ERA12FA412

An inflight fire, the origin of which could not be determined because of postaccident fire damage. Contributing to the accident was the pilot's improper modifications to the airplane.

The pilot departed his home airport in North Carolina with the intention of flying the airplane to Germany where he had another residence. During the weeks before the accident, the pilot made several modifications to the airplane in preparation for the trip. Friends and witnesses described the installation of a white plastic fuel tank in the backseat, "similar to a tank you would see on a riding lawnmower." Such a tank is not aviation-approved. The installation included fuel lines that were smaller than recommended by the airplane manufacturer, and the system was vented into the cabin. Local mechanics also reported that the pilot performed his own maintenance to the turbocharger and the exhaust system. In the 2 weeks before the accident, mechanics "topped off" the oxygen system twice, the most recent service occurring 3 days before the accident. During that servicing, mechanics noted water leaking from the oxygen line, and the pilot reported trouble breathing at an altitude of 25,000 feet. On the day of the accident, the pilot departed before dawn into instrument meteorological conditions. A witness observed the airplane trailing white and gray smoke, which turned to an orange color, consistent with an in-flight fire. Shortly after, the airplane impacted trees about ½ mile north of the departure airport. The airplane was consumed by fire and the investigation was unable to determine the fire's origin; however, evidence of several non-approved modifications to the airplane were observed in the wreckage path, including the non-approved fuel line and valve as well as an aluminum can that was safety-wired to the outlet of the air-oil separator. Such modifications could have likely contributed to the fire's origin or spread. Fueling records from a nearby airport revealed that the pilot purchased fuel twice during the week before the accident. Airport security video showed the pilot placing the fuel hose inside the cabin of the airplane on the dates he purchased fuel, likely to fill the tank that was in the back seat. While the pilot's most recent documented flight time was logged 2 years before the accident, his recent and total flight time could not be confirmed after the accident. Accordingly, the investigation was unable to determine if a lack of recent piloting experience may have contributed to the accident. Although the autopsy also identified coronary artery disease and a mass in the pilot's abdomen, the manner in which the airplane was flown before the accident and the witness report of an inflight fire indicates that the pilot was most likely in control of the airplane and was not incapacitated.

The North Carolina Department of Health and Human Services, Office of the Chief Medical Examiner, performed an autopsy on the pilot on June 26, 2012. The cause of death was listed as blunt force trauma. The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. Following were the results of the toxicological testing: 104.7 (ug/ml, ug/g) Acetaminophen detected in Urine The NTSB Chief Medical Officer reviewed the autopsy results, toxicology results, FAA blue ribbon medical file, FAA medical review, and had a conversation with the reviewing pathologist from the medical examiner's office. Her review of the information revealed the following: The autopsy also identified coronary artery disease and a mass in the abdomen. The heart was enlarged, weighing 380 grams. There was moderate to high grade atherosclerotic stenosis of the proximal and middle aspects of the right coronary artery and middle and distal aspects of the left anterior descending artery. The examining pathologist did not further quantify the degree of stenosis but according