Homebuilt, Experimental, or Light Sport Aircraft

Transcription

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# CEN14CA532
09/01/2014 650 CDT
Regis# N2017A
Willow Springs, MO
Acft Mk/Mdl AIRBORNE EDGE X
Acft SN 582-587
Acft Dmg: SUBSTANTIAL
Rpt Status: Factual Prob Caus: Pending
Eng Mk/Mdl ROTAX 582
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: JAMES W. VOKAC
Opr dba:
431
0
Ser Inj
Apt: Willow Springs Memorial 1H5
0
Aircraft Fire: NONE
AW Cert: SPX
Summary
The pilot stated that, about 45 minutes before departure, he obtained the current weather conditions via an internet website and observed a thunderstorm
located about 100 miles west of the departure airport. About 20 minutes into the local area flight, he recalled seeing a low cloud bank, with a base of about
1,000 feet above ground level (agl), about 1/4 mile east of the airport. At the same time, he noticed an area of heavy rain from clouds located about 15 miles
west of his position. He decided to land as soon as possible due to the deteriorating weather. Instead of making an approach to the airport's single runway, he
decided to land toward the west in an open pasture area that was located on the airport property. Shortly after clearing trees and hangars that were located on
the east side of the airport, the weight-shift-control aircraft suddenly lost altitude, from about 20 feet agl, and impacted the ground in an upright attitude. After
the impact, the aircraft rolled over onto its left side. The pilot reported that the aircraft did not appear to have any forward velocity when it impacted terrain, as
indicated by a lack of damage to the surrounding vegetation. The aircraft sustained substantial damage to the wing and fuselage. He stated that there were no
mechanical malfunctions of the aircraft that would have precluded normal operation. Additionally, he reported that the aircraft's operating limitations included a
maximum headwind and crosswind component of 21 knots and 11 knots, respectively.
Meteorological data collected during the accident investigation indicated that, at the time of the accident, there was a squall line of strong-to-severe
thunderstorms within a few miles of the accident site. Local weather stations indicated that there was a wind shift from the south to the north that was
associated with the passage of the frontal boundary. The weather stations also reported wind gusts reaching 24 knots. A review of weather radar imagery
indicated that, at the time of the pilot's preflight weather check, there was a line of thunderstorms located about 40 miles northwest of the departure airport. The
same line of thunderstorms was within a few miles of the airport at the time of the accident and moved through the area almost immediately thereafter. The
meteorological data suggested that the aircraft likely encountered a gust front that was associated with approaching line of thunderstorms. Although the pilot
checked the weather before departure, his failure to correctly identify the location and speed of the approaching line of thunderstorms contributed to the
low-level wind shear encounter shortly before touchdown.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of control after
the weight-shift-control aircraft encountered low-level wind shear shortly before touchdown. Also causal to the accident was the pilot's inadequate preflight
weather assessment that failed to correctly determine the actual location and speed of the approaching line of thunderstorms.
Events
1. Prior to flight - Preflight or dispatch event
2. Landing - Windshear or thunderstorm
3. Landing - Loss of control in flight
4. Landing - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Environmental issues-Conditions/weather/phenomena-Wind-Windshear-Ability to respond/compensate - C
2. Personnel issues-Task performance-Planning/preparation-Weather planning-Pilot - C
3. Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Pilot - C
Narrative
The pilot stated that, about 45 minutes before departure, he obtained current weather conditions via an internet website and observed a thunderstorm located
about 100 miles west of the departure airport. The pilot subsequently departed about 0630 for the local area flight. About 20 minutes into the flight, he recalled
seeing a low cloud bank, with a base of about 1,000 feet above ground level (agl), about 1/4 mile east of the airport. At the same time, he noticed an area of
heavy rain from clouds located about 15 miles west of his position. He decided to land as soon as possible due to the deteriorating weather. Instead of making
an approach to the airport's single runway (17/35), he decided to land toward the west in an open pasture area that was located on the airport property. Shortly
after clearing trees and hangars that were located on the east side of the airport, the weight-shift-control aircraft suddenly lost altitude, from about 20 feet agl,
and impacted the ground in an upright attitude. After the impact, the aircraft rolled over onto its left side. The pilot reported that the aircraft did not appear to
have any forward velocity when it impacted terrain, as indicated by a lack of damage to the surrounding vegetation. The aircraft sustained substantial damage
to the wing and fuselage. He stated that there were no mechanical malfunctions of the aircraft that would have precluded normal operation. Additionally, he
reported that the aircraft's operating limitations included a maximum headwind and crosswind component of 21 knots and 11 knots, respectively.
Printed: April 08, 2015
Page 1
an airsafety.com e-product
Prepared From Official Records of the NTSB By:
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Meteorological data collected during the accident investigation indicated that, at the time of the accident, there was a squall line of thunderstorm activity present
within a few miles of the accident site. Additionally, the National Weather Service (NWS) Storm Prediction Center had issued a warning for the development of
severe thunderstorms. The NWS storm warning called for scattered strong-to-severe thunderstorms associated with the passage of a cold front. Local weather
stations indicated that there was a wind shift from the south to the north that was associated with the passage of the frontal boundary. The weather stations
also reported wind gusts reaching 24 knots. A review of weather radar imagery indicated that, at the time of the pilot's preflight weather check, there was a line
of thunderstorms located about 40 miles northwest of the departure airport. The same line of thunderstorms was within a few miles of the airport at the time of
the accident and moved through the area almost immediately thereafter.
