Aviation Accident Summaries

Aviation Accident Summary DEN06FA010

Steamboat Spgns, CO, USA

Aircraft #1

N101HK

Lancair LC-40-550FG

Analysis

The private pilot held an instrument rating and had logged 2 hours of night flight time within the previous 60 days. At the time of the accident, he was operating under night visual flight rules, in mountainous terrain, without a flight plan. The National Track Analysis Program (NTAP) radar data illustrated that the pilot initiated a descent from 14,000 feet msl at 1919:55. The rate of descent varied between 500 feet and 1,000 feet per minute. The last radar position recorded was at 1927:20. The airplane was at a location of 40 degrees, 21 minutes, 24 seconds north latitude, 106 degrees, 41 minutes, 49 seconds west longitude, at an encoded altitude of 10,500 feet msl. The airplane was located in a densely wooded area on the north face of a peak, at an approximate elevation of 10,500 feet msl, 580 feet west of the last radar position. Sunset was recorded at 1817 and the end of civil twilight was 1844. The moon rose at 2057 on the preceding day (October 21, 2005), and set at 1312 on the day of the accident. An examination of the airplane's systems, airframe, and engine, revealed no anomalies that would have precluded normal operation prior to impact.

Factual Information

HISTORY OF FLIGHT On October 22, 2005, at 1927 mountain daylight time (MDT), a Lancair LC-40-550FG, N101HK, operated by Kittyhawk Partners LLC., and piloted by a private pilot, was destroyed when it impacted terrain 10 miles east of Steamboat Springs, Colorado. Night visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The private pilot and his passenger were fatally injured. The cross-country flight departed Burlington (BRL), Iowa, 1421 MDT (1521 central daylight time), and was en route to Bob Adams Field, Steamboat Springs (SBS), Colorado. According to the pilot's family, he had departed an airport on the east coast the morning of the accident, and had stopped in BRL due to weather. The pilot called the Kankakee Automated Flight Service Station at 1446 MDT, obtained a weather briefing, and filed an instrument flight rules (IFR) flight plan. The pilot departed BRL, and climbed to an initial altitude of 12,000 feet mean seal level (msl). While en route, the pilot contacted Flight Watch on two separate occasions to obtain an update on the forecasted winds aloft, en route weather, and weather at his destination. At 1832 MDT, the pilot contacted the Denver Center controller, requested, and was cleared to an altitude of 16,000 feet msl. At 1912 MDT, the pilot cancelled his IFR flight plan and stated he was going to descend to 14,000 msl with visual flight rules (VFR) radar flight following services from Denver Center. At 1920 MDT the pilot cancelled his VFR radar flight following. The flight duration, from departure until impact, was 5 hours and 6 minutes. The National Track Analysis Program (NTAP) radar data illustrated that the pilot initiated a descent from 14,000 feet msl at 1919:55 MDT. The rate of descent varied between 500 feet and 1,000 feet per minute. The NTAP recorded the last radar information at 1927:20 MDT, at a location of 40 degrees, 21 minutes, 24 seconds north latitude, 106 degrees, 41 minutes, 49 seconds west longitude, at an encoded altitude of 10,500 feet msl. This location was 580 feet from where the main wreckage was located. According to a group of hunters in the area, the airplane flew over their camp approximately 300 feet above ground level (agl). The airplane was extremely low and the lights of the airplane illuminated the ground. One hunter reported the engine was sputtering, and backfiring, and another hunter reported the "engine was exceptionally loud, and [he] could hear it sputtering and just not sounding right." Another hunter in the same party stated he did not "notice any abnormal engine noises or strange flying behavior." Shortly after the airplane flew over the camp, the hunters heard three loud pops, and one hunter reported that the engine noise ceased. The airplane was located by the Routt County Search and Rescue Team approximately 1130 on October 23, 2005. The airplane was located in a densely wooded area on the north face of Walton Peak at an approximate elevation of 10,500 feet msl. PERSONNEL INFORMATION The pilot, age 41, held a private pilot certificate issued on August 10, 2000, with airplane single engine land and instrument ratings. The instrument rating was issued on August 22, 2005. The pilot held a third class airman medical certificate issued on November 5, 2004. The certificate contained the limitations "Holder Shall Wear Corrective Lenses." The pilot's personal logbook was located within the airplane wreckage. According to the logbook, he had logged 310 hours total time; 122 hours of which were in the accident airplane. The pilot had logged 44 hours of night flying experience, 2 hours of which were logged in the accident airplane (within the previous 60 days). He had performed three landings at night within the last 90 days. The pilot had successfully completed the requirements of a flight review on June 16, 2005, in the accident airplane. According to Columbia Aircraft Manufacturing Corporation (CAM), they conducted an initial airplane checkout in the accident airplane with the accident pilot, on June 14, through June 16, 2005. The total flight time reflected in the pilot's logbook and training records was 8.6 hours. Units I through V were completed for VFR flight only. The instructor's only written comments were "good job all things considered, good decisions." AIRCRAFT INFORMATION The accident airplane, a Columbia Lancair LC-40-550FG (serial number 40005), was manufactured in 2000. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate. The airplane was equipped with a Teledyne Continental Motors IO-550-N2B (serial number 683366) engine rated for 310 brake horsepower at 2,700 rpm. The engine was equipped with a three-blade, constant speed, hydraulically actuated Hartzell propeller. The airplane was registered to Kittyhawk Partners LLC, and maintained under an annual inspection program. The maintenance records indicated that the airplane underwent an annual inspection on June 6, 2005, at a Hobbs meter reading of 1,454.6 and an airframe total time of 1,395.3. The airplane had flown 142.2 hours between the last annual inspection and the accident. The airplane was equipped with a Precise Flight oxygen system, which was installed in accordance with the Supplemental Type Certificate (STC) SA01060SE, in June of 2002. The system had a 22 cubic foot oxygen bottle. The bottle was equipped with a Nelson Oxygen Equipment Model 300-M regulator and four manually operated oxygen supply flow controls. METEOROLOGICAL INFORMATION The closest official weather observation station was Yampa Valley Airport (HDN), Hayden, Colorado; which was located 26 nautical miles (nm) northwest of the accident site. The elevation of the weather observation station was 6,602 feet msl. The routine aviation weather report (METAR) for HDN, issued at 1915 MDT, reported, wind, 190 degrees at 3 knots; visibility, 10 statute miles; sky condition, clear; temperature, 09 degrees Celsius (C); dewpoint, minus 02 degrees C; altimeter, 30.12 inches. According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 1817 MDT and the end of civil twilight was 1844 MDT. The moon rose at 2057 MDT on the preceding day (October 21, 2005), and set at 1312 MDT on the day of the accident. The moon rose again at 2152 MDT the day of the accident. WRECKAGE AND IMPACT INFORMATION The National Transportation Safety Board Investigator-in-Charge (IIC) arrived on scene approximately 1300 on October 24, 2005. The accident site was located in forested, mountainous terrain. A global positioning system (GPS) receiver reported the location as 40 degrees 21.382 minutes north latitude and 106 degrees 41.940 minutes west longitude. The accident elevation was 10,500 feet msl and the airplane impacted on a heading of 255 degrees. The initial impact point was located to the east of the main wreckage. Several trees, 50 to 60 feet in height, were broken towards the top, in the direction of the main wreckage. Paint chips, fiberglass, fuel splatter, and broken tree branches were located in the snow, directly below the initial impact point. A debris path extended from the initial impact point to the wing and empennage assemblies. Torn composite material, paint chips, acrylic, the left and right wing tips, personal effects, and broken branches were located within the debris path. Both wing assemblies and the empennage were located 222 feet west of the initial impact point. The right wing, to include a portion of the right flap assembly and the right aileron, separated from the fuselage approximately 24 inches outboard of the wing root. The fuel tank was compromised and the wing assembly exhibited splintered and crushed fiberglass along the leading edge and at the top of the wing, over the fuel tank. The left wing, to include the left flap assembly and the left aileron, separated from the fuselage at the wing root. The wing assembly exhibited splintered and crushed fiberglass along the leading edge and top of the wing. No measurable amounts of fuel were noted. Control continuity to both the aileron and flap assemblies was established. The empennage, to include the horizontal and vertical stabilizer, rudder and elevator, separated from the fuselage approximately 30 inches forward of the vertical stabilizer. The leading edge of the right horizontal stabilizer contained a four-inch crush along its leading edge. The left horizontal stabilizer was crushed and torn along its leading edge, towards the tip of the elevator. The left elevator assembly was torn and splintered at midspan and the right elevator was unremarkable. The base of the leading edge of the vertical stabilizer was crushed aft and splintered and the rudder was unremarkable. Control continuity to the rudder and elevator was established. The fuselage and engine assembly were located 78 feet west of the wing assemblies and empennage. The fuselage came to rest in a nose low attitude. The firewall and floorboard of the airplane had been crushed up and aft into the fuselage. The windscreen was fragmented and personal effects had come forward into the front two seats and out in front of the airplane. The airplane's instrument panel exhibited the following indications: Airspeed Indicator - 230 knots Attitude Indicator - destroyed Altimeter Kollsman Window - 30.12 inches Horizontal Situational Indicator - destroyed Vertical Speed Indicator - 500 foot per minute climb MFD - destroyed The airplane's engine controls exhibited the following indications: Ignition Switch - Both Throttle - Full power Propeller - High rpm Mixture - Full rich Fuel Selector Valve - Right Tank The engine separated from the fuselage at the firewall and came to rest, inverted, 36 feet west of the fuselage. The propeller remained attached to the engine at the propeller flange. The propeller blades were arbitrarily labeled "A," "B," and "C" for identification purposes only. Blade A was bent aft 80 degrees and exhibited slight 45-degree chordwise scratches along the face of the blade. The outer tip was bent forward and twisted. Blade B was twisted, bent aft 60 degrees, and exhibited 90 and 45-degree chordwise scratches on the face of the blade, and leading edge nicks. Blade C stuck in the ground and exhibited chordwise scratches and leading edge nicks. