Pilot Debrief

LANCAIR IV near Fort Lauderdale, FL — 2015-08-30

Final reportERA15LA332
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Date
2015-08-30
Location
Fort Lauderdale, FL, USA
Aircraft
LANCAIR IV
Registration
N864KM
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

The mechanic's improper installation of the turbocharger assembly, which resulted in oil starvation and a subsequent total loss of the engine power.

NTSB narrative

The pilot stated that, during the climb to cruise altitude, he noticed a loss of engine oil pressure. He declared an emergency with air traffic control (ATC) and requested to return to the airport. After ATC acknowledged, the pilot advised ATC that he lost all engine power and had to make an emergency landing. During the forced landing, the airplane collided with a ditch and was destroyed by postcrash fire. An examination of the engine revealed that it failed catastrophically, displaying signatures of lubrication distress; further, no measurable quantity of oil could be recovered from within the engine. Detailed examination of the engine's turbochargers revealed that one of the two units displayed evidence of burnt oil on the external surface and evidence of a foreign material in the unit's center housing, on the thrust bearing, and on the thrust collar. The foreign material was identified as polyethylene (plastic), similar to that used to protect the exposed orifices of the engine during shipment. Review of maintenance records revealed that the pilot/mechanic had replaced both turbochargers with overhauled units two days before the accident flight. The turbocharger overhauler provided installation instructions and warnings that, in part, stated, "Remove all protective caps and plugs BEFORE installing this turbocharger." The foreign material discovered within the turbocharger's center housing suggests that the protective plastic cap at the oil outlet was likely not removed during the installation. It is likely that the turbocharger center housing filled with oil, which then flowed out of the engine via the turbocharger housing backplate, resulting in oil starvation and the subsequent total loss of engine power.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have opted for a precautionary landing before engine failure.

NTSB coding

Evidence available

  • Photos
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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