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Accident Rpt# ERA15CA146
03/07/2015 1050 EST Regis# N348CC
Elizabethton, TN
Apt: Elizabethton Municipal K0A9
Acft Mk/Mdl CUB CRAFTER CC11-160
Acft SN CC11-00348
Eng Mk/Mdl TITAN
Acft TT
Fatal
Opr Name: MICHAEL J. BROWN, DVM
Opr dba: SELF
36
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPX
Summary
The pilot of the Experimental Light Sport Airplane stated he was practicing touch and go takeoffs and landings in light winds. During rollout following the fifth
landing, as he configured the airplane for the subsequent takeoff, the airplane departed the right side of the runway. He applied full power in an attempt to abort
the landing. The airplane continued on the grass apron approximately seventy-five feet before striking a drainage culvert and embankment, which resulted in
substantial damage to both wings. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airplane that would have precluded
normal operations.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
directional control during the landing roll.
Events
1. Landing-landing roll - Loss of control on ground
2. Landing-aborted after touchdown - Collision with terr/obj (non-CFIT)
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained - C
Narrative
The pilot of the Experimental Light Sport Airplane stated he was practicing touch and go takeoffs and landings in light winds. During rollout following the fifth
landing, as he configured the airplane for the subsequent takeoff, the airplane departed the right side of the runway. He applied full power in an attempt to abort
the landing. The airplane continued on the grass apron approximately seventy-five feet before striking a drainage culvert and embankment, which resulted in
substantial damage to both wings. The pilot reported there were no pre-impact mechanical failures or malfunctions with the airplane that would have precluded
normal operations.
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Accident Rpt# ERA15LA156
03/15/2015 1818 EDT Regis# N193Y
Reynolds, GA
Apt: Butler Muni 6A1
Acft Mk/Mdl KOLB MK-II
Acft SN CW011370
Rpt Status: Prelim
Eng Mk/Mdl ROTAX 503DCSI
Acft TT
Fatal
Opr Name: MORRELL WAYNE R
Opr dba:
356
1
Ser Inj
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: SPX
Events
1. Maneuvering-low-alt flying - Loss of control in flight
Narrative
On March 15, 2015, at 1818 eastern daylight time, an experimental light sport Kolb Twinstar MK-II, N193Y operated by a private individual, was substantially
damaged when it impacted terrain near Reynolds, Georgia. The student pilot was fatally injured. Visual meteorological conditions prevailed and no flight plan
was filed for the local personal flight which departed Thomaston-Upson County Airport (OPN), Thomaston, Georgia. The personal flight was conducted under
the provisions of Title 14 Code of Federal Regulations Part 91.
According to a witness, a few minutes prior to the accident the airplane approached her property and flew two oval shaped patterns over her house. It then
proceeded west towards her neighbor's property. Subsequently, the airplane had turned, was heading east, and was in line with the neighbor's driveway. At that
time, the airplane had descended to about 150 to 200 feet above ground level, when it suddenly "took a sharp pitch forward and turned right at the same time"
and impacted the ground in a nose down attitude. The witness further stated "the engine was running" while the airplane was overhead and they did not hear
the engine "sputter or stop."
The wreckage was examined by a Federal Aviation Administration inspector. All major components were accounted for at the accident location. The airplane
came to rest in a nose down attitude with the entire length of the wing leading edge resting on the ground. There were no ground scars noted leading to the
airplane. Flight control continuity was established from the flight controls to the respective control surfaces. An undermined amount of blue fluid, similar in color
to and smell as 100 LL aviation fuel was located throughout the entire fuel system.
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Accident Rpt# CEN15CA159
02/27/2015 1600 MST Regis# N715AK
Greeley, CO
Apt: Greeley-weld County GXY
Acft Mk/Mdl ARNOLD ZODIAC CH 650-NO SER
Acft SN 65-8391
Eng Mk/Mdl ROLLS ROYCE O-200A
Acft TT
Fatal
Opr Name: PILOT
Opr dba:
48
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: SPE
Summary
The pilot had recently purchased the experimental amateur-built airplane. He was flying with a flight instructor to gain flight experience in the airplane. The pilot
reported that he had made a normal left hand pattern and approach to the runway. During the flare, he attempted to maneuver the airplane to the right using
aileron and right rudder inputs. The pilot said that the rudder would not move and he focused on the rudder problem. The airplane rolled out on the runway in a
"sideways motion," the nose landing gear collapsed, and the airplane came to rest nose down on the runway. After exiting the airplane, the pilot and instructor
observed an auxiliary electrical plug had lodged behind the right rudder pedal and had jammed it. The pilot indicated that there were no airplane mechanical
malfunctions. The flight instructor's safety recommendation, in part, stated, "This could have been prevented by stowing all movable items before and during
flight to keep them away from the flight controls."
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot was unable to maintain
directional control during the landing due to the foreign object that lodged behind the rudder.
Events
1. Landing-landing roll - Loss of control on ground
2. Landing-landing roll - Flight control sys malf/fail
3. Landing-landing roll - Nose over/nose down
1. Environmental issues-Physical environment-Object/animal/substance-Debris/dirt/foreign object-Contributed to outcome - C
2. Aircraft-Aircraft systems-Landing gear system-Nose/tail landing gear-Capability exceeded
3. Personnel issues-Action/decision-Action-Lack of action-Pilot - C
Narrative
The pilot had recently purchased the experimental amateur-built airplane. He was flying with a flight instructor to gain flight experience in the airplane. The pilot
reported that he had made a normal left hand pattern and approach to the runway. During the flare, he attempted to maneuver the airplane to the right using
aileron and right rudder inputs. The pilot said that the rudder would not move and he focused on the rudder problem. The airplane rolled out on the runway in a
"sideways motion," the nose landing gear collapsed, and the airplane came to rest nose down on the runway. After exiting the airplane, the pilot and instructor
observed an auxiliary electrical plug had lodged behind the right rudder pedal and had jammed it. The pilot indicated that there were no airplane mechanical
malfunctions. The flight instructor's safety recommendation, in part, stated, "This could have been prevented by stowing all movable items before and during
flight to keep them away from the flight controls."
