Pilot Debrief

LANCAIR COMPANY LC42-550FG near Humboldt Bay, CA — 2024-06-20

Final reportWPR24LA210
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Date
2024-06-20
Location
Humboldt Bay, CA, USA
Aircraft
LANCAIR COMPANY LC42-550FG
Registration
N141PB
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

Maintenance personnel’s incorrect installation of an engine rocker cover gasket, which resulted in oil exhaustion and subsequent loss of engine power during the initial climb.

NTSB narrative

Shortly after takeoff, the engine lost most of its oil, resulting in a partial engine seizure and a total loss of engine power. During a forced landing to a soft field, the airplane nosed over, sustaining substantial damage to the vertical stabilizer, rudder, and fuselage. Postaccident examination of the engine revealed that a rocker cover gasket was misaligned before the accident. The gasket was unable to maintain an adequate seal and opened during the accident flight. Oil was then ejected out of the gap between the rocker cover and cylinder head, which resulted in oil exhaustion. Maintenance that was performed about 20 flight hours before the accident flight would have included installing the gasket. Maintenance instructions required a series of specific steps to install the gasket; based on the condition of the gasket after the accident, the instructions were likely not followed properly.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Proper installation of the rocker cover gasket could have prevented the oil leak.

NTSB coding

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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