Pilot Debrief

CESSNA LC41-550FG near Titusville, FL — 2015-04-18

Final reportERA15LA189
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Date
2015-04-18
Location
Titusville, FL, USA
Airport
TIX
Aircraft
CESSNA LC41-550FG
Registration
N400BZ
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

An inflight fire and a total loss of engine power due to oil starvation, after separation of the No. 3 cylinder exhaust valve rocker box cover for reasons that could not be determined based on the available information.

NTSB narrative

During a preflight inspection, the private pilot verified that the engine contained about 7 quarts of oil; he subsequently departed on a cross-country flight. About 1 hour into the flight, the pilot observed the oil pressure decline. The propeller stopped turning, and smoke entered the cabin. The pilot declared an emergency and subsequently completed a forced landing at a nearby airport. As the airplane came to rest, the pilot observed flames coming from the engine cowling. After the passengers egressed, most of the airplane was consumed by fire. Postaccident examination of the airplane revealed thermal damage to the engine compartment and fuselage. One exhaust valve rocker box cover was missing, another rocker box cover was missing multiple screws, and a third rocker box cover was loose. Multiple oil journals were dry and displayed heat discoloration. The separation of the rocker box cover resulted in the engine depleting its oil supply during the flight and a subsequent catastrophic engine failure due to oil starvation. A review of the airplane's maintenance history indicated that the rocker box covers would have been removed about 4 years before the accident when the engine was disassembled following a propeller strike. However, based on maintenance log entries, it could not be determined whether the rocker box covers had been removed or inspected since that time.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have checked engine covers before departure to prevent oil pressure loss.

NTSB coding

Evidence available

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

Docket documents10

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