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Accident Rpt# WPR13LA034
10/27/2012 925 MST
Regis# N19GS
Payson, AZ
Acft Mk/Mdl JEFFAIR BARRACUDA-NO SERIES
Acft SN 0001
Eng Mk/Mdl LYCOMING IO-540
Acft TT
Fatal
Opr Name: JEFFREY WEISEL
Opr dba:
520
0
Apt: Payson PAN
Ser Inj
0
Aircraft Fire: NONE
Events
1. Landing-landing roll - Landing gear collapse
Narrative
HISTORY OF FLIGHT
On October 27, 2012, about 0925 mountain standard time, an experimental amateur-built JeffAir Barracuda, N19GS, was substantially damaged when all three
landing gear collapsed after touchdown on runway 6 at Payson airport (PAN), Payson, Arizona. Neither the pilot/owner nor his passenger was injured. The
personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no FAA
flight plan was filed for the flight.
According to the pilot, the airplane landing gear system was equipped with three green annunciation lights, which illuminate when the landing gear is fully
extended for landing, and three amber annunciation lights, which illuminate when the landing gear is fully retracted. On departure from Ernest A. Love field
(PRC), Prescott, Arizona, for PAN, the pilot noticed that the nose landing gear (NLG) amber light illuminated about 5 to 8 seconds after the two main landing
gear (MLG) lights; normally all three illuminate approximately simultaneously. The pilot was uncertain whether there really was a problem, and the airplane
operated normally for most of the remainder of the flight. In the traffic pattern at PAN, after the pilot selected the landing gear to the extended position, he
observed that the two green MLG lights illuminated, but the green NLG light did not. He conducted a low flyby of the airport, and a ground observer radioed that
the NLG appeared to be fully extended.
The pilot then conducted a normal landing, but the NLG retracted when the pilot lowered the nose of the airplane. Very shortly thereafter, the two MLG then
retracted, and the airplane slid to a stop on the runway. Portions of both MLG assemblies pushed up through the upper wing skins after the unintentional
retraction. The airplane was partially disassembled, and transported to the pilot's hangar at PRC for further examination.
PERSONNEL INFORMATION
According to Federal Aviation Administration (FAA) information, the pilot held a private pilot certificate with airplane single- and multi-engine ratings. His most
recent FAA third-class medical certificate was issued in November 2011. According to the pilot, he had a total flight experience of about 2,500 hours, including
about 40 hours in the accident airplane make and model. His most recent flight review was accomplished in September 2012.
AIRCRAFT INFORMATION
FAA records indicated that the airplane the first model of its type, and was built by its principal designer, G.L. Siers. The airplane was first issued its
airworthiness certificate in 1975. The design was a single-engine, low-wing monoplane constructed primarily of wood. It was equipped with
hydraulically-operated tricycle-configuration landing gear, and a Lycoming IO-540 series engine.
The accident pilot was the second owner of the airplane; he purchased it from the designer/builder in February 2007. According to the pilot, in July 2007, he
"had the engine and prop rebuilt as they were both past TBO." In 2009 the airplane was damaged on landing due to a problem with the nose landing gear. The
nose gear contacted a gear door while retracting; the pilot subsequently determined that the components intended to align the nose gear for retraction were of
insufficient strength and had deformed, preventing normal nose gear operation. The pilot reported that the components "were repaired and reinforced."
The airplane's most recent annual condition inspection was completed on October 27, 2011, exactly 1 year prior to the accident. Maintenance records indicated
that at that time, the airplane had accumulated a total time (TT) in service of about 516 hours. The pilot reported that the airplane had flown "about 8 or 9 times"
since that inspection, and that "there were no problems."
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METEOROLOGICAL INFORMATION
The PAN 1635 automated weather observation included winds from 130 degrees at 8 knots, visibility 10 miles, clear skies, temperature 13 degrees C, dew
point -8 degrees C, and an altimeter setting of 30.18 inches of mercury.
AIRPORT INFORMATION
PAN was equipped with a single paved runway designated 06-24. The runway measured 5,504 by 75 feet, and field elevation was reported as 5,157 feet. PAN
was not equipped with an operating air traffic control tower.
WRECKAGE AND IMPACT INFORMATION
Several days after the accident, and FAA inspector examined the wreckage in the pilot's hangar. The inspector reported that "both main gear had punctured
through the tops of both wings," the landing gear doors were damaged, and that the "propeller was destroyed." The inspector did not note any obvious
underlying reasons for the initial failure of the NLG.
According to the pilot, the uncommanded retraction of the MLG was an expected result of the NLG failure, due to the system architecture.
