# NTSB WPR15LA085: Cubcrafters CC11-160, N232LT, San Luis Obispo, CA, January 16, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 16, 2015, 10:34 local (18:34 UTC) - Place: San Luis Obispo, CA - Coordinates: 35.096389, -120.063613 - Nearby events: https://openairdocs.org/map.md?lat=35.0964&lon=-120.0636&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: 2 uninjured - Status: Completed, report July 7, 2015 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Cubcrafters, Federal Aviation Administration, Danbury Aerospace - NTSB case key (mKey): 90611 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA085 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90611/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90611 - Page: https://openairdocs.org/ntsb/WPR15LA085 ## Probable cause The pilot's inadequate instrument scan during cruise flight, which resulted in his failure to notice a loss of engine oil pressure. Contributing to the accident was the failure of the oil pressure transducer supply line, which resulted in oil exhaustion and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=060006N), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/cases.md) - [Eng oil sys (airframe furnish): engine oil indicating system](https://openairdocs.org/ntsb-findings/01057930): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-findings/01057930/cases.md?model=060006N), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057930/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=060006N), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Attention/monitoring](https://openairdocs.org/ntsb-findings/02021500): Personnel issues › Psychological · Pilot; cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-findings/02021500/cases.md?model=060006N), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/02021500/cases.md) - [Light condition: glare](https://openairdocs.org/ntsb-findings/03036030): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-findings/03036030/cases.md?model=060006N), [All aircraft, 109 cases](https://openairdocs.org/ntsb-findings/03036030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Cubcrafters CC11-160, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=060006N), [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: [Cubcrafters CC11-160, 2 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=060006N), [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: [Cubcrafters CC11-160, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=060006N), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cubcrafters CC11-160, 10 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=060006N), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that, about 40 minutes after takeoff for the local sightseeing flight, he noticed that the engine oil gauge wasn't indicating properly and that, about 1 minute later, the engine started to "skip." Shortly later, the engine lost all power, and the pilot performed a forced landing to a field. The experimental light-sport airplane nosed over and sustained substantial damage. Neither occupant was injured. Examination revealed considerable oil streaking along the airplane's entire belly in an area obscured from the pilot's view while in flight. Further examination revealed that the oil pressure transducer supply line, which was made of copper tubing, had separated from its fitting on the engine accessory case. Data from the airplane's engine monitoring system (EMS) showed that, about 9 minutes after takeoff, the engine oil pressure dropped out of range, indicating that the supply line failed at that time; the data also showed that a flashing visual oil pressure alert occurred. For the remaining 28 minutes of flight, the oil pressure remained the same, and the alert remained active as all of the engine's oil was expelled out of the separated oil pressure transducer supply line and overboard. The failed copper tubing oil pressure transducer supply line was the subject of a service bulletin (SB), which recommended either periodic inspection of the copper tubing for leaks or replacement of it with a flexible hose. Despite being inspected in accordance with the SB, the supply line still failed. Following the accident, the airplane manufacturer issued a mandatory service alert, which required the replacement of the copper tubing with a flexible hose. As noted, the EMS data indicated that a flashing visual oil pressure alert was issued to the pilot as soon as the oil pressure transducer supply line failed; however, he did not notice the alert and continued the flight. He eventually observed the alert just before the engine seized. If he had noticed when the supply line failed, he would have had ample time to return to the departure airport before the oil was exhausted. Given that this was a sightseeing flight and that the majority of it was flown toward the sun, it is likely that the pilot was distracted during the flight and possibly encountered sun glare that obscured a clear view of the airplane's instrument panel. ## Factual narrative On January 28, 2015, Cubcrafters issued Safety Alert SA 0010, which superseded Service Bulletin SB00025. The alert removed the inspection compliance requirements, and instead required replacement of the oil pressure line with the flexible hose. The alert required mandatory compliance, and was due within the next 10 flight hours, or at the next annual condition inspection, whichever occurred first. FAA records indicated that in March 2013, the airplane was converted by Cubcrafters from the Special Light-Sport to Experimental Light-Sport category, and was issued a new set of operating limitations. According to a representative from Cubcrafters, the conversion is often requested by owners so that they can modify aircraft without the manufacturer's intervention. On January 16, 2015, about 1034 Pacific standard time, a Cubcrafters CC11-160 (Carbon Cub SS), N232LT, nosed over following a forced landing near San Luis Obispo, California. The experimental light-sport airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91. The commercial pilot and passenger were not injured, and the airplane sustained substantial damage to both wings during the accident sequence. The local sightseeing flight departed San Luis County Regional Airport, San Luis Obispo, at 0956. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot reported departing with the intention of performing a local sightseeing flight with a relative. The preflight checks were uneventful, and the engine contained 3.5 quarts of oil. About 40 minutes after takeoff he noticed the engine oil gauge was indicating "---" instead of oil pressure, and about 1 minute later, the engine started to, "skip." He made a radio call to the San Luis Obispo tower, declaring an emergency. A short time later the engine lost all power, and he guided it towards a highway. As he approached the highway he observed traffic, so configured the airplane for landing on an adjacent riverbed. During the landing roll the airplane nosed over, coming to rest inverted. According to the U.S. Naval Observatory, Astronomical Applications Department, during the period of flight the altitude of the Sun when viewed from San Luis Obispo would have been about 26 degrees, with an Azimuth (E of N) of 147 degrees. This would have placed the suns position within the pilot's field of vision for the majority of the flight. Weather at San Luis Obispo included clear skies, and visibilities of 10 miles. The airplane was examined following recovery by the NTSB investigator-in-charge, along with representatives from the Federal Aviation Administration (FAA), Cubcrafters, and Danbury Aerospace. Examination revealed considerable oil streaking along the fuselage, covering the lower right side and entire belly. The oil residue was in an area that was obscured from the view of the pilot and passenger while in flight. The engine oil level was checked, and the sumpwas empty. The engine was rotated by hand at the propeller, and excessive force was required to rotate the crankshaft. The engine cowling was removed, and the entire right side of the engine and firewall was coated in a film of oil. Further examination revealed that the oil pressure supply line, which connected the engine to the oil pressure transducer, had separated from its fitting on the engine accessory case. The pressure line was made of copper tubing, and was connected to the transducer and accessory case with compression fittings, which utilized brass ferrules. The line exhibited necking at the separation surface adjacent to the ferrule edge. Removal of the line at the transducer revealed similar necking, but no separation. Oil Pressure Line Service Bulletin At the time of the accident, Cubcrafters Service Bulletin SB00025 Rev A, "Oil Pressure Line Inspection" was in effect. The purpose of the bulletin was to, "inspect the oil pressure line for leaks, and to provide the option to upgrade to a flexible hose." The service bulletin called for mandatory compliance on or before the next 100-hour or annual condition inspection, with a subsequent recurrent inspection at 50-hour intervals, unless the line was upgraded to the flexible hose. The last annual condition inspection occurred 130 flight hours prior to the accident. The mechanic who performed the inspection stated that he examined the oil lines in accordance with the Cubcrafters service manual. He was aware of Service Bulletin SB00025, (and had in fact ordered a set of flexible hoses for inventory) and although it was not specifically documented in the maintenance logbooks, he complied with it utilizing the inspection method both during the annual, and the two subsequent oil changes. Engine Monitoring System The airplane was equipped with a Dynon Avionics FlightDEK-D180 combination electronic flight instrument system (EFIS) and engine monitoring system (EMS). The unit was installed on the left side of the instrument panel, directly in front of the pilot. The unit was capable of storing over 180 engine and flight parameters in non-volatile memory. Parameters included GPS location, engine oil pressure, and alert status. Data for the flight was downloaded from the unit during the examination. The data indicated that shortly after takeoff the airplane initiated a climb to the southwest towards San Luis Obispo Bay. The engine oil pressure remained about 68 pounds per square inch (psi), and about 7 minutes later, having reached the bay, the airplane changed course to the east. Two minutes later the oil pressure reading dropped to -106 psi, and the unit logged an oil alert indicating the oil pressure was out of range. The flight continued for an additional 28 minutes on a meandering east-southeast track along the coast, and then inland to the accident location. Throughout the rest of the flight, the oil pressure remained at -106 psi, with the alert still active. Documentation provided by Dynonindicated that the alert would have resulted in both the digital readout and oil pressure needle "tick" flashing. The airplane