Aviation Accident Summaries

Aviation Accident Summary MIA93FA180

OCALA, FL, USA

Aircraft #1

N87CK

Glasair SH-2F

Analysis

The airplane was observed by a witness on downwind. The engine was heard backfiring. Another witness observed the airplane at about 200 feet agl, and the fuselage was moving back and forth from left to right. The airplane was very slow with a slight nose-up attitude. The airplane rolled right, nosed over, and disappeared from view before colliding with the terrain. The airplane was destroyed. The private pilot and one passenger were fatally injured. The fuel selector pointer was found positioned halfway between the main fuel tank position and the header tank position.

Factual Information

HISTORY OF FLIGHT On August 20, 1993, at about 1600 eastern daylight time, a Klein, homebuilt Glasair II SH-2F, N87CK, registered to Cletus G. Klein, Minnetonka, Minnesota, operating as a 14 CFR Part 91 personal flight crashed while maneuvering. The airplane was destroyed. The private pilot and one passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from La Grange, Georgia, about 2 hours before the accident. PERSONNEL INFORMATION Information pertaining to the pilot-in-command is contained in NTSB Form 6120.4. AIRCRAFT INFORMATION Examination of the engine log book revealed the engine was overhauled on April 24, 1973, with a total time of 2,379 hours since new, "0" hours since major overhaul, at a tach time of 2,406.2 hours. Further examination revealed the engine was overhauled again on November 11, 1976, with a tach time of 3,496 hours. The total time since major overhaul is 1,089.8 hours and 3,468.8 total hours since new. The correct total time in the engine log book was not carried forward. The recorded entry in the engine log book indicates engine time as 1,190 hours and "0" hours since major overhaul. The engine time should have indicated 3,468.8 hours and "0" hours since major overhaul. The November 11, 1976, entry is the last entry where the word "tach time" is used, and hobbs time begins. Review of the Aviation Engine Record on file with Textron Lycoming revealed the engine left the factory on January 26, 1959, as an 0-360-A1A engine. On September 12, 1967, Textron Lycoming furnished a new name plate to T.W. Smith for converting the engine to a IO-360-B1A engine. There is no record to indicate when the engine was converted to a IO-360- B1B engine. The engine was removed at hobbs time 4,208.7 at an undetermined date. The IO-360-B1B engine was converted to a IO- 360-B1E engine on May 1, 1993. The airplane was issued a Special Airworthiness Certificate on June 25, 1992. The engine was removed for major overhaul on April 29, 1993, and had accumulated 70.3 hours. The overhaul facility did not carry the total time forward and the engine log does not reflect the total engine time as of July 28, 1993. METEOROLOGICAL INFORMATION Visual meteorological conditions prevailed at the time of the accident. For additional information, see NTSB Form 6120.4. WRECKAGE AND IMPACT INFORMATION Initial examination of the airplane wreckage was conducted by the FAA on August 21, 1993. The airplane was located in an open field about one-half mile southeast of runway 36 at the Ocala Municipal Airport, Ocala, Florida, adjacent to S.W. 60th avenue. The airplane collided with the terrain in a nose down, right wing low attitude on a heading of about 1500 magnetic. The airplane rotated around the vertical axis to the right and came to rest on a heading of 2400 magnetic. The nose gear collapsed. The right main landing gear was bent outward and aft. The left main landing gear collapsed inward. The propeller assembly separated from the engine aft of the propeller flange. One propeller blade was bent aft, and the remaining propeller blade was not damaged. Torsional twisting and chordwise scaring was not present on either propeller blade. The engine assembly, firewall, and instrument panel separated from the fuselage adjacent to the leading edge of the left and right wing. The header fuel tank was ruptured. The right wing was bent upward and aft. The leading edge of the right wing was separated at the wing root extending outward to the wing tip. The left wing was bent downward and pushed forward. The right wing interconnected fuel tank was ruptured. The left wing interconnected fuel tank was not ruptured and about 3" of fuel was present in the fuel tank. The fuel selector pointer was positioned halfway between the main