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Accident Rpt# GAA15CA029
03/28/2015 1015
Acft Mk/Mdl KERR JOHN A KITFOX CLASSIC IV-IV
Opr Name: KERR JOHN A
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Regis# N195KF
Logan, UT
Acft SN C94110085
Rpt Status: Prelim
Fatal
0
Apt: N/a
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
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Accident Rpt# ERA14LA272
05/31/2014 944 EDT
Regis# N6RP
Suffolk, VA
Acft Mk/Mdl LANDRUM KELLY T VANS RV6
Acft SN 23075
Eng Mk/Mdl SUBARU EJ 25
Acft TT
Fatal
Opr Name: LANDRUM KELLY T
Opr dba:
247
0
Apt: N/a
Ser Inj
0
Aircraft Fire: NONE
Events
2. Enroute-cruise - Powerplant sys/comp malf/fail
Narrative
HISTORY OF FLIGHT
On May 31, 2014, about 0944 eastern daylight time, an experimental amateur built Vans RV-6, N6RP, operated by a private individual, was substantially
damaged in Suffolk, Virginia. The private pilot sustained minor injuries. Visual meteorological conditions prevailed for the personal flight conducted under Title
14 Code of Federal Regulations Part 91. The local flight originated from William Tuck Airport (W78), South Boston, Virginia at 0830 and was destined for Suffolk
Executive Airport (SFQ), Suffolk, Virginia.
According to the pilot's written statement, he intended to fly from W7B direct to SFQ to attend a fly-in event. After departing W7B at 0830 the pilot climbed the
airplane to 3700 ft. mean sea level (msl) and leveled off for cruise flight. The pilot then descended to 2000 ft. msl about 10 nm from the airport. At the first
waypoint designated by the fly-in instructions the pilot turned to a heading of 100 degrees magnetic. The engine RPM then went to redline, the pilot lost thrust
and a reddish residue resembling hydraulic fluid from the propeller covered the windscreen. The pilot pitched the nose up, pulled throttle, and turned the
airplane into the wind. During the descent the pilot selected an emergency landing site. He attempted to add power, but the engine yielded no thrust. While
above the trees, the pilot realized he was not going to make the landing site and slowed the aircraft. As the airplane neared the tree tops the pilot pulled the
control stick aft and the airplane stalled before making contact with the tree tops. The airplane subsequently fell through the trees, impacted the ground, and
came to rest nose first, which resulted in substantial damage to the wings and fuselage.
The pilot held a private pilot certificate with ratings for single engine land. He had accumulated about 1,418 hours of total flight time, of which 242 hours were in
the accident airplane make and model. His most recent third class Federal Aviation Administration (FAA) medical certificate was issued on September 3, 2013.
AIRPLANE INFORMATION
According to FAA records, the RV-6, a two-seat, all-metal, low-wing airplane with tricycle configured landing gear was issued an airworthiness certificate, in the
experimental category, on August 25, 2006. It was built from a series of kits provided by Vans Aircraft and Eggenfellner Aircraft, Inc. The airplane was equipped
with an Eggenfellner Subaru H4 modified automobile engine, which included a Gen 3 V4 propeller speed reduction unit (PSRU) gearbox that was used to drive
the Vari-Prop VP 01 propeller assembly that consisted of three hydraulically actuated wooden propeller blades. The propeller was designed as a closed, airless
hydraulic system, independent of all other aircraft systems and rated at 165 HP and 6500 rpm. The airplane had 158 total flight hours when the Vari-Prop
assembly was installed. The blades were replaced at 221 total flight hours.
The propeller system was designed for in-flight adjustment of the propeller. Power was transferred from the engine gearbox to the propeller hub through a
propeller drive shaft. The aft end of the propeller drive shaft bolted to the output shaft of the gearbox and the opposing end was inserted through a slave servo
into a female key slot in the propeller hub. The blade pitch angle was adjusted through a non-rotating slave piston cup and a rotating blade pin spool that were
separated by a needle thrust bearing. Hydraulic fluid was provided by a separate reservoir located in the fuselage that would feed hydraulic fluid to an
expandable hydraulic fluid chamber in the slave piston. The piston moved the blade pin spool fore and aft along the shaft to change the blade pitch angles. The
blade pin spool consisted of two bolts that extended beyond the propeller hub. The bolts were equipped with two nuts to provide a mechanical low pitch stop in
the event of a loss in hydraulic pressure. According to the builder/pilot, the stop nuts that provided the mechanical limit to the low pitch angle were tightened so
that the washers were slightly loose when the propeller blade pitch angles provided the required static rpm. The builder was responsible for positioning the
blade angles to achieve 2520 rpm while the airplane was stationary.
According to the pilot, the airplane had accumulated a total of 247 flight hours at the time of the accident. The propeller was last inspected and serviced about
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28 flight hours prior to the accident when the pilot/builder cleaned and lubricated the bearings. The propeller blade bearings were lubricated with either Sig
Wurth 3000 grease, a highly viscous lubricant, or a mixture of Honda Moly 60 and Sig Wurth 3000. The pilot subsequently reported that he used only Sig Wurth
3000 grease to lubricate the needle thrust and slave servo bearings. According to the lubrication manufacturer, the Sig Wurth 3000 grease is advertised for use
on fleet and heavy equipment for the automotive and trucking industries. An internet search revealed several public videos that demonstrated use of the Sig
Wurth 3000 grease on the fifth wheel of an eighteen wheeler. The manufacturer also remarked that the company's policy is not to sell its products for use in
flying applications.
The 0935 automated weather observation at SFQ included winds from 020 degrees at 7 knots; visibility 10 statute miles; sky clear; temperature 21 degrees
Celsius (C); dew point 15 degrees C, and an altimeter setting of 30.16 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
The propeller, wings, and tail section were accounted for at the accident site. According to information provided by the FAA, the airplane came to rest in a
nose down attitude in an area surrounded by trees. Photographs provided by a recovery service showed the airplane was supported in an upright position by
the left wingtip and nose and the fuselage rested against a tree. Both wings exhibited significant leading edge damage; a tree was embedded in the right wing
about mid-span about eight inches from the leading edge. The left wing displayed horizontal crush damage along the outboard section of the leading edge. The
vertical stabilizer and rudder displayed some compression wrinkles. All control surfaces remained attached to their respective airfoils. All three propeller blades
were separated from the propeller hub and only two of the three propeller blades were accounted for at the accident site.
