Pilot Debrief

BROWN MICHAEL KITFOX IV near Escondido, CA — 2009-07-25

Final reportWPR09LA369
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Date
2009-07-25
Location
Escondido, CA, USA
Airport
RNM
Aircraft
BROWN MICHAEL KITFOX IV
Registration
N6140S
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Climb

Probable cause

A total loss of power due to an oil exhaustion induced seizure of the engine. The pilot's decision to continue flight to the original destination after becoming aware of the in-flight oil leak instead of landing at an intermediate airport to investigate the source and extent of the problem is also causal. Contributing to the accident was the pilot's reuse of the pushrod oil seal during maintenance in contradiction to the engine manufacturer's maintenance instructions.

NTSB narrative

During cruise flight the pilot observed oil trailing along the landing gear strut. He checked the engine oil pressure indicator, and confirmed it was displaying a normal oil pressure. He then altered his flight path to include areas suitable for performing a forced landing. He continued to monitor the oil pressure as he approached an airstrip. The oil pressure did not change, and he decided to continue the flight to his destination. Shortly thereafter, the oil pressure dropped to zero, and the engine lost all power. The pilot performed a forced landing; however, during the landing roll out, the airplane struck a ditch and nosed over. Inspection of the engine revealed that the number four cylinder exhaust pushrod O-ring seal had failed, which allowed the oil to exit the engine, causing the engine to seize. The pilot stated that he had removed the cylinder head 2 years prior to the accident, and reused the exhaust pushrod O-ring seal. According to the engine manufacturer's maintenance manual recommendations, all sealing rings, gaskets, securing elements, O-rings and oil seals are to be replaced at engine reassembly.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot should have checked engine oil level before continuing flight.

NTSB coding

Evidence available

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

Docket documents9

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