# NTSB WPR09LA369: Brown Michael Kitfox IV, N6140S, Escondido, CA, July 25, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 25, 2009, 11:00 local (18:00 UTC) - Place: Escondido, CA - Coordinates: 33.152778, -116.906944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.1528&lon=-116.9069&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO, Rotax Aircraft Engines - NTSB case key (mKey): 74373 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA369 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74373/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74373 - Page: https://openairdocs.org/ntsb/WPR09LA369 ## Probable cause A total loss of power due to an oil exhaustion induced seizure of the engine. The pilot's decision to continue flight to the original destination after becoming aware of the in-flight oil leak instead of landing at an intermediate airport to investigate the source and extent of the problem is also causal. Contributing to the accident was the pilot's reuse of the pushrod oil seal during maintenance in contradiction to the engine manufacturer's maintenance instructions. ## 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 · Pilot; cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05611I1), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=05611I1), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=05611I1), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05611I1), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05611I1), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05611I1), [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: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05611I1), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Brown Michael KITFOX IV, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05611I1), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis During cruise flight the pilot observed oil trailing along the landing gear strut. He checked the engine oil pressure indicator, and confirmed it was displaying a normal oil pressure. He then altered his flight path to include areas suitable for performing a forced landing. He continued to monitor the oil pressure as he approached an airstrip. The oil pressure did not change, and he decided to continue the flight to his destination. Shortly thereafter, the oil pressure dropped to zero, and the engine lost all power. The pilot performed a forced landing; however, during the landing roll out, the airplane struck a ditch and nosed over. Inspection of the engine revealed that the number four cylinder exhaust pushrod O-ring seal had failed, which allowed the oil to exit the engine, causing the engine to seize. The pilot stated that he had removed the cylinder head 2 years prior to the accident, and reused the exhaust pushrod O-ring seal. According to the engine manufacturer's maintenance manual recommendations, all sealing rings, gaskets, securing elements, O-rings and oil seals are to be replaced at engine reassembly. ## Factual narrative HISTORY OF FLIGHT On July 25, 2009, about 1100 Pacific daylight time, an experimental Kitfox IV, N6140S, nosed over after a forced landing near Escondido, California. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The certificated sport pilot received minor injuries. The airplane sustained substantial damage to the aft fuselage and vertical stabilizer. The personal flight departed Hemet, California, about 1030, with a planned destination of Ramona Airport, Ramona, California. Visual meteorological conditions prevailed, and no flight plan had been filed. After departing Hemet, and as the airplane approached Pauma Valley Airpark (CL33), Pauma Valley, California, the pilot observed oil trailing along the left landing gear strut. He checked the engine oil pressure indicator, and confirmed it was displaying 45 to 50 pounds per square inch (PSI). He elected to continue the flight to Ramona; however, he altered his course so that he was able to fly over several areas, including a private ranch landing strip, where a landing could be made if it was necessary. He reported that as he approached the private landing strip the oil pressure did not change, and he decided to continue the flight to Ramona. After flying for an additional 2 miles, he observed the oil pressure level drop to zero, and shortly thereafter, the engine stopped. He then changed his heading to the north, and prepared for a forced landing. The airplane landed in a dirt field. During the landing roll the main landing gear struck a ditch, and the airplane nosed over. The pilot reported performing a preflight inspection on a prior flight earlier in the day. During the inspection he confirmed that the engine contained adequate oil. He stated that on the accident flight, he had not checked the engine oil level. AIRCRAFT INFORMATION The two-seat, experimental airplane, was issued a Special Airworthiness Certificate in