Additional examination of the propeller assembly was performed at a secure recovery facility under the supervision of NTSB investigators. Severe thermal
damage was present throughout the servo unit; the non-rotating portion of the slave servo had seized to the rotating portion at the needle thrust bearing
interface and the entire unit rotated with the propeller. The hydraulic hose support bracket, which secured the hydraulic fitting to the non-rotating portion of the
slave servo was fractured. The hydraulic fitting associated with the non-rotating portion was also fractured allowing the hydraulic fluid to escape.
The needle thrust bearing, which provided the interface between the rotating and non-rotating portions of the slave servo was severely heat damaged; the three
components had become fixed and rotated as one unit. No grease was present in the needle thrust bearing and the needle rollers had separated and were
displaced within the bearing. Samples of burned material were consistent with the presence of Sig Wurth 3000 grease. There was also significant heat damage
present throughou t the needle thrust bearing and the collar of the slave servo, which contained no lubrication. The Delrin bushings that fit over the pins in the
propeller hub and inserted into a groove of the blade pin spool were melted.
ADDITIONAL INFORMATION
Manufacturer Guidance - Lubrication
The Vari-Prop VP-01 installation manual dated January 12, 2010 states to "lightly grease the bearings on the blade/bearing assembly." In another section, the
manual instructed the builder to grease the thrust bearing between the spool and piston; however, there was no recommended lubricant in the installation
manual. A representative of Vari-Prop said that he had recommended using Lubriplate lubrication on the needle thrust bearing. According to the pilot/builder,
the Vari-Prop manufacturer did not provide any additional guidance for lubricating the bearings.
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Accident Rpt# WPR14FA218
05/31/2014 1620 PDT Regis# N62DN
Toledo, OR
Apt: N/a
Acft Mk/Mdl NEBERT VANS RV-10
Acft SN 40546
Eng Mk/Mdl TEXTRON LYCOMING O-540-B4B5
Acft TT
Fatal
Opr Name: DOUGLAS NEBERT
Opr dba:
375
2
Ser Inj
1
Aircraft Fire: NONE
Summary
The pilot, who was also the builder of the experimental kit airplane, departed for a cross-country flight from his home airport. The passenger reported that,
following a normal departure, the airplane continued the takeoff climb through some cloud wisps and ascended above a lower cloud cover with an overcast
layer above. Suddenly, the engine experienced a total loss of power. The pilot maneuvered the airplane toward the closest airport, but, when he realized that
the airplane would not be able to glide to the airport, he attempted to make an off-airport landing. The airplane stalled and then collided with terrain in an open
area of a paper mill. Ground scar analysis and wreckage fragmentation revealed that the airplane descended in a steep, near-vertical, nose-down,
left-wing-down attitude before it impacted terrain.The pilot installed a fuel flow transducer about 2 to 3 weeks before the accident and used heavy applications
of room temperature vulcanization (RTV) silicone to seal the fuel lines. A friend of the pilot, who was also a mechanic, reported that he had observed the pilot
about a year earlier using heavy applications of RTV silicone to seal parts during a condition inspection and that he had mentioned to the pilot that this was an
improper practice. A bead of RTV silicone was found in the fuel line, and it is likely that it blocked the inlet of the transducer and starved the engine of fuel.
Additionally, subsequent to the loss of engine power, the pilot failed to maintain sufficient airspeed while maneuvering to locate a suitable off-airport landing site
and flew the airplane beyond its critical angle-of-attack, which resulted in a stall and loss of airplane control.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A total loss of engine power due
to fuel starvation because of a blocked fuel line that resulted from the pilot's improper maintenance practices and the pilot's subsequent failure to maintain
adequate airspeed while attempting a forced landing, which led to the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall.
Events
1. Enroute-climb to cruise - Loss of engine power (total)
1. Aircraft-Aircraft systems-Fuel system-(general)-Incorrect service/maintenance - C
2. Personnel issues-Task performance-Maintenance-Installation-Owner/builder - C
3. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
4. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
5. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
Narrative
HISTORY OF FLIGHT
On May 31, 2014, about 1620 Pacific daylight time, a single-engine experimental Nebert Vans RV-10, N62DN, experienced a loss of power and departed
controlled flight while the pilot was maneuvering for a forced landing in Toledo, Oregon. The airplane was substantially damaged. The private pilot and four-year
old passenger were fatally injured; the adult passenger sustained serious injuries. The airplane was registered to and being operated by the pilot under the
provisions of 14 Code of Federal Regulations Part 91. The personal cross-country flight departed Newport Municipal Airport, Newport, Oregon, with a planned
destination of Seattle, Washington. Visual meteorological conditions prevailed and no flight plan had been filed.
Numerous witnesses located in Toledo reported observing the airplane flying at a low altitude from the north. The witnesses reported hearing no sound from the
airplane's engine and saw it progressively descend in altitude. The airplane approached the Georgia Pacific paper mill and made a steep turn to the left. The
airplane subsequently made a rapid descent and impacted terrain in a nose-low, near-vertical attitude.
