ERA21LA250

NTSB accident investigation · Diamond DA20 · Matthews, VA · June 14, 2021

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
June 14, 2021, 12:30 local (16:30 UTC)
Place
Matthews, VA · Bay
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N458MADiamond DA20
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Transportation Safety Board of Canada
FAA report
20210614007489A
Case key
103257

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

The mechanic’s failure to properly secure the oil sump drain plug during a 100-hour maintenance inspection, which resulted in a total loss of engine power due to oil starvation.

Findings · 2

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.

Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 130 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Maintenance personnelDiamond Aircraft Ind DA20-C1: 1 caseAll aircraft: 440 casesProbable cause

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

Due to an active military operations area, the flight instructor and student pilot on a short cross-country instructional flight to an island were instructed by air traffic control to descend from 5,500 ft mean sea level (msl) to 2,500 ft msl. After the student pilot leveled the airplane at 2,500 ft msl, the engine shook violently and lost all power. The flight instructor took control of the airplane and realized that there was not enough altitude to glide to shore. The flight instructor then ditched the airplane near a fishing trawler where he and the student pilot were rescued. The wreckage was recovered about 2 weeks after the accident and examined at a recovery facility. Examination of the engine revealed that the oil sump drain plug was missing, and the Nos. 1 and 2 connecting rods were fractured in a manner consistent with oil starvation. Review of maintenance records revealed that the airplane’s most recent 100-hour inspection was completed 4 days and 9.3 operating hours before the accident. During an interview, the mechanic who performed the 100-hour inspection stated that he remembered draining the old oil, reinstalling the drain plug with a new gasket, torquing it per the maintenance manual, and securing it with safety wire. He did not remember anything abnormal or any interruptions during the work. Although the mechanic stated that he torqued and safety wired the drain plug, the findings of the investigation the accident suggest that the mechanic likely installed the plug finger-tight and forgot to secure it. Due to normal engine vibration, the plug unscrewed, and the engine oil drained out, which resulted in the total loss of engine power due to oil starvation.

Factual narrative

On June 14, 2021, about 1230 eastern daylight time, a Diamond DA20-C1, N458MA, was substantially damaged when it was involved in an accident near Matthews, Virginia. The flight instructor and student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that during preflight inspection, he added 1 quart of oil to the engine to bring the total quantity to 5 quarts. During a short cross-country flight to Tangier Island in the Chesapeake Bay, air traffic control instructed the flight to descend from 5,500 ft mean sea level (msl) to 2,500 ft msl, due to an active military operations area. After the student pilot leveled the airplane at 2,500 ft msl, the flight instructor noticed engine vibration and roughness that he initially corrected by advancing the throttle from 1,900 to 2,200 rpm; however, the engine subsequently shook “violently” followed by a total loss of engine power. The flight instructor took control of the airplane and realized that there was not enough altitude to glide to a shore. The flight instructor then ditched the airplane in the Chesapeake Bay near a fishing trawler where he and the student pilot were rescued. The wreckage was recovered about 2 weeks after the accident and examined at a recovery facility. Examination of the wreckage revealed that the right wing sustained substantial damage. Examination of the engine revealed that that oil sump drain plug was missing, and the Nos. 1 and 2 connecting rods were fractured in a manner consistent with oil starvation. Review of maintenance records revealed that the airplane’s most recent 100-hour inspection was completed 4 days and 9.3 operating hours before the accident. During an interview, the mechanic who performed the 100-hour inspection stated that he remembered draining the old oil, reinstalling the drain plug with a new gasket, torquing it per the maintenance manual, and securing it with safety wire. He did not remember anything abnormal or any interruptions during the work.

Aircraft

Registration
N458MA
Reported as
Diamond DA20 (C1)
Category
Airplane
Serial number
C0340
Built
2005
Airframe hours
6,133
Engine
Continental IO-240-B, 125 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
American Aviation LLC
Registered owner
Magrahen Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 9, 2021 · 9.3 hours before
Departed
HEF · Manassas, VA
Destination
TGI · Tangier Island, VA
Flight plan
VFR
Airport
NONE
Equipment
Electronic multifunction display, Electronic flight bag or handheld device, ADS-B, Stall warning system, Onboard weather, Handheld GPS

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
46
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
September 1, 2019
Seat
Right
Restraint
4-point
Flight hours
997 total · 96 in this make and model · 783 as pilot in command · 32 in the last 90 days · 9 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
22
Injuries
Minor
Seat
Left
Restraint
4-point
Flight hours
7 total · 7 in this make and model · 0 as pilot in command · 7 in the last 90 days · 7 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 70 °F
Altimeter
29.85 inHg
Observed at
KPHF, 19 nm away
METAR
METAR KPHF 141654Z 26007KT 10SM CLR 28/21 A2985

Docket · 6

The files NTSB released with the investigation on March 1, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 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.