Aviation Accident Summaries

Aviation Accident Summary WPR11FA428

Caldwell, ID, USA

Aircraft #1

N624JS

VEATCH KITFOX

Analysis

The builder/owner/pilot of the kit-built experimental airplane and his non-pilot-rated passenger flew from California to Idaho in order to attend the kit manufacturer's fly-in and visit relatives. Two days before the accident, they flew to Idaho, and the next day they flew 4 hours. On the third day, the airplane was taxied from its parking spot on the ramp about 0740, and the pilot conducted a takeoff to about 50 feet, before landing straight ahead on the remaining runway. The investigation was unable to determine the purpose of this flight, or whether the passenger was on board at that time. The airplane was then taxied back to the ramp. About 13 minutes later, the airplane left the ramp again, taxied to the opposite runway, and began another takeoff roll. When the airplane was about 200 feet above the runway, the engine stopped developing power. The airplane stalled and spun to the ground, impacting on airport property near the departure end of the runway. Weight and balance calculations indicated that the airplane was likely 60 to 100 pounds above its maximum allowable weight, and that the center of gravity was about 1.7 inches forward of the aft limit, which would have increased the airplane pitch up tendency following the loss of engine power. Because the airplane was experimental and the pitch trim setting was unable to be determined during postaccident examination, the investigation was unable to determine whether there was sufficient control authority to prevent the stall and also what the required control forces would have been. Examination of the wreckage revealed that the two installed air filters had flow capacities well below the minimum value specified by the engine manufacturer, which would have limited the engine's ability to develop its full rated power. However, this was not a factor in this accident, because the airplane had been flown successfully in the previous days. The engine was not equipped with carburetor heat, even though it was required by the engine manufacturer. When plotted on a carburetor icing chart, the ambient air temperature and dew point values indicated that conditions for serious carburetor icing at cruise power existed. The engine-driven fuel pump was too damaged to test, but the engine manufacturer noted that it should have been replaced in accordance with a 2007 Service Bulletin, which warned that excessively high fuel pressure could result in "engine malfunction and/or massive fuel leakage." Although the possibility exists that the engine experienced a total loss of power due to carburetor icing, excessive fuel pressure, or a combination of the two, the investigation was unable to conclusively determine whether either caused the loss of engine power. Finally, no evidence of an angle-of-attack or stall warning system was observed in the wreckage. Although not required, such a system might have alerted the pilot of the impending stall and helped him avoid the stall and subsequent spin.

