
Visibility
10 statute miles
Lowest ceiling
7,000 ft broken
Temperature
75 °F, dew point 66 °F
Altimeter
29.88 inHg
Observed at
KLYH, 16 nm away

Docket · 7

The files NTSB released with the investigation on April 4, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N5327K · 1

Matched to the same aircraft by N-number and date.