WPR19LA129

NTSB accident investigation · Storch FL-156C · Upland, CA · May 1, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
May 1, 2019, 10:01 local (17:01 UTC)
Place
Upland, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N156LZStorch FL-156C
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA FSDO
FAA report
20190501003769A
Case key
99360

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 pilot’s improper installation of the No. 3 cylinder valve cover, which resulted in an oil leak, oil starvation, and a subsequent total loss of engine power.

Findings · 3

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.

Maintenance: installationPersonnel issues › Task performance · PilotStorch FL-156C: 1 caseAll aircraft: 371 casesProbable cause
Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceStorch FL-156C: 1 caseAll aircraft: 130 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelStorch FL-156C: 1 caseAll aircraft: 174 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

Shortly after takeoff, the engine lost oil pressure and subsequently lost total power. The pilot maneuvered the airplane to return to the airport, but the airplane touched down in a field and came to rest upright. Postaccident examination of the engine revealed evidence of an oil leak. The leak likely came from the No. 3 cylinder, as the valve cover was loose, with a gap between the cylinder and the valve cover, which was likely the result of an improperly torqued allen screw. The improper torquing likely occurred during the pilot’s recent inspection of the crankcase throughbolts and re-installation of the engine’s four valve covers. Eventually, the No. 3 allen screw became loose during the engine run-up and continued to loosen during the taxi, takeoff, and climb phases of flight, which resulted in a loss of engine oil and a subsequent total loss of engine power due to oil starvation.

Factual narrative

On May 1, 2019, about 1001 Pacific daylight time, a special light sport Storch Aircraft LLC, N156LZ, was substantially damaged when it was involved in an accident near Upland, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, after takeoff, as the airplane climbed through about 300 ft, the engine lost oil pressure but continued to produce power. As the pilot maneuvered the airplane toward the departure airport, the engine suddenly stopped developing power. The airplane touched down in a field east of the airport and came to rest upright. A review of photographs provided by the Federal Aviation Administration (FAA) revealed substantial damage to the forward cabin and engine truss. An examination of the engine performed by the FAA revealed that the No. 3 cylinder valve cover was loose (see figure 1), with a gap about 1/4-inch between the cylinder and the cover; oil was found throughout the engine and the engine compartment. Oil was discovered outside the hangar where the pilot started the engine for the accident flight, and an oil trail led to the runup area he used, which also exhibited oil spray (see figure 2). Figure 1. Close-up view of No. 3 cylinder valve cover Figure 2. Oil residue discovered on taxiway in relation to pilot’s hangar and wreckage site A review of the airplane’s maintenance records revealed that the engine was removed on May 24, 2018, and reinstalled on August 31, 2018, by the pilot. No other maintenance on the engine was recorded in the logbooks. The pilot reported that before the last flight, he removed the valve covers to inspect the crankcase throughbolts and “thought” he retorqued all four valve cover screws. He re-examined the valve covers after the accident and confirmed that the No. 3 cylinder valve cover was loose. The Rotax Powertrain Maintenance Manual 72-00-00 pg. 93, instructs, “fit valve cover and tighten with allen screw M6x30 and washer to a tightening torque of 10 Nm (90 in. lbs).” The caution associated with the tightening of the allen screw at reinstallation stated: IF THIS SCREW IS LOOSE OR IF THE VALVE COVER IS LEAKING, THE OIL RETURN TO THE OIL TANK BY “BLOW-BY GAS” WILL NOT WORK PROPERLY AT ALL OR ONLY INSUFFICIENTLY. According to the engine manufacturer, the oil system relies on crankcase pressure to return oil back to the tank from the crankcase. The valve covers need to be sealed, as this crankcase pressure will escape from that location and oil will not return to the tank. If the No. 3 valve cover is loose during an engine start-up, the inadequate seal would result in a substantial oil leak, followed by an imminent engine failure due to oil starvation.

Aircraft

Registration
N156LZ
Reported as
Storch FL-156C
Category
Airplane
Serial number
SA-001K
Built
2009
Engine
Rotax 912ULS, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Departed
CCB · Upland, CA
Flight plan
Unknown
Airport
CCB · Cable, runway 24, 3,863 × 75 ft, asphalt
Equipment
Unknown

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
72
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 3, With waivers/limitations
Flight hours
10,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 45 °F
Altimeter
30.02 inHg
Observed at
CCB

Docket · 5

The files NTSB released with the investigation on December 14, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 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.