fuel tank position and the header fuel tank position. The fuselage separated aft of the pilot and passenger seat. The airplane was removed from the crash site by recovery personnel on August 21, 1993, and was examined by the NTSB investigator-in-charge, FAA, and parties to the investigation on August 24, 1994. Examination of the airframe revealed no evidence to indicate any preimpact failure or malfunction. All components necessary for flight were present at the crash site. Examination of the flight control system revealed no evidence to indicate any preimpact failure or malfunction. Continuity of the flight control system was established for pitch, roll, and yaw. Examination of the engine assembly and engine accessories revealed no evidence to indicate a precrash failure or malfunction. A Textron Lycoming or equivalent nameplate was not located on the engine. A homemade nameplate was attached to the engine. Review of Textron Lycoming Service Instruction No. 1042T revealed that the GPD (Red Seal) SJ-270 spark plugs removed from the engine are not approved for use by Textron Lycoming in its piston aircraft engines. MEDICAL AND PATHOLOGICAL INFORMATION Post-mortem examination of the pilot, Cletus G. Klein, was conducted by Dr.Don C. Cornell, Associate Medical Examiner, District 5, Leesburg, Florida, on August 21, 1993. The cause of death was multiple traumatic injuries. Post-mortem toxicology studies of specimens from the pilot were performed by the Doctors & Physicians Laboratory, Leesburg, Florida, and by the Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma. These studies were negative for neutral, acidic, and basic drugs. Post-mortem examination of the passenger, Joan Klein, was conducted by Dr. Don C. Cornell, Associate Medical Examiner, District 5, Leesburg, Florida, on August 21, 1993. The cause of death was multiple traumatic injuries. Post-mortem toxicology studies of specimens from the passenger were performed by the Doctors & Physicians Laboratory, Leesburg, Florida. These studies were negative for neutral, basic, and acidic drugs. TEST AND RESEARCH Refueling personnel at Lebanon, Tennessee, and Lagrange, Georgia, stated the pilot supervised the refueling of the left and right interconnected wing fuel tanks. No fuel was added to the header fuel tank. Review of the Glasair Owner's Manual, Section 4, Normal Operating Procedures, para 4-13.1 Approach states, "Enter the pattern on the 450 at about 130 to 140 mph. Turn on the electric fuel boost pump, switch to the desired tank," The fuel selector pointer was found positioned halfway between the main fuel tank position and the header fuel tank position. Stoddard-Hamilton Aircraft Incorporated was asked by the NTSB investigator-in-charge what would occur if the three way fuel selector, were to be left in an intermediate position between the main and header tank position. Christian Klix, Accident Coordinator, Stoddard-Hamilton Aircraft Incorporated., stated in a letter to the NTSB investigator-in-charge on September 19, 1993, "Should the header tank be empty air would be introduced into the fuel line and cause fuel starvation to the engine. This would result in a subsequent loss of power." Review of personal notes found in the Glasair Owner's Manual, and recorded entries located in Section 1, page 1-15, and page 1-19, indicates the stalling speed (VS) or the minimum steady flight speed which the airplane is controllable is 60 mph. The stalling speed (VSO) in the landing configuration was not recorded. The Glasair Owner's Manual, Section 3, Emergency Procedures states on page 3-10, paragraph 3-4.1 Spins: "The pilot must be familiar with the Glasair's stall and pre-stall behavior to avoid inadvertent stalls. Remember that a stall can occur at any airspeed and altitude; a pilot who is thoroughly familiar with the Glasair's stall behavior under all conditions will be unlikely to enter an inadvertent spin." ADDITIONAL INFORMATION The aircraft wreckage was released to Mr. Ronald Dudley, Director of Maintenance, Hawthrone Ocala Inc., on August 24, 1993.

Probable Cause and Findings

THE PILOT-IN-COMMAND'S FAILURE TO MAINTAIN AIRSPEED (VSO) DURING A FORCED LANDING, RESULTING IN AN IN-FLIGHT LOSS OF CONTROL (STALL), AND SUBSEQUENT IN-FLIGHT COLLISION WITH TERRAIN. CONTRIBUTING TO THE ACCIDENT WAS THE PILOT-IN-COMMAND'S IMPROPER POSITIONING OF THE FUEL TANK SELECTOR VALVE RESULTING IN FUEL STARVATION.

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports