14 CFR Part 91: General Aviation
Accident occurred Friday, January 16, 2015 in San Luis Obispo, CA
Probable Cause Approval Date: 07/07/2015
Aircraft: CUBCRAFTERS INC CC11-160, registration: N232LT
Injuries: 2 Uninjured.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
The pilot reported that, about 40 minutes after takeoff for the local sightseeing flight, he noticed that the engine oil gauge wasn’t indicating properly and that, about 1 minute later, the engine started to “skip.” Shortly later, the engine lost all power, and the pilot performed a forced landing to a field. The experimental light-sport airplane nosed over and sustained substantial damage. Neither occupant was injured.
Examination revealed considerable oil streaking along the airplane’s entire belly in an area obscured from the pilot’s view while in flight. Further examination revealed that the oil pressure transducer supply line, which was made of copper tubing, had separated from its fitting on the engine accessory case. Data from the airplane’s engine monitoring system (EMS) showed that, about 9 minutes after takeoff, the engine oil pressure dropped out of range, indicating that the supply line failed at that time; the data also showed that a flashing visual oil pressure alert occurred. For the remaining 28 minutes of flight, the oil pressure remained the same, and the alert remained active as all of the engine’s oil was expelled out of the separated oil pressure transducer supply line and overboard. The failed copper tubing oil pressure transducer supply line was the subject of a service bulletin (SB), which recommended either periodic inspection of the copper tubing for leaks or replacement of it with a flexible hose. Despite being inspected in accordance with the SB, the supply line still failed. Following the accident, the airplane manufacturer issued a mandatory service alert, which required the replacement of the copper tubing with a flexible hose. As noted, the EMS data indicated that a flashing visual oil pressure alert was issued to the pilot as soon as the oil pressure transducer supply line failed; however, he did not notice the alert and continued the flight. He eventually observed the alert just before the engine seized. If he had noticed when the supply line failed, he would have had ample time to return to the departure airport before the oil was exhausted. Given that this was a sightseeing flight and that the majority of it was flown toward the sun, it is likely that the pilot was distracted during the flight and possibly encountered sun glare that obscured a clear view of the airplane’s instrument panel.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's inadequate instrument scan during cruise flight, which resulted in his failure to notice a loss of engine oil pressure. Contributing to the accident was the failure of the oil pressure transducer supply line, which resulted in oil exhaustion and a total loss of engine power.
HISTORY OF FLIGHT
On January 16, 2015, about 1034 Pacific standard time, a Cubcrafters CC11-160 (Carbon Cub SS), N232LT, nosed over following a forced landing near San Luis Obispo, California. The experimental light-sport airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91. The commercial pilot and passenger were not injured, and the airplane sustained substantial damage to both wings during the accident sequence. The local sightseeing flight departed San Luis County Regional Airport, San Luis Obispo, at 0956. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported departing with the intention of performing a local sightseeing flight with a relative. The preflight checks were uneventful, and the engine contained 3.5 quarts of oil. About 40 minutes after takeoff he noticed the engine oil gauge was indicating "---" instead of oil pressure, and about 1 minute later, the engine started to, "skip." He made a radio call to the San Luis Obispo tower, declaring an emergency. A short time later the engine lost all power, and he guided it towards a highway. As he approached the highway he observed traffic, so configured the airplane for landing on an adjacent riverbed. During the landing roll the airplane nosed over, coming to rest inverted.
TESTS AND RESEARCH
The airplane was examined following recovery by the NTSB investigator-in-charge, along with representatives from the Federal Aviation Administration (FAA), Cubcrafters, and Danbury Aerospace. Examination revealed considerable oil streaking along the fuselage, covering the lower right side and entire belly. The oil residue was in an area that was obscured from the view of the pilot and passenger while in flight.