was not equipped with an audible alert system, or the optional external alert annunciator light. In a subsequent exchange, the pilot stated that he noticed the oil pressure alert just before the loss of engine power occurred, conceding that it was possible that it came on earlier in the flight, and that he did not notice it. ## Aircraft - Registration: [N232LT](https://openairdocs.org/aircraft/N232LT), registered now, S/N CC11-00262, built 2013 (OpenAirDocs) - Reported make and model: CUBCRAFTERS INC CC11-160 - Registry model: [Cubcrafters CC11-160](https://openairdocs.org/model/cubcrafters-cc11-160) (registry code 060006N) (OpenAirDocs) - Registry engine: [Cubcrafter CC340](https://openairdocs.org/engine/cubcrafter-cc340) (registry code 18050, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: CC11-00262 - Year built: 2013 - Airframe hours: 298 - Engines: ECi CC340 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Last inspection: Condition, April 4, 2014, 130 hours before - Departed: SBP, SAN LUIS OBISPO, CA - Destination: SBP, SAN LUIS OBISPO, CA - Airport: SBP, San Luis County Rgnl - Equipment: Stall warning system, Auto-pilot, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 3, with waivers/limitations; last flight review April 21, 2014; seat: front; restraint: 3-point; flight hours: 3,833 total, 294 in this make and model, 2,304 as pilot in command, 34.4 in the last 90 days, 9.6 in the last 30 days, 1.2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 15 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 43 °F - Altimeter: 30.23 inHg - Observed at: KSBP, 31 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 20150116001379A](https://openairdocs.org/incident/20150116001379A), Jan 16, 2015: Cubcrafters Inc CC11-160, Santa Maria, CA, Substantial damage. N232LT experienced a forced off-airport landing on 01/16/2015 near ?mile marker 40 ½? On California highway 166, in Santa Maria, CA. The pilot reported a loss… ## Docket (19 files) The files NTSB released with the investigation on April 17, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90611. 19.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 794 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425237&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425238&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Mechanic Statement (item 3, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425239&FileExtension=.PDF&FileName=Mechanic%20Statement-Master.PDF - Image of Ground Track and Oil Pressure (item 4, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425240&FileExtension=.PDF&FileName=Image%20of%20Ground%20Track%20and%20Oil%20Pressure-Master.PDF - Sunrise Data (item 5, .TXT, 1 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425241&FileExtension=.txt&FileName=Sunrise%20Data-Master.txt - Photo 1: Airplane at Accident Site (Provided Sherriff Department) (item 6, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425242&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20at%20Accident%20Site%20(Provided%20Sherriff%20Department)%0D%0A-Master.PDF - Photo 2: Oil Streak (item 7, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425243&FileExtension=.PDF&FileName=Photo%202%3A%20Oil%20Streak-Master.PDF - Photo 3: Oil Pressure Transducer Line and Fitting (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425244&FileExtension=.PDF&FileName=Photo%203%3A%20Oil%20Pressure%20Transducer%20Line%20and%20Fitting-Master.PDF - Photo 4: Oil Pressure Transducer Line (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425245&FileExtension=.PDF&FileName=Photo%204%3A%20Oil%20Pressure%20Transducer%20Line-Master.PDF - Photo 5: Oil Pressure Transducer Line (item 10, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425246&FileExtension=.PDF&FileName=Photo%205%3A%20Oil%20Pressure%20Transducer%20Line-Master.PDF - Photo 6: Oil Pressure Transducer Line Fitting and Tip (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425247&FileExtension=.PDF&FileName=Photo%206%3A%20Oil%20Pressure%20Transducer%20Line%20Fitting%20and%20Tip-Master.PDF - Photo 7: Oil Pressure Transducer Line Tip (item 12, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425248&FileExtension=.PDF&FileName=Photo%207%3A%20%20Oil%20Pressure%20Transducer%20Line%20Tip-Master.PDF - Photo 8: Oil Pressure Transducer Line (Transducer Side) (item 13, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425249&FileExtension=.PDF&FileName=Photo%208%3A%20Oil%20Pressure%20Transducer%20Line%20(Transducer%20Side)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 390 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425250&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425251&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Engine Logbook Excerpts (item 16, .PDF, 670 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425252&FileExtension=.PDF&FileName=Engine%20Logbook%20Excerpts-Redacted.PDF - Cubcrafters Service Bulletin SB00025 (item 17, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425253&FileExtension=.PDF&FileName=Cubcrafters%20Service%20Bulletin%20SB00025-Master.PDF - Cubcrafters Service Alert SA0010 (item 18, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425254&FileExtension=.PDF&FileName=Cubcrafters%20Service%20Alert%20SA0010-Master.PDF - Dynon D180 Data for Accident Flight (item 19, .CSV, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40425255&FileExtension=.csv&FileName=Dynon%20D180%20Data%20for%20Accident%20Flight-Master.csv 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.