MIA08FA122

NTSB accident investigation · Yates Lancair IV-P · Springfield, KY · June 18, 2008

Accident · FatalField investigationFinal report
Date
June 18, 2008, 13:10 local (17:10 UTC)
Place
Springfield, KY
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N441LYates Lancair IV-P
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 11, 2009
Report
Approved by Office Director
Parties
Teledyne Continental Motors, FAA/FSDO
FAA report
20080618839799A
Case key
68251

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

A total loss of engine power due to a loss of engine oil as a result of the installation of the wrong oil adapter O-ring seal.

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.

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

Shortly after takeoff, the pilot radioed air traffic control to report that he was losing engine oil pressure and that his windscreen was covered with oil. He was advised that he was 4 miles from the nearest suitable airport. Air traffic control lost radar and communications with the pilot and the airplane crashed at the approach end of a runway at the airport. Visual examination of the engine revealed that the No. 2 connecting rod penetrated through the top of the aft section of the engine case. Examination of the accessory case revealed that a Supplemental Type Certificate (STC) SE5743NM Aviation Development Corporation oil filter adapter was attached to the accessory oil filter adapter fitting. A visual inspection of the oil filter adapter revealed that the O-ring between the mating surfaces was extruding 3/4 inch. Visual inspection of the O-ring revealed that it was leaking oil for an undetermined amount of time and was dry rotted and brittle. Review of the STC revealed that the O-ring was the incorrect part that was installed on the engine. A review of the engine and airframe logbooks did not reveal when the installation of the improper O-ring was performed. The engine had accumulated about 351 hours of operation since manufacture.

Factual narrative

HISTORY OF FLIGHT On June 18, 2008, at 1310 eastern daylight time, an amateur-built Lancair IV-P, N441L, impacted terrain adjacent to runway 11 at Lebanon-Springfield Airport (6I2), Springfield, Kentucky, during an emergency landing. The airplane was substantially damaged and the certificated commercial pilot was killed. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Personnel at the Indiana Air Route Traffic Control Center (ARTCC) reported that the pilot departed from Blue Grass Airport (LEX), Lexington, Kentucky, at 1300. Soon after departing, the pilot contacted a controller to advise that he was losing engine oil pressure. At 1305, he requested radar vectors to the nearest airport and was advised that 6I2 was the closest airport. He was also advised that the airport was 8 miles at his 12 o'clock position. At 1306, he notified ARTCC that his windscreen was covered with oil. The controller then advised him that he was 4 miles from 6I2. The pilot responded that he did not have visual contact with the airport, and at 1308, ARTCC lost radar and communications with the airplane. A witness stated that he saw an airplane flying overhead and heard it "backfire." The witness further stated that shortly thereafter, he saw smoke coming from underneath the airplane. He said that the engine appeared to be running at full power, while continuing to backfire and emit smoke until it disappeared from sight. PERSONNEL INFORMATION The pilot, age 54, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, helicopter, and instrument airplane, which was issued on November 12, 1998. The pilot's last medical examination was on November 8, 2007, for a second-class medical certificate with no limitations or waivers. Review of the pilot's logbook revealed that he had accumulated 6,209 total flight hours, of which 196.5 hours were in the Lancair IV-P. He had logged 30 flight hours, which were flown within the last 90 days prior to the accident. AIRCRAFT INFORMATION The four-seat, low-wing, retractable-gear airplane, serial number LIV-177, was manufactured in 1997. It was powered by a Teledyne Continental Motor (TCM)TSIO-550-B, 350-horsepower engine and was equipped with a three-bladed Hartzell constant-speed propeller, model F7693 DF. Review of the maintenance logbook records showed that a conditional inspection was completed on February 29, 2008, at a Hobbs reading of 313 hours, and an airframe total time of 313 hours. The airplane's logbooks revealed that on May 6, 2008, the engine and airframe total time was 351.1 hours. The pilot's personal logbook indicated that he flew the airplane approximately 18.5 hours since the last recorded inspection. METEOROLOGICAL INFORMATION The reported weather at Stuart Powell Field, located about 15 miles east of the accident site, at1259, was: wind from 290 degrees at 10 knots, gusting to 14 knots; visibility 10 miles; sky clear; temperature 23 degrees Celsius; dew point 9 degrees Celsius; altimeter 29.98 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the wreckage was located at the approach end of runway 11. The crash debris line was approximately 200 feet in length on a 150-degree magnetic heading. A postcrash fire consumed the composite airframe. All flight control surfaces were located at the wreckage site, and flight control continuity was confirmed. Examination of the airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. The engine and its accessories were separated from the firewall and airframe. Examination of the propeller and system components revealed no evidence of preimpact mechanical malfunction. Visual examination of the engine revealed that the No. 1, 2 and 5 connecting rods were broken, and that the No. 2 connecting rod penetrated through the top of the aft section of the engine case. Examination of the accessory case revealed that a Supplemental Type Certificate (STC) SE5743NM Aviation Development Corporation (ADC) oil filter adapter was attached to the TCM accessory oil filter adapter fitting. A visual inspection of the ADC oil filter adapter revealed that the O-ring seal between the mating surfaces was extruding 3/4 inch. Further examination revealed that the O-ring was leaking oil for an undetermined amount of time, was dry-rotted, and brittle. Review of the ADC STC revealed that the current installed O-ring was incorrect. A review of the engine, and airframe logbooks did not reveal when the installation of the improper O-ring was performed. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on June 18, 2008, by the Office of the Chief Medical Examiner, Commonwealth of Kentucky, Louisville, Kentucky, as authorized by the Coroner of Washington, Kentucky. The cause of death was reported as "Generalized Blunt-force Trauma." Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report revealed that no ethanol was detected in the liver or muscle. Quinine was detected in the urine.

Aircraft

Registration
N441L
Reported as
Yates Lancair IV-P
Category
Airplane, amateur-built
Serial number
LIV-177
Airframe hours
313
Engine
Continental TSIO-550-B, 350 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Dan C Hutson II
Registered owner
Dan C Hutson II
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · February 29, 2008
Departed
LEX · Lexington, KY
Destination
CEY · Murry, KY
Airport
6I2 · Lebanon-Springfield Airport, runway 11, 5,000 × 75 ft, asphalt

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
54
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
6,209 total · 196 in this make and model · 30 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 10 knots, gusting 14
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 48 °F
Altimeter
29.97 inHg
Observed at
DVK, 15 nm away

Docket · 17

The files NTSB released with the investigation on March 11, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 27.2 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.