# NTSB WPR21LA173: Flight Design Ctsw, N378CT, Santa Fe, NM, April 22, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: April 22, 2021, 10:04 local (16:04 UTC) - Place: Santa Fe, NM - Coordinates: 35.517, -106.182 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.5170&lon=-106.1820&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, 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 102964 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21LA173 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102964/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102964 - Page: https://openairdocs.org/ntsb/WPR21LA173 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Effect on equipment; cases with it: [Flight Design CTSW, 2 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=0600001), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=0600001), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Eng oil sys (airframe furnish): eng oil dist (airframe furn)](https://openairdocs.org/ntsb-findings/01057920): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-findings/01057920/cases.md?model=0600001), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/01057920/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Unknown/Not determined (probable cause); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=0600001), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Flight Design CTSW, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0600001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-cruise: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Flight Design CTSW, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=0600001), [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: [Flight Design CTSW, 9 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=0600001), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N378CT-2022-08-24), registration cancelled 2022-08-24, S/N 06-02-10, built 2006 (OpenAirDocs) - Reported make and model: FLIGHT DESIGN GMBH CTSW - Registry model: [Flight Design CTSW](https://openairdocs.org/model/flight-design-ctsw) (registry code 0600001) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 06-02-10 - Year built: 2006 - Airframe hours: 1526 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 63; injuries: none; 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 - Pilot; age 41; injuries: minor; 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 ## 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 20210422004669A](https://openairdocs.org/incident/20210422004669A), Apr 22, 2021: 2006 Flight Design Gmbh CTSW, Santa Fe, NM, Substantial damage. On April 22, 2021, at 0946 MST, a flight design gmbh special light sport, N378CT, registered to [privacy data omitted], experienced a loss of oil pressure and… ## Docket (7 files) The files NTSB released with the investigation on September 20, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102964. 6.4 MB in all. - Engine monitoring system - specialist's factual report (item 1, PDF, 7 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13644541&FileExtension=pdf&FileName=WPR21LA173%20Engine%20Monitoring%20System%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine monitoring system - specialist's factual report (item 2, CSV, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13643820&FileExtension=csv&FileName=WPR21LA173%20Attachment%201%20to%20Engine%20Monitoring%20System%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 3, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13579278&FileExtension=pdf&FileName=NTSB%20Form%206120_1_Redacted-Rel.pdf - Flight data plots (item 4, PDF, 4 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580328&FileExtension=pdf&FileName=WPR21LA173%20Data%20Plots-Rel.pdf - Engine examination summary report (item 5, PDF, 4 pages, 378 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14463366&FileExtension=pdf&FileName=WPR22LA173%20Engine%20Examination%20Summary-Rel.pdf - Statement of party representatives to NTSB investigation (item 6, PDF, 6 pages, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14465983&FileExtension=pdf&FileName=Certification%20of%20Party%20Representative%20August%202017%20(2)_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13579070&FileExtension=pdf&FileName=Release%20of%20Wreckage%20Final_Redacted-Rel.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.