The surviving passenger recalled the flight, although was heavily medicated during the recounting of the events that transpired. She stated that she was in the
aft right seat and her daughter was buckled in a car seat positioned in the aft left seat. Luggage was strapped in the front right seat in an effort to compensate
for the aft weight. The departure seemed normal and the pilot commented that the engine sounded better than it had in awhile. The airplane continued the
takeoff climb through some cloud wisps and ascended above a lower cloud cover, with an overcast layer above.
The passenger further stated that suddenly the engine experienced a total loss of power, which she described as the airplane stopping forward motion, and
there was no engine sound. An alarm sounded, and shortly thereafter all of the airplane's electrical system failed. She recalled observing the screen in front of
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the pilot flickered and then went blank. The pilot was busy pressing buttons and maneuvering levers, and indicated that they were going to land at the closest
airport [which was the Toledo State Airport]. The airplane descended through clouds heading toward the airport. The pilot stated that they were going to make it
to the airport, and that he was looking for a place to land. The airplane made an alert sound, which she thought indicated the airplane was moving too slow. The
pilot made a left turn and tried to pull up, but the airplane spiraled down harder to the ground.
A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the pilot, age 51, held a private pilot certificate with
airplane rating for single-engine land, which was issued in March 2008. He additionally held a Repairman Experimental Aircraft certificate. His most recent
third-class medical was issued on January 04, 2013, with no limitations.
According to the pilot's flight logbook he had about 785 hours of total flight experience, of which about 375 was amassed in the accident airplane. Based on the
airport identifiers listed in the logbook for flight origin and destination points, the pilot accumulated the majority of his flying hours around Newport, his home
airport and where the airplane was based. The pilot recorded having flown 6.4 hours in the preceding 30 days, which was accumulated over 6 different flights.
The pilot was a member of the Experimental Aircraft Association (EAA) since August 1991, and had numerous EAA technical counselor visits during the
building process.
AIRCRAFT INFORMATION
The Vans RV-10 is an amateur-built experimental airplane that is sold as a kit. The low-wing airplane was equipped with four seats, fixed tricycle landing gear,
and traditional flight control surfaces. The accident airplane, serial number (s/n) 40546, received a special airworthiness certificate in the experimental category
for the purpose of being operated as an amateur-built aircraft in August 2010; the pilot purchased the kit in October 2009. The airplane was equipped with a
Lycoming O-540-B4B5 engine, s/n L-7862-40C, and, according to the manufacturer, is rated at 235 shaft horse power (SHP). The powerplant contained a data
tag labeling it as a Lycoming O-540-B1AB, which contained the vibropeened identification next to the stamp of "B4B5."
The airplane's test flight hours were completed in September 2010. Thereafter, the logbooks indicated that the pilot estimated that the airplane's stalling speed
in the landing configuration (Vso), at a weight of 1,858 lbs and a CG of 108.5 inches aft of datum, was 58 knots.
Fuel System Design
The airplane's fuel system was a gravity-fed design where fuel flowed from the metal tanks in the inboard section of each wing, through a selector valve, and
continued to a fuel filter. From the filter, the fuel was routed to an electric fuel pump and then to a transducer where it was plumbed through the firewall to the
gascolator. Thereafter, the fuel was directed to the engine-driven fuel pump, and finally enter into the carburetor.
The Van's Aircraft build manual states in section 37, Fuel System, "When installing fluid fittings with pipe threads do not use Teflon tape. Use instead, fuel lube
or equivalent pipe thread sealing paste."
Maintenance
According to the aircraft maintenance records and the recording tachometer in the cockpit, the airplane had accumulated a total time in service of 375.4 hours.
The most recent condition inspection was recorded as completed by the pilot on October 4, 2013, 71.5 hours prior to the accident. Examination of the logbook
revealed that the last maintenance that had occurred was an oil change and the tightening of the left magneto on February 09, 2014 at a total time of 354.2
hours.
From the pilot's photographs on his website blog, the original build, the pilot did not install the fuel transducer.
A friend of the pilot, who was also a FAA certified mechanic, stated that about two to three weeks prior to the accident, the pilot had installed the fuel
transducer. The pilot commented to him that he had not installed the unit previously because it needed a certain amount of space (needed to be about seven to
nine inches from the filter) and he would have to bend some of the fuel lines to make it fit. The pilot borrowed a flaring tool from him to complete the installation.
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The friend noted that earlier in the year, when the pilot was performing a condition inspection and the airplane's cowling was removed, he observed that the
pilot had used heavy applications of red/orange RTV(room temperature vulcanization) silicone to seal everything, including the area around the airbox
(oval-shaped) where it attaches to the carburetor (square-box-shaped). He mentioned to the pilot that this was an improper practice.
Another friend of the pilot stated that the pilot had installed a fuel transducer about one to two weeks prior to the accident flight, and noted at the time that the
unit did not have a bypass. The friend also observed that the pilot had not connected the electrical wires for the transducer to be operational, but had installed
the unit.
Lycoming Manual
According to the engine's maintenance manual, the rated horsepower was 235 at 2,575 rpm. To obtain the maximum recommended service life of the engine,
the manual recommends that the cylinder head temperature be maintained below 435 degrees Fahrenheit (F) during high-performance cruise operation, with a
maximum temperature of 500 degrees F. The Lycoming manual additionally stated that the fuel pressure requirements were a minimum pressure of .5 psi and
a maximum of 8 psi.
A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) in Newport reported that at 1635 there was an
overcast cloud layer at 1,900 feet above ground level (agl) with 5 miles visibility. It recorded the temperature at 52 degrees Fahrenheit; dew point 50 degrees
Fahrenheit.
