# NTSB ERA16LA333: Ryan Navion, N5327K, Hurt, VA, September 27, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 27, 2016, 17:45 local (21:45 UTC) - Place: Hurt, VA - Coordinates: 37.055278, -79.294998 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.0553&lon=-79.2950&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report June 25, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors, Inc., FAA/FSDO - NTSB case key (mKey): 94212 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA333 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94212/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94212 - Page: https://openairdocs.org/ntsb/ERA16LA333 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=6150170), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=6150170), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=6150170), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=6150170), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=6150170), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/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: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=6150170), [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) (defining event); cases with it: [Ryan NAVION B, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=6150170), [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); cases with it: [Ryan NAVION B, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=6150170), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Ryan NAVION B, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=6150170), [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: [Ryan NAVION B, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6150170), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N5327K), registered now, S/N NAV-4-2227-B, built 1950 (OpenAirDocs) - Reported make and model: RYAN NAVION (B) - Registry model: [Ryan NAVION B](https://openairdocs.org/model/ryan-navion-b) (registry code 6150170) (OpenAirDocs) - Registry engine: [Lycoming GO-435C&D series](https://openairdocs.org/engine/lycoming-go-435c-d-series) (registry code 41521, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-2227-B - Year built: 1950 - Airframe hours: 4488 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; 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 ## 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 20160927018099A](https://openairdocs.org/incident/20160927018099A), Sep 27, 2016: Ryan NAVION B, Lynchburg, VA, Substantial damage. The engine stopped producing power due to catastrophic failure. During landing, the aircraft struck a fence post on right wing causing damage to monocoque… ## Other investigations on N5327K (1) 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. - [NTSB CHI72FEE48](https://openairdocs.org/ntsb/CHI72FEE48), Dec 11, 1971: Navion B (N5327K), Harvard, IL, substantial damage ## Docket (7 files) The files NTSB released with the investigation on April 4, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94212. 7.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471632&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement (item 2, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471633&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Photo Array (item 3, .PDF, 3 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471634&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Oil Cooler (item 4, .PDF, 3 photos, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471635&FileExtension=.PDF&FileName=Oil%20Cooler-Master.PDF - Service-Maintenance Manual Excerpts (item 5, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471636&FileExtension=.PDF&FileName=Service-Maintenance%20Manual%20Excerpts-Master.PDF - NTSB Engine Examination Report (item 6, .PDF, 33 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471637&FileExtension=.PDF&FileName=NTSB%20Engine%20Examination%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation - Continental Motors (item 7, .PDF, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471638&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Continental%20Motors-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.