NTSB Factual 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."

NTSB Probable Cause

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