The engine oil level was checked, and the sump was empty. The engine was rotated by hand at the propeller, and excessive force was required to rotate the crankshaft. The engine cowling was removed, and the entire right side of the engine and firewall was coated in a film of oil. Further examination revealed that the oil pressure supply line, which connected the engine to the oil pressure transducer, had separated from its fitting on the engine accessory case.
The pressure line was made of copper tubing, and was connected to the transducer and accessory case with compression fittings, which utilized brass ferrules. The line exhibited necking at the separation surface adjacent to the ferrule edge. Removal of the line at the transducer revealed similar necking, but no separation.
Oil Pressure Line Service Bulletin
At the time of the accident, Cubcrafters Service Bulletin SB00025 Rev A, "Oil Pressure Line Inspection" was in effect. The purpose of the bulletin was to, "inspect the oil pressure line for leaks, and to provide the option to upgrade to a flexible hose."
The service bulletin called for mandatory compliance on or before the next 100-hour or annual condition inspection, with a subsequent recurrent inspection at 50-hour intervals, unless the line was upgraded to the flexible hose.
The last annual condition inspection occurred 130 flight hours prior to the accident. The mechanic who performed the inspection stated that he examined the oil lines in accordance with the Cubcrafters service manual. He was aware of Service Bulletin SB00025, (and had in fact ordered a set of flexible hoses for inventory) and although it was not specifically documented in the maintenance logbooks, he complied with it utilizing the inspection method both during the annual, and the two subsequent oil changes.
Engine Monitoring System
The airplane was equipped with a Dynon Avionics FlightDEK-D180 combination electronic flight instrument system (EFIS) and engine monitoring system (EMS). The unit was installed on the left side of the instrument panel, directly in front of the pilot. The unit was capable of storing over 180 engine and flight parameters in non-volatile memory. Parameters included GPS location, engine oil pressure, and alert status.
Data for the flight was downloaded from the unit during the examination. The data indicated that shortly after takeoff the airplane initiated a climb to the southwest towards San Luis Obispo Bay. The engine oil pressure remained about 68 pounds per square inch (psi), and about 7 minutes later, having reached the bay, the airplane changed course to the east. Two minutes later the oil pressure reading dropped to -106 psi, and the unit logged an oil alert indicating the oil pressure was out of range. The flight continued for an additional 28 minutes on a meandering east-southeast track along the coast, and then inland to the accident location. Throughout the rest of the flight, the oil pressure remained at -106 psi, with the alert still active.
Documentation provided by Dynon indicated that the alert would have resulted in both the digital readout and oil pressure needle "tick" flashing. The airplane was not equipped with an audible alert system, or the optional external alert annunciator light.
In a subsequent exchange, the pilot stated that he noticed the oil pressure alert just before the loss of engine power occurred, conceding that it was possible that it came on earlier in the flight, and that he did not notice it.
METEOROLOGICAL INFORMATION
According to the U.S. Naval Observatory, Astronomical Applications Department, during the period of flight the altitude of the Sun when viewed from San Luis Obispo would have been about 26 degrees, with an Azimuth (E of N) of 147 degrees. This would have placed the suns position within the pilot's field of vision for the majority of the flight.
Weather at San Luis Obispo included clear skies, and visibilities of 10 miles.
ADDITIONAL INFORMATION
On January 28, 2015, Cubcrafters issued Safety Alert SA 0010, which superseded Service Bulletin SB00025. The alert removed the inspection compliance requirements, and instead required replacement of the oil pressure line with the flexible hose. The alert required mandatory compliance, and was due within the next 10 flight hours, or at the next annual condition inspection, whichever occurred first.
FAA records indicated that in March 2013, the airplane was converted by Cubcrafters from the Special Light-Sport to Experimental Light-Sport category, and was issued a new set of operating limitations. According to a representative from Cubcrafters, the conversion is often requested by owners so that they can modify aircraft without the manufacturer's intervention.