December 2001. It was powered by a four-cylinder, liquid cooled, Rotax 912 ULS engine, and equipped with a Sensenich ground adjustable composite propeller. The engine incorporated a dry sump forced lubrication system with an oil tank capacity of 3.2 quarts. The engine was manufactured in 2001; 330.3 flight hours prior to the accident. Maintenance records revealed that an annual inspection was completed on June 1, 2009; 8.2 flight hours prior to the accident. TESTS AND RESEARCH Engine The NTSB investigator-in-charge and representatives from the Federal Aviation Administration and Rotax Aircraft Engines examined the engine. The engine could not be rotated by hand. Removal of the engine oil dipstick, and visual inspection of the oil tank revealed the absence of oil. Oil streaks were observed on the left main landing gear strut, with the left side of the belly mounted engine coolant radiator oil soaked. External inspection of the engine revealed no obvious sources of an oil leak. Investigators connected a 15 PSI regulated airsource to the engine oil tank breather line, and observed air leaking from the base of the number four cylinder exhaust pushrod. Removal of the cylinder revealed the exhaust pushrod O-ring seal had spilt. The pilot/owner stated that about 2 years, and 100 flight hours prior to the accident, he had removed the number four cylinder head in order to perform a repair of the spark plug hole. He stated that he reused the original O-ring seal during reassembly of the cylinder head. In the 'Procedure Notes' section of the 912 Series Rotax Engine Maintenance Manual it states, "At reassembly of the engine, replace all sealing rings, gaskets, securing elements, O-ring and oil seals." ## Aircraft - Registration: [N6140S](https://openairdocs.org/aircraft/N6140S), registered now, S/N C9909-0253, built 2001 (OpenAirDocs) - Reported make and model: BROWN MICHAEL KITFOX IV - Registry model: [Brown Michael KITFOX IV](https://openairdocs.org/model/brown-michael-kitfox-iv) (registry code 05611I1) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: C9909-0253 - Airframe hours: 330 - Engines: Rotax 912ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Traunero Harold L - Registered owner: Traunero Harold L - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, June 1, 2009, 8 hours before - Departed: HMT, Hemet, CA - Destination: RNM, Ramona, CA - Airport: RNM, Ramona ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: minor; sport pilot; airplane ratings: single-engine land; medical: sport pilot; last flight review September 29, 2008; seat: left; flight hours: 200 total, 200 in this make and model, 150 as pilot in command, 20 in the last 90 days, 10 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 29.98 inHg - Observed at: RNM, 9 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 20090725018039A](https://openairdocs.org/incident/20090725018039A), Jul 25, 2009: Amtr KITFOXIV, Ramona, CA, Substantial damage. (-23) On July 25, 2009, the following accident was reported by the region operation center WP-09. N6140S a kit fox iv piloted by [privacy data omitted],… ## Docket (9 files) The files NTSB released with the investigation on September 17, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74373. 8.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 653 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318512&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Record of Conversation (item 2, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318743&FileExtension=.PDF&FileName=Pilot%20Record%20of%20Conversation-Redacted.PDF - Photo 1: Cylinder Number 4 Exhaust Pushrod O-Ring (item 3, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318517&FileExtension=.PDF&FileName=Photo%201%3A%20Cylinder%20Number%204%20Exhaust%20Pushrod%20O-Ring-Master.PDF - Photo 2: Cylinder Number 4 Intake and Exhaust Pushrod O-Rings (item 4, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318518&FileExtension=.PDF&FileName=Photo%202%3A%20Cylinder%20Number%204%20Intake%20and%20Exhaust%20Pushrod%20O-Rings-Master.PDF - Photo 3: Pushrod Oil Leak Location (item 5, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318519&FileExtension=.PDF&FileName=Photo%203%3A%20Pushrod%20Oil%20Leak%20Location-Master.PDF - Photo 4: Airplane Damage (item 6, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318520&FileExtension=.PDF&FileName=Photo%204%3A%20Airplane%20Damage-Master.PDF - Engine Logbook Excerpts (item 7, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318511&FileExtension=.PDF&FileName=Engine%20Logbook%20Excerpts-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318513&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Rotax 912 Maintenance Manual Excerpts (item 9, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318514&FileExtension=.PDF&FileName=Rotax%20912%20Maintenance%20Manual%20Excerpts-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.