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed by the Jefferson County Coroner's Office, in Golden, Colorado, on October 10, 2005, as authorized by the Routt County Coroner's Office. The autopsy revealed the cause of death "due to head injuries secondary to blunt force trauma sustained in the airplane crash." A toxicology was performed by the Federal Aviation Administration's Civil Aeromedical Institute, Oklahoma City, Oklahoma. The toxicology was negative for carbon monoxide, cyanide, ethanol, and tested drugs. TESTS AND RESEARCH Airframe Examination The wreckage was recovered and relocated to a hangar in Greeley, Colorado, for further examination. The airframe fuel lines were examined by the NTSB IIC on November 16, 2005. The gascolator bowl was removed and the screen examined. No fuel or moisture was noted within the bowl and the screen was clear of contaminants. The fuel lines (engine, return, vent and pressure) located at the fuel strainer assembly were checked and found free of contamination. The pressure and return fuel lines for the right and left fuel tanks were checked and found free of contamination and blockage. The fuel selector was found free of contamination. The flap actuator was measured at 5/8 of an inch from the 12-degree retraction micro switch. This position is consistent with a flap setting of approximately 18 degrees. Engine Examination The engine was relocated to Teledyne Continental Motors in Mobile, Alabama, for further examination by the NTSB IIC. The engine was removed from the Bond Room on January 31, 2006, examined and test run on January 31, and February 1, 2006. In attendance during the examination were party members from Teledyne Continental Motors, and Columbia Aircraft Manufacturing Corporation. The engine baffles were crushed and bent and the right aft corner of the crankcase exhibited a 5-inch crack with deformation of the oil sump mounting surface. The engine mounted oil filter was punctured and the lever portion of the propeller governor separated. The intake tubing on the number five cylinder was crushed and the intake and exhaust valve covers on the both the number four and number five cylinders were crushed in. The number six cylinder exhibited impact damage and was fractured on the intake and exhaust ports. The intake and exhaust valve covers were both crushed and both pushrod housings were bent and crushed. Both the intake and exhaust valves were bound within the valve guide and required force for removal. The inner chamber of the cylinder and piston head showed signs of normal wear. The fuel pump separated from the engine at the fuel pump mount adapter and remained attached at the airframe firewall. The fuel pump rotated freely and exhibited a slight discoloration on the casting at the outlet fitting. Damaged portions of the engine were removed and replaced for engine run purposes only. The fuel pump mount adapter, and the inlet, outlet, and vapor return fittings were replaced on the fuel pump assembly and the fuel pump was re-attached to the accessory housing on the engine. The number six cylinder was removed and replaced. The engine was fitted with thermo couplings, pressure lines, and test pads for test purposes only and was relocated to engine test cell 43. The engine was mounted to the test cell for operation and a test club propeller for the IO-550-N engine was attached at the propeller flange. A pre-engine run compression test was performed with the following results: Cylinder 1 - 60, cylinder 2 - 32, cylinder 3 - 58, cylinder 4 - 22, cylinder 5 - 5, and cylinder 6 - 77. The master orifice level prior to the test was 39. The engine started and ran through a series of rpm increases for 20 minutes without any hesitation, stumbling, or interruption in power. Cylinder temperature, manifold pressure, oil temperature, oil pressure, fuel pressure, and fuel temperature were monitored and recorded at varying engine rpms. A post-engine run compression test was performed with the following results: Cylinder 1 - 70, cylinder 2 - 70, cylinder 3 - 66, cylinder 4 - 72, cylinder 5 - 58, and cylinder 6 - 72. During the engine run, a fuel leak was noted at the mixture shaft location on the fuel pump. Discoloration was noted on the fuel pump assembly and the face of the accessory case, directly below the fuel pump unit. The fuel pump was removed from the engine and flow tested on a production test bench for functionality only. No anomalies were noted during the flow test. The fuel pump unit was disassembled and examined further, revealing a tear in the o-ring around the mixture shaft. Propeller Examination The propeller was shipped to Hartzell Propeller and on February 16, 2005, was examined by the NTSB IIC and a representative from Hartzell Propeller. According to Hartzell, "the blade damage suggests impact at low power. The blade preload plates had impact markings at 6 [degrees], 10 [degrees], and 13 [degrees] blade angle. These were lower than the low pitch stop settings and are considered to be post-impact indications. There were no blade angle indications that could be used to calculate power output. The propeller was rotating at the time of impact." Electric Fuel Boost Pump The electric fuel boost pump was shipped to the FAA in Van Nuys, California, in April of 2006, and was examined under the auspices of the FAA at Dukes, Inc. The pump was installed in the test stand, and power was applied to the motor. The pump operated but did not meet the required ATP criteria. On Low and High Boosts, the pump did not meet minimum pressure/flow requirements. The pump head was removed from the pump assembly and all detail parts were examined. The pump showed no evidence of wear (other than normal time and

Probable Cause and Findings

the pilot's failure to maintain altitude/clearance from terrain. Contributing factors include the pilot's lack of recent experience, the pilot's improper in-flight planning and decision making, the dark night and the mountainous terrain.

 

Source: NTSB Aviation Accident Database

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