Pilot Debrief

FLIGHT DESIGN GMBH CTSW near Santa Fe, NM — 2021-04-22

Final reportWPR21LA173
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Date
2021-04-22
Location
Santa Fe, NM, USA
Aircraft
FLIGHT DESIGN GMBH CTSW
Registration
N378CT
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

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.

NTSB narrative

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.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have landed earlier when oil pressure first decreased significantly.

NTSB coding

Evidence available

  • FDR / data
  • 7 docket documents
View NTSB final reportView NTSB docket

Docket documents7

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