WPR21LA173

NTSB accident investigation · Flight Design Ctsw · Santa Fe, NM · April 22, 2021

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
April 22, 2021, 10:04 local (16:04 UTC)
Place
Santa Fe, NM
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N378CTFlight Design Ctsw
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
Western Pacific Region
Parties
FAA
FAA report
20210422004669A
Case key
102964

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 leak in the oil line that supplied the engine with oil, which resulted in oil exhaustion and the total loss of engine power. Contributing to the accident was the routing of the oil line to close to the exhaust manifold.

Findings · 4

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.

Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Effect on equipmentFlight Design CTSW: 2 casesAll aircraft: 253 cases
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelFlight Design CTSW: 1 caseAll aircraft: 174 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Unknown/Not determinedFlight Design CTSW: 1 caseAll aircraft: 371 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

On an instructional flight, a flight instructor and the pilot receiving instruction practiced touch and go landing maneuvers and were en route back to their destination. The pilot noticed the oil pressure had decreased and positioned the airplane to fly over a suitable landing environment. However, the oil pressure continued to decrease and when the pressure reached about 4 psi, the engine abruptly stopped. Subsequently, the flight instructor made a forced landing on a dirt field. During the ground roll, the nose wheel struck a rock and the airplane nosed over. Postaccident examination of the airplane revealed a leak in the oil line supplying oil to the engine. The leak in the oil line likely led to the loss of oil during flight and resulted in the abrupt loss of engine power. The damage to the oil line was consistent with heat damage, which was likely a result of it having been routed too close to the exhaust manifold.

Factual narrative

On April 22, 2021, about 1004 mountain daylight time, a Flight Design GMBH, CSTW light sport airplane, N378CT, was substantially damaged when it was involved in an accident near Santa Fe, New Mexico. The flight instructor was not injured and the pilot receiving instruction sustained a minor injury. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported they were returning to their departure airport at an altitude of of about 7,500 ft mean sea level when he noticed the oil pressure had decreased and of theother engine indications appeared normal. He climbed to a higher altitude, monitored the oil pressure, and positioned the airplane to fly over a suitable landing environment. The oil pressure continued to decrease and when the pressure reached about 4 psi, the engine abruptly came to a complete stop. The flight instructor made a forced landing on a dirt field about 8 miles south of the airport. During the ground roll, the nose wheel struck a rock and the airplane nosed over. Additionally, the flight instructor reported that during the preflight inspection the oil level was correct and there were no indications of an oil leak A review of the data provided by the Dynon EMS-D120 device revealed the oil pressure steadily decreased for about the last 25 minutes of flight. About 3 minutes before the off-field landing, the oil pressure rapidly decreased to zero. Shortly thereafter, the engine rpm decreased to zero. Postaccident examination of the airplane revealed that the oil supply line from the oil tank to the oil pump, which supplied the engine, was observed to leak once compressed air was introduced into the line. The leak was in the area where the oil line rested against the exhaust manifold. The damage to the oil line was consistent with it being subjected to heat from the exhaust manifold. The oil line was connected correctly but routed to close to the exhaust manifold.

Aircraft

Registration
N378CT
Reported as
Flight Design Ctsw
Category
Airplane
Serial number
06-02-10
Built
2006
Airframe hours
1,526
Engine
Bombardier/Rotax 912 ULS, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
100 hour · April 8, 2021
Departed
SAF · Santa Fe, NM
Airport
None
Equipment
Angle of attack indicator, Electronic primary flight display, Airframe parachute, Auto-pilot, Electronic flight bag or handheld device, ADS-B, Handheld GPS, Electronic multifunction display

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
63
Injuries
None
Certificates
Flight instructor, Private, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 1, 2020
Seat
Right
Flight hours
3,983 total · 106 in this make and model · 3,720 as pilot in command · 35 in the last 90 days · 12 in the last 30 days · 1 in the last 24 hours
Role
Pilot
Age
41
Injuries
Minor
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Medical
Sport pilot
Last flight review
January 27, 2021
Seat
Left
Flight hours
32 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 19 °F
Altimeter
29.95 inHg
Observed at
KSAF, 8 nm away
METAR
KSAF 221614Z 14011KT 10SM CLR 11/M07 A2995 RMK AO2 T01061067

Docket · 7

The files NTSB released with the investigation on September 20, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.4 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.