NTSB Identification: WPR15LA085
14 CFR Part 91: General Aviation
Accident occurred Friday, January 16, 2015 in San Luis Obispo, CA
Aircraft: CUBCRAFTERS INC CC11-160, registration: N232LT
Injuries: 2 Uninjured.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On July 16, 2015, about 1035 Pacific standard time, a Cubcrafters CC11-160 (Carbon Cub SS), N232LT, nosed over following a forced landing near San Luis Obispo, California. The light sport airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and passenger were not injured, and the airplane sustained substantial damage to both wings during the accident sequence. The local flight departed San Luis County Regional Airport, San Luis Obispo, about 0950. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported departing with the intention of performing a local sightseeing flight. The preflight checks were uneventful, and the engine contained 3.5 quarts of oil. About 45 minutes after takeoff the pilot noticed the engine oil gauge was indicating zero pressure, and the engine started to "skip." He made a radio call to the San Luis Obispo tower, declaring an emergency. Shortly thereafter the engine lost all power, and he guided it towards a highway. As he approached the highway he observed traffic, so configured the airplane for landing on an adjacent riverbed. During the landing roll the airplane nosed over, coming to rest inverted.
FAA Flight Standards District Office: FAA Van Nuys FSDO-01
232 LIMA TANGO AIR LLC: http://registry.faa.gov/N232LT
A plane landed upside-down in a riverbed east of Highways 101 and 166 near the San Luis Obispo-Santa Barbara county line on Friday.
A small plane crash-landed and overturned in a remote riverbed in south San Luis Obispo County on Friday morning, but both occupants were able to walk away from the incident.
San Luis Obispo County Sheriff's Office spokesman Tony Cipolla said Friday that 76-year-old pilot John Charles Butler, of Phoenix, Ariz., reported engine trouble and told authorities he was going to attempt to land on Highway 166.
Sheriff’s Office officials and the CHP blocked a stretch of the highway for the landing, but the plane continued for about 40 miles before landing in a riverbed east of Highway 101 and Highway 166, flipping upside-down with both people inside.
Butler and his passenger, 67-year-old Pamela Butler Zirion, of San Luis Obispo, were able to get out of the plane on their own and declined medical treatment, Cipolla said.
The Sheriff's Office, Cal Fire, Santa Barbara County Fire, the CHP, the California Department of Fish and Wildlife and the U.S. Forest Service are all assisting in the investigation into the crash.
Cipolla said local authorities have notified the Federal Aviation Administration and the National Transportation Safety Board, both of which will also investigate the matter.
Source: http://www.sanluisobispo.com
SLO Press Release
Friday 01/16/2015 3:30 PM - Plane Crash
Type of Incident: Plane Crash
Date and Time of Incident: 1-16-15, Approximately 10:36 AM
Place of Occurrence: Highway 166 at mile marker 40, San Luis Obispo County
Victim Information: John Charles Butler, 76, Phoenix, AZ Pamela Butler Zirion, 67, San Luis Obispo
Suspect Information: N/A
Details of News Release: On 1-16-15, Sheriff's Deputies responded to a plane that was reporting problems with its engine and was attempting to land on Highway 166. A portion of that road was closed to allow the plane to land. The aircraft landed in a riverbed adjacent to Highway 166 and flipped upside down. Two occupants were on board on the plane. The pilot is 76-year-old John Charles Butler of Phoenix, AZ. The passenger is 67-year old Pamela Butler Zirion of San Luis Obispo. Both occupants are fine and were able to extricate themselves from the plane without any assistance. Both declined medical assistance at the scene. Cal Fire, Santa Barbara County Fire, CHP, State Fish & Wildlife, and U.S. Forest Rangers assisted with the investigation. The Sheriff's Office conducted the initial investigation and will turn over its findings to the Federal Aviation Administration (FAA) and the National Transportation Safety Board (NTSB) for further investigation.
Prepared By: tcipolla
Released: Friday 01/16/2015 3:31 PM
Source: http://www.slosheriff.org
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