Factual Information

HISTORY OF FLIGHTOn September 4, 2011, about 0830 mountain daylight time, an experimental amateur-built Kitfox 7, N624JS, was substantially damaged when it impacted airport property shortly after takeoff from Caldwell Industrial Airport (EUL), Caldwell, Idaho. The certified private pilot/owner and his wife, the passenger, received fatal injuries. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight. The pilot and airplane were based at Rio Vista Municipal Airport (O88), Rio Vista, California. The pilot and his wife departed O88 on September 2 for Idaho, where they visited relatives, and attended a Kitfox fly-in. According to information provided by Lockheed Martin Flight Services (LMFS), the pilot telephoned LMFS for a weather briefing, and he reported that he planned to depart EUL at 0830 on September 4, with a planned stop in Lovelock, Nevada, and a final destination of O88. A pilot in a Cessna who taxied out behind N624JS stated that at "exactly 0800" he observed N624JS take off from runway 12, climb to about 50 feet, and then heard the pilot announce he was making a "short landing" on the remaining runway. He observed N624JS land and turn off onto the runup area for runway 30. The Cessna pilot then departed runway 12. About 20 to 30 minutes later, the Cessna pilot heard the pilot of N624JS announce a "straight out" departure from runway 30. Review of track log data extracted from the accident pilot's handheld GPS unit confirmed the takeoff-landing observed by the Cessna pilot. The data indicated that after that takeoff-landing, the airplane stopped briefly on the runup ramp at the end of runway 30, and then taxied back to the ramp where the airplane had been parked. About 13 minutes later the airplane began a second taxi-out from that ramp, and proceeded to runway 30 for another takeoff. The GPS data indicated that the takeoff roll began about 5 minutes later. The data indicated that the airplane reached a maximum altitude of about 200 feet above ground level. Witnesses reported that the airplane then began a spin to the left, and impacted the ground in a near-vertical trajectory. PERSONNEL INFORMATIONFederal Aviation Administration (FAA) records indicated that the 69-year-old pilot held a private pilot certificate with a single-engine airplane land rating. A review of his personal flight log and other documentation indicated that he had a total flight experience of about 315 hours at the time of the accident, including about 162 hours in the accident airplane. His most recent FAA third-class medical certificate was issued in December 2010. His most recent flight review was completed in the accident airplane in February 2011. According to the pilot's autopsy conducted by the Canyon County Coroner, the cause of death was "massive, traumatic deceleration injuries involving the head, torso, and upper and lower extremities." Both Canyon County and the FAA Civil Aeromedical Institute conducted forensic toxicology examinations on specimens from the pilot, and reported that no carbon monoxide, cyanide, ethanol, or any screened drugs, except salicylate (aspirin), were detected. AIRCRAFT INFORMATIONFAA records indicated that the pilot finished building the airplane in 2008. It was equipped with a Rotax 912ULS 100 hp engine. The maintenance records indicated that the most recent annual condition inspection was completed on November 17, 2010. At that time, the airplane had a total time in service of 119.27 hours. The records indicated that on August 27, 2011, the propeller hub bolts were re-torqued. The records indicated that on August 29, 2011, the oil, oil filter, fuel filter and spark plugs were replaced, when the airplane and engine had a total time in service of 162.15 hours. METEOROLOGICAL INFORMATIONThe EUL 0835 automated weather observation included winds from 110 degrees at 5 knots; visibility 10 miles; clear skies; temperature 9 degrees C; dew point 2 degrees C; and an altimeter setting of 30.12 inches of mercury. Temperature and dew point values for the approximate time and location of the accident indicated that the relative humidity was approximately 60 percent. When the intersection of the two temperature values was located on a chart that depicted carburetor ice envelopes, the point was in the envelope labeled "Serious Icing at Cruise Power." AIRPORT INFORMATIONFAA records indicated that the pilot finished building the airplane in 2008. It was equipped with a Rotax 912ULS 100 hp engine. The maintenance records indicated that the most recent annual condition inspection was completed on November 17, 2010. At that time, the airplane had a total time in service of 119.27 hours. The records indicated that on August 27, 2011, the propeller hub bolts were re-torqued. The records indicated that on August 29, 2011, the oil, oil filter, fuel filter and spark plugs were replaced, when the airplane and engine had a total time in service of 162.15 hours. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest in a near-vertical nose-down attitude, on an approximate magnetic heading of 270 degrees, about 850 feet northeast of the threshold of runway 12. The wreckage was tightly contained, and except for the propeller and hub, no major components, including flight controls and surfaces, were found separated from the wreckage. The propeller reduction gearbox was fragmented, and the propeller hub was under, but separated from, the engine. All three blades of the composite propeller were cracked, but remained attached to the hub, consistent with lack of rotation at impact. The propeller spinner was found in the baggage compartment, and its appearance was consistent with it not being installed at the time of the accident. The engine cowl, nose gear, cockpit, and the leading edges of the wings exhibited significant crush damage in the aft direction. The aft fuselage exhibited moderate buckling. Both wing fuel tanks were ruptured. The impact positions of the flaperons and the pitch trim tabs could not be determined. The airplane was equipped with a ground-adjustable incidence horizontal stabilizer. The stabilizer was found to be at the maximum stabilizer leading edge down incidence, which corresponds to maximum airplane nose up setting. No evidence of any pre-impact flight control failures was observed. Impact damage and susceptibility to disturbance by first responders precluded definitive determination of the pre-impact settings of all the controls, switches, and valves, but no pre-impact failures or deficiencies were noted. A detailed wreckage examination report is contained in the public docket for this accident. No evidence of any angle of attack or stall warning system was observed in the wreckage. The engine was significantly impact-damaged. The propeller gearbox was fractured, and witness marks from the gear teeth in the case were consistent with lack of rotation at impact. Both carburetors were fracture-separated from the engine. The intake and exhaust manifolds, oil filter, and muffler were crushed and fractured. The ignition units remained partially attached to the engine and wiring harnesses, but were successfully function-tested. There was no evidence of fire, thermal damage, or smoke/sooting on any engine components. The installed air filters were significantly smaller, and had less flow capability, than those recommended by Rotax. The airplane was not equipped with a carburetor heat system for induction air. The Rotax 912 Series Installation Manual (para 16.2) stated that "provisions for preheating the intake air have to be made to prevent formation of ice in the intake air system." Non-metallic fuel lines were date-stamped " 3Q 04," and the lines were no longer flexible. The possibility that the lines may have desiccated and/or loosened with disuse since the accident could not be ruled out. The line material, its compatibility with autogas, and its recommended service life were not able to be determined. The fuel pump was fractured-separated from the engine. The diaphragm was intact, and the interior of the pump, including the internal screen, was clean and free of contamination and corrosion. The fuel pump was sent to Rotax Austria for additional evaluation. The condition of the pump precluded any testing, but Rotax did note that the pump should have been replaced in accordance with a 2007 Service Bulletin (SB-912-053). The stated reason for that SB was that excessively high fuel pressure could result in "engine malfunction and/or massive fuel leakage." Cylinders, valves, and spark plugs all exhibited yellow crystalline deposits that appeared to be sulfur from the fuel. Internal engine examination revealed clean oil throughout, with no scoring, brinelling, thermal distress, or non-impact related failures noted. The only unknown weight was that of the fuel on board at the time of the accident. For the accident flight, in order to avoid exceeding the maximum allowable weight, the airplane would have been limited to about 10 gallons of fuel. If the fuel tanks were full, the airplane would have exceeded the maximum allowable weight by 100 pounds, and the center of gravity (CG) would have been about 1.7 inches forward of the aft limit. Based on the best estimate of the fuel quantity, the airplane takeoff weight was about 60 pounds over the maximum allowable weight, and the CG was again about 1.7 inches forward of the aft limit. ADDITIONAL INFORMATIONHandheld GPS A handheld Garmin GPSMap 396 device was recovered from the wreckage, and sent to the NTSB Recorders Laboratory in Washington, DC, for download of track log data. A total of 9 flights, including the accident flight, were recovered from the device. Correlation of the data with geographic information indicated that the first recovered flight was from Carson City, Nevada (NV) to Lovelock, NV on September 2, 2011. The data indicated that on the morning of the accident, the device was activated at 0739, and the airplane made a very brief liftoff from runway 12 before returning to the ramp at 0812. Thirteen minutes later, the device was again powered up, the airplane taxied out to runway 30, and the takeoff roll began at 0830. Detailed information is available in the public docket for this accident.

Probable Cause and Findings

The pilot’s failure to prevent a low-altitude stall and spin following a complete loss of engine power during the initial climb after takeoff.

 

Source: NTSB Aviation Accident Database

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