Lancair IVP, N864KM: Accident occurred August 30, 2015 near Fort Lauderdale Executive Airport (KFXE), Broward County, Florida

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Analysis 

The pilot stated that, during the climb to cruise altitude, he noticed a loss of engine oil pressure. He declared an emergency with air traffic control (ATC) and requested to return to the airport. After ATC acknowledged, the pilot advised ATC that he lost all engine power and had to make an emergency landing. During the forced landing, the airplane collided with a ditch and was destroyed by postcrash fire. An examination of the engine revealed that it failed catastrophically, displaying signatures of lubrication distress; further, no measurable quantity of oil could be recovered from within the engine. Detailed examination of the engine's turbochargers revealed that one of the two units displayed evidence of burnt oil on the external surface and evidence of a foreign material in the unit's center housing, on the thrust bearing, and on the thrust collar. The foreign material was identified as polyethylene (plastic), similar to that used to protect the exposed orifices of the engine during shipment.

Review of maintenance records revealed that the pilot/mechanic had replaced both turbochargers with overhauled units two days before the accident flight. The turbocharger overhauler provided installation instructions and warnings that, in part, stated, "Remove all protective caps and plugs BEFORE installing this turbocharger." The foreign material discovered within the turbocharger's center housing suggests that the protective plastic cap at the oil outlet was likely not removed during the installation. It is likely that the turbocharger center housing filled with oil, which then flowed out of the engine via the turbocharger housing backplate, resulting in oil starvation and the subsequent total loss of engine power. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be: 

The mechanic's improper installation of the turbocharger assembly, which resulted in oil starvation and a subsequent total loss of the engine power.

Findings

Aircraft
Turbocharger - Incorrect service/maintenance (Cause)
Recip engine power section - Failure (Cause)

Personnel issues
Installation - Maintenance personnel (Cause)

Sonia and Ken McKenzie

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The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Continental Motors; Mobile, Alabama 

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N864KM

Ken McKenzie 
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NTSB Identification: ERA15LA332
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 30, 2015 in Fort Lauderdale, FL
Aircraft: LANCAIR IV, registration: N864KM
Injuries: 1 Serious, 1 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.

On August 30, 2015, about 1055 eastern daylight time, an experimental amateur-built Lancair IV-P, N564KM, was destroyed by collision with terrain and a postcrash fire during a forced landing after takeoff from the Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The commercial pilot sustained serious injuries, and the passenger was not injured. The privately owned and operated airplane was operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual flight rules conditions were reported at the airport about the time of the accident, and an instrument flight rules flight plan had been filed for the flight destined for Lynchburg Regional Airport (LYH), Lynchburg, Virginia.

According to the pilot, during a climb to cruise he noticed that the engine's oil pressure dropped to 9 psi. He declared an emergency with air traffic control (ATC) due to the low oil pressure indication and requested to return to FXE. ATC provided radar vectors and cleared the airplane for the visual approach to runway 9. Shortly thereafter, the pilot contacted the FXE tower controller and reported an "engine failure." The pilot made a forced landing on a levee located 5 miles west of the approach end of runway 9. During the landing rollout, the airplane veered off the levee, collided with a ditch, and caught fire.

The airplane was recovered and the engine was retained for examination. During the examination of the engine puncture holes were discovered in both upper crankcase halves. Further examination revealed that no measurable amount oil could be drained from the engine. All of the spark plugs were removed and displayed a sooty appearance. The cylinders were removed and the cylinder attaching hardware torque and break away torque was checked and found within manufactures specifications; the No. 1, No. 2 and No. 3 pistons and cylinder skirts were damaged. The No. 1 piston exhibited signatures consistent with a valve strike on the dome. The oil sump was removed and contained pieces of connecting rod, rod bolts, rod bearing, and aluminum material in the bottom of the sump.

The crankcase was separated and the main bearings were not damaged. All of the bearing tabs were intact and no fretting was noted on the thru-bolt bosses. There was no evidence of bearing shift and the crankcase mating surfaces were machined. Puncture holes were also noted on bottom right crankcase half below the No. 1 cylinder. No obstructions were found in the crankcase oil galleries. Prior to removal, the camshaft was bent forward of the rear journal.

The crankshaft was removed and disassembled, the main journals had a normal operating appearance. The No. 1 connecting rod journal was found burnt and deformed. The No. 4 connecting rod journal was found burnt; the No. 2, No. 3, No. 5 and No. 6 connecting rod journals had a normal operating appearance. Examination of the connecting rod bearings revealed the No. 1 rod bearing was located in oil sump and found burnt and wiped. The No. 4 rod bearing was found burnt and wiped but was still contained within the rod and cap; No.2, No. 3, No. 5, and No.6 rod bearings indicated signs of lubrication distress.