COMMUNICATIONS
No record exists of the pilot, or a pilot using the airplane's registration number, contacting any Air Traffic Control tower, or Common Traffic Advisory Frequency,
during the duration of the flight.
WRECKAGE AND IMPACT
The accident site was located in the paper mill adjacent to the Yaquina River in Toledo, Oregon, with the debris confined to the immediate area near the main
wreckage. The Global Positioning System (GPS) coordinates for the main wreckage were approximately 44 degrees 36 minutes 53 seconds north latitude and
123 degrees 56 minutes and 14 seconds west longitude, at an elevation about 10 feet mean sea level (msl). A complete pictorial of the wreckage location and
surrounding terrain is contained in the public docket for this accident.
The closest airport to the accident was in Toledo, Oregon and was located 0.7 nm from the accident site on a heading of 192 degrees. The wreckage came to
rest in a flat area, which was a portion of dirt road on the perimeter of the mill. Surrounding the site were 20 foot (ft) high stacked bales of crushed cardboard
boxes, and a railroad track with parked train cars. Additionally, a northwest-southeast oriented 12 ft-diameter tubular conveyer was observed near the accident
site that was about 70 feet high and 1,625 feet long. The airplane departed from Newport, Oregon which was located 5.6 nautical miles (nm) from the main
wreckage on a heading of 248 degrees.
The main wreckage, which consisted of nearly the entire airplane, came to rest on a heading of 310 degrees. The initial point of impact consisted of a ground
scar and disrupted dirt located about 25 feet and on the heading of 220 degrees from the cockpit section of the main wreckage. Embedded in the dirt were
fragments of red lens and shards of paint and fiberglass, consistent with the left wing impacting first.
From the red lens fragments there was disrupted dirt and ground scars up to blue paint rub marks on an adjacent woodpile. On an exposed yellow pipe
embedded in the ground were numerous blue paint transfer marks, which at 16 feet from the red lens, was consistent with being a signature of the
undercarriage contacting it (the airplane's wingspan was about 32 feet). In a ditch just below the pipe was a 7-ft section of the inboard left wing from the leading
edge at to about the spar. From the pipe, on a heading of about 020 degrees, was engine casing debris and lower engine pieces, including the oil drain plug.
MEDICAL AND PATHOLOGICAL INFORMATION
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The Lincoln County Medical Examiner completed an autopsy of the pilot and passenger. The FAA Civil Aeromedical Institute (CAMI) performed toxicological
screenings on the pilot. According to CAMI's report (#201400089001) the toxicological findings were negative for carbon monoxide and tested drugs.
TESTS AND RESEARCH
A detailed examination report with accompanying pictures is contained in the public docket for this accident.
Airframe
The main wreckage cockpit area was open, with the engine and firewall twisted toward the right wing. Most of the upper cabin area had broken free from the
airframe; the section that remained attached consisted of fiberglass on the aft right side about four feet forward of the bulkhead.
The throttle, propeller, and mixture control levers were bent in their respective control quadrant, which was consistent with them being in the full-forward
position at the time of impact.
The right wing remained attached to the fuselage at all attach points, and the flap and aileron control surfaces remained attached to their respective hinges. The
right wingtip aft section and fragments of a blue/green lens were located just below the right wing adjacent to a concrete divider. Around the divider was
evidence of blithe, and numerous areas of vegetation had been crushed, which was consistent with fuel exposure. The right wing sustained major skin
deformation crushing from the aft outboard tip to about three feet inboard; this was consistent with the size and orientation of the concrete divider that was
located immediately below it. The wing sustained aft crush deformation, with the bottom leading edge skin folded into itself, giving it an accordion-type
appearance. The crush was nearly uniform through the entire length of the wing. The leading edge displayed characteristics consistent with hydrodynamic
deformation. Control continuity was confirmed in the right wing up to the crush deformation in the cockpit area.
The left wing was attached to the fuselage at all attach points, and the flap and aileron control services remained attached to their respective hinges. The left
flap was attached to the two inboard respective hinges and creased at the center hinge in an upward crush. The left aileron was found wedged underneath the
main wreckage cockpit area. The leading edge displayed characteristics consistent with hydrodynamic deformation. Control continuity was confirmed in the left
wing up to the crush deformation in the cockpit area.
The right and left horizontal stabilizers and elevator remained intact with creasing noted on some of the surfaces; continuity to the cockpit was established. The
vertical stabilizer and rudder remained intact with a slight crease on the rudder control surface about six inches from the top and consisted of a four inch bend.
The rudder was attached to its control cables and continuous to the rudder pedals and secured. The elevator was attached to the push-pull tube, which was
continuous up to the cockpit area. Both control sticks were attached and safetied.
Powerplant
The engine mount support tubes were severed by investigators between the engine and firewall, which essentially separated the engine from the airframe. An
external visual examination of the engine revealed that it had sustained crush damage to the bottom of the crankcase, with the majority of damage to the left
side. There were dark stains to the left of the upper spark plug holes, which was consistent with oil staining.
The spark plugs were removed and no mechanical damage was noted; the electrodes and posts exhibited a light ash white coloration, which according to the
Lycoming representative was consistent with a very lean operation(s). The ignition harnesses were attached from both magnetos to their respective spark
plugs. The right magneto was secured to its respective mounting pad. Upon rotation, investigators observed spark produced at all posts. The left magneto
sustained varying degrees of damage that rendered the unit inoperative and therefore, could not be functionally tested.
