Pilot Debrief

LANCAIR LC42 - 550FG near Winston-Salem, NC — 2013-03-31

Final reportERA13FA184
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Date
2013-03-31
Location
Winston-Salem, NC, USA
Airport
INT
Aircraft
LANCAIR LC42 - 550FG
Registration
N6506L
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Climb

Probable cause

The pilot's failure to detect multiple indications and cues in the cockpit of the steady loss of engine oil pressure, which resulted in a catastrophic engine failure over terrain unsuitable for landing. Also causal was the loss of internal engine lubrication for reasons that could not be determined during postaccident examinations due to postcrash fire damage.

NTSB narrative

The airplane was in cruise flight about 5,000 feet mean sea level (msl) in instrument meteorological conditions when the pilot declared an emergency and reported a loss of "fuel pressure" and engine power. The air traffic controller vectored the airplane toward the nearest airport, and, during the descent and when the airplane was about 6 miles from the airport, the pilot reported that smoke was in the cockpit and that the engine was "barely" producing power. No further transmissions were received from the pilot. The airplane collided with flat, wooded terrain and was significantly damaged by postcrash fire. Data downloaded from the primary and multifunction cockpit displays indicate that the engine began steadily losing oil pressure during the airplane's initial climb until it leveled off at a cruise altitude of 5,000 feet msl. Data suggest that, at that time, the pilot leaned the fuel mixture for cruise flight. Although the pilot could have detected the decreasing oil pressure at that time, he did not report a loss of fuel pressure and engine power to the air traffic controller until about 6 minutes later. Data also indicate that there were multiple additional indications and cues of a loss of engine oil pressure in the cockpit but that the pilot did not respond to these in a timely manner. The operations manual indicates that the pilot should land as soon as possible if the engine oil pressure drops and then to prepare for a loss of engine power and an emergency landing. The pilot's delayed recognition of the drop in engine oil pressure was likely the result of a breakdown in her instrument scan, specifically, her systems monitoring during the climb and initial cruise phases of flight, during which time, her attention was likely directed at airplane control, power management, and navigation. The reason for the loss of engine oil pressure could not be determined during postaccident examinations due to postcrash fire damage.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have landed at Elkin Municipal Airport when oil pressure dropped below 30 psi.

NTSB coding

Evidence available

  • ATC audio
  • ADS-B / radar
  • Photos
  • 22 docket documents
View NTSB final reportView NTSB docket

Docket documents22

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