The oil pump was disassembled and scoring was present in the internal oil pump housing and oil pump gear facing. Metal contamination was present in the oil relief valve. The oil filter was removed and opened for examination. The filter element exhibited metal contamination (aluminum & steel).

A visual examination of both turbochargers revealed one turbocharger had a normal grayish coloration on the internal turbine blades, while the other turbocharger was found blackend and oily on the turbine and compressor impeller blades.

The turbochargers were sent to Hartzell Engine Technologies for further examination and identified as urbo A (serial No. tKL01420), and turbo B (serial No. KFN00434). Examination of the turbo A revealed the turbocharger was overhauled by Main Turbo Systems. The turbocharger rotating assembly spun freely with no indication of compressor or turbine rub. Both the axial and radial end play was within specification. The turbocharger assembly was consistent with the design data and there was no evidence of mechanical malfunction. The internal lubrication passages were present with no indications of concern. The turbocharger was dry and displayed evidence of internal and external corrosion.

Examination of turbo B revealed that it was also overhauled by Main Turbo Systems. The turbocharger rotating assembly spun freely with no indication of compressor or turbine rub. Both the axial and radial end play was within specification. The turbocharger assembly was consistent with the design data and there was no evidence of mechanical malfunction. The internal lubrication passages were present with no indications of concern. There was evidence of foreign material in the center housing, on the thrust bearing, and on the thrust collar. Evidence of "burnt" oil was discovered on the external surfaces of turbocharger. The turbo was dissembled and it was revealed that oil residue was evident on the backside of the compressor wheel. Further examination also revealed oil residue on the turbo backplate.

A review of the engine logbook entries revealed that both turbochargers were removed and replaced by the pilot/mechanic with overhauled units two days prior to the accident flight. The entry in the logbook noted, "three engine test runs/operational checks and conducted leak check in accordance with SB no. 23, dated Feb 8, 2006. No leak/discrepancies noted at this time."

An examination of the foreign material located in the center housing of the turbo was conducted. The unknown material was examined using a Fourier Transform Infrared (FTIR) spectrometer with a diamond attenuated total reflectance (ATR) accessory in accordance to ASTM E1252-98 (American Society for Testing Materials E1252- 98). The spectrum was consistent with a straight-chained aliphatic hydrocarbon. A spectral library search found a very strong spectral match to polyethylene.

During the shipment of the turbochargers, polyethylene protective caps and plugs were used to plug the oil line openings. These protective caps and plugs must be removed before installation. The turbocharger overhauler provided instruction and warning tags with the units, one of which stated, "Remove all protective caps and plugs BEFORE installing this turbocharger."
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 MIAMI (WSVN) -- A pilot recovering in the hospital is thanking God after his plane crash-landed in the Everglades.

Pilot Ken McKenzie told 7News that he credits his faith and his military experience for getting himself and his wife out just in time. "I opened the door, jumped out. Everything was engulfed in flames. I turned around and Sonia was working to get out of her seatbelt, so I grabbed a hold of her," he said.

He is expected to recover after several days at Jackson Memorial Hospital, but as he looks over at his wife, who only received a cut and bruises from the crash, he is simply grateful he was able to lead her to safety. Officials released the 911 call that was made during the landing. "It appears he has gone down about 11 miles North, Northwest," the caller said. "We don't know if he's in the road, or if he's in the Everglades or anything. We've lost contact with him."

McKenzie said that he is astonished how his training from the military instantly resurfaced. "With the time I spent in the Air Force, we did a lot of training on jet aircraft and how to get out of an aircraft on the ground," he said. "It was funny how all those thoughts came back."

As an experienced pilot, he described how his decades of aviation and service in the Canadian Armed Forces served him well. "He's lucky to not have more severe burns given the nature of the accident," said Dr. Carl Schulman, of Jackson Memorial Hospital's University of Miami Burn Center.

Schulman described McKenzie's second degree burns that cover up eight percent of his body as painful.

Still, the McKenzie family's faith has not faltered. "It's in the book of Isaiah, and it's about God's angels who will take care of the distress and that fire that surrounds you," said the pilot's wife, Sonia McKenzie.

McKenzie's eldest daughter, Monika McKenzie, who they were flying to visit in Virginia calls him her hero. "Even while he's laying in his hospital bed, and he's doing this for me, he's thinking about others," she said.

"When I look at all of what could have gone much worse than it did, I think we have a great deal of faith that there's a plan for our lives," McKenzie said.

Doctors said that McKenzie may be a perfect candidate for a stem cell trial that speeds the recovery process in burn patients only offered at this hospital.