The crankshaft was rotated by hand utilizing the propeller. The crankshaft was free and easy to rotate in both directions. "Thumb" compression was observed
in proper order on all six cylinders. The complete valve train was observed to operate in proper order, and appeared to be free of any pre-mishap mechanical
malfunction. Normal in uniform "lift action" was observed at each rocker assembly. Clean, uncontaminated oil was observed at all six rockerbox areas.
Mechanical continuity was established throughout the rotating group, valve train and accessory section during hand rotation of the crankshaft.
The cylinders' combustion chambers were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers remained
mechanically undamaged, and there was no evidence of foreign object ingestion. The valves were intact and undamaged. There was no evidence of valve to
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piston face contact. The chambers and valve faces all displayed little combustion signatures and there was a whitish light ash coloration; the exhaust valve
faces were slightly darker, exhibiting a white-orange-coloration. This white residue/soot was additionally seen throughout the remainder of the exhaust system.
The Hartzell propeller, model HC-C2YK-1BF, serial number 40546, remained attached to the engine crankshaft. All propeller mounting bolts remained in the
hub and exhibited no signatures consistent with shear stress. The propeller blades remained attached at the hub. The spinner was displaced from the propeller
hub. The propeller blades were straight and did not show any evidence of rotational forces applied at the crankshaft at the time of impact. Removal of the
propeller governor disclosed that the screen was free of contaminants.
Fuel System
The fuel selector was found with the handle pointing to the "LEFT" tank position. Later, it was confirmed by a friend of the pilot that the handle was installed
with the handle giving a reverse indication, which meant that the fuel would be selected in the "OFF" position. The position of the fuel selector valve,
manufactured by Andair, LTD, was off with both lines shut off. The selector was found in several pieces: the handle (which was still attached to the airframe),
the extender (which was located loosely in the wreckage adjacent to the pilot seat), the upper coupling (which had broken free from its remaining core and was
found loosely in the wreckage), the valve (which was found loosely in the wreckage near the firewall). There was no evidence that the extender had been
safetied to either couplings.
The fuel filter, manufactured by Airflow Performance, was disassembled and the screen was found to be clean. Investigators located a Facet automotive
electric fuel pump within the wreckage and upon supplying power source the pump was found to activate. The transducer, a FloScan 201 A-6 flow sensor (s/n
179922), was found in the wreckage. The fuel line from the electric fuel-pump to the transducer was separated at the pump's B-nut fitting as a result of post
impact forces. An approximate one-inch portion of the line remained attached on the inlet side of the transducer and the end was crimped tightly together and
bent. Investigators pried open the crimped section and found an oval bead of red/orange RTV that measured about 0.25 inches in length. According to the
manufacture, the inlet hole (metering orifice) is reamed to approximately 0.114 to 0.116 inches. Removal of both the inlet and outlet fittings revealed that RTV
was in the threads of both the nipples and the surrounding casing.
The upper cap section and mounts of the gascolator remained attached to the firewall; the metal bowl was located under the right wing and there was no
evidence it had been secured/safetied to its attachment arm/ thumb-tightening screw; the screen was additionally found loose under the right wing and was
clean. The engine-driven fuel pump was displaced from the engine. Disassembly of the fuel pump revealed that is was free of internal mechanical malfunction
and obstruction to flow; the diaphragm was intact. Liquid contained in the body was collected and tested for water; there is no indication water was present.
The carburetor was not attached at its forward mounts; it had remained attached to the aft mounts, coming to rest bent aft with the body flush against the case,
and partially embedded in the oil sump casing. The casing of the carburetor had been broken apart and the plastic floats were in pieces.
Seats
All occupants appeared to have had both their lap and shoulder belts secured during the accident sequence. The child passenger was seated in Graco booster
seat, model 1781044 (s/n 0784129). According to the manufacture, the seat is designed to sustain g-loading as specified in Federal Safety Standard 213. This
includes a space envelope of 32 inches for the head and 36 inches for the knees. The seat's manual specifically prohibits usages in aircraft, which states is
due to the limitation of no shoulder harnesses available.
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Accident Rpt# GAA15LA025
03/27/2015 1300
Acft Mk/Mdl SPAULDING ERROL RANS S 7
Regis# N4272M
Pinedale, WY
Acft SN 0693110
Rpt Status: Prelim
Fatal
Eng Mk/Mdl BOMBARDIER ROTAX (ALL)
Opr Name: SPAULDING ERROL
0
Apt: N/a
Ser Inj
Opr dba:
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: SPE
Events
1. Takeoff - Loss of control on ground
Narrative
On March 27, 2015 about 1300 mountain daylight time, an experimental amateur-built, Rans S-7, N4272M, experienced a loss of directional control while
attempting to takeoff from a road 25 miles southeast of Pinedale, Wyoming. The pilot was not injured and the sole passenger sustained serious injuries. The
airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a day, visual flight rules personal flight under 14 Code of
Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The flight originated from the
Rigby Airport (U56), Rigby, Idaho and was destined to the Rock Springs-Sweetwater County Airport (RKS), Rock Springs, Wyoming.
According to the pilot, after departing U56, he observed the auxiliary fuel transfer pump malfunction. The pilot decided to make a precautionary landing on a
road to investigate the malfunction. After resetting the circuit breaker, the fuel pump was functional and the pilot attempted to takeoff from the road with a
crosswind. During the takeoff roll, the pilot lost directional control of the airplane and the airplane departed the road; subsequently the right main landing gear
collapsed and the right wing impacted the ground. The airplane sustained substantial damage to the right wing aileron and the right wing spar.
The pilot verified that there were no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
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Homebuilt, Experimental, or Light Sport Aircraft

Transcription

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