MIAMI (WSVN) -- The pilot of a small plane is recovering in the hospital, hours after he and his wife crash-landed in the Everglades, off the Sawgrass Expressway, Sunday morning. 

Authorities said Ken McKenzie and his wife Sonia were heading to Lynchburg, Va. on board a Lancair IV-P when, shortly after takeoff from Fort Lauderdale Executive Airport, they ran into mechanical issues. "The pilot told his wife that they had engine problems with the oil pressure, and ultimately an engine failure," said Broward Sheriff's Office spokesperson Mike Jachles.

Faced with the certainty that the single engine aircraft was not going to stay airborne, McKenzie reportedly opted to head for an access road surrounded by mangroves and water near the Broward-Palm Beach County line, just before noon.

Witnesses fishing in the area said they were stunned by the commotion. "I see an ambulance coming down with lights on," said Julie Podmokly.

Officials released the 911 call made after the plane made its emergency landing. "He's in the Coral Springs vicinity. It appears he's gone down about 11 miles north-northwest," said the caller.

"How many souls on board?" asked the dispatcher.

"Two souls on board," responded the caller.

A thick black column of smoke helped rescue crews locate the couple. Dramatic photographs taken by the Coral Springs Fire Department captured the Lancair's charred remains. "The aircraft was completely destroyed by the flames. It's barely recognizable," said Coral Springs Fire Division Chief Mike Moser.

Jachles said McKenzie and his wife were injured, but they were able to exit the aircraft at the right time. "They were both really lucky to get out of the wreckage and sustain as minimal injuries as they did considering the impact," he said.

McKenzie was transported to Jackson Memorial Hospital, where he is spending his birthday Monday, receiving treatment for severe burns he sustained after the crash.

Sonia was airlifted to Broward Health North, where she was listed in good condition. She was later released and spoke to the media about the frightening flight. "Really, really odd. It was almost surreal, as if I was watching it in a movie," she said. "We just spun around really quickly, and he had already unlatched the door like you're supposed to on approaching an emergency landing, and he said, 'Sonia, we have to get out.' He went to jump out, I undid our seat belts I noticed his wasn't, and he ran out onto the wing."

Sonia continued, "As soon as we touched down, there was orange and red flames everywhere. He jumped out, reached back to grab my hand," she said.

Investigators said the pilot's professional experience may have helped prevent a tragic outcome. McKenzie, a father of two, is a dedicated Calvary Chapel board member who works for Airbus Group. He spent 14 years in the Canadian Armed Forces. "I think our faith in God just ... I knew we were gonna be OK. If it was gonna be our time, it was gonna be our time, and apparently it's not, so we're here for a little longer, and I think God has a purpose for our life," said Sonia.

The crash remains under investigation.

Story and video: http://www.wsvn.com

A day after a pilot suffered burns during a fiery crash landing in the Everglades, he remained hospitalized in stable condition while his wife and passenger in the single-engine aircraft was treated and released. 

Kenneth McKenzie, former chief operating officer of Spirit Airlines and Canadian Armed Forces pilot, marked his 53rd birthday Monday at Ryder Trauma Center in Miami.

After Sonia McKenzie's release from Broward Health North, she told reporters she remained "surprisingly calm" during the dramatic landing into a levee in the Everglades near the Broward-Palm Beach county line.

"We just spun around super quickly," Sonia McKenzie, 50, said. "As soon as we touched down there were orange and red flames everywhere."

A 911 call from Fort Lauderdale Executive Airport reporting that an airplane in the Coral Springs area had gone down came in at 10:44 a.m. Sunday.

"It appears he's gone down," the tower told the 911 dispatcher. "We don't know if he's in the road or if he's in the Everglades or anything, we've lost contact with him."

Shortly after the Fort Lauderdale couple departed the airport in a Lancair IV-P aircraft bound for Lynchburg, Va. they reported low oil pressure, authorities said.

The pilot told air traffic controllers he was unable to return to the airport and would attempt to land on a road near the Everglades, an FAA spokesman said.

Sonia McKenzie said that as they made their descent, her husband unlatched the door and told her: "'Sonia, we have to get out.'"

"It was almost surreal," she said, "like watching a movie."

After the plane went down, a thick column of black smoke rose into the air followed by gunshot-like explosions nearby anglers said.

Within minutes, a Broward Sheriff's Office helicopter landed a couple hundred feet from the burning aircraft. They were joined by Coral Springs firefighters who used foam and water to douse the flames.

The survivors were standing on the levee when firefighters arrived. The aircraft was completely destroyed.

Sonia McKenzie credited their survival to her husband's piloting experience and quick-thinking.

"I think God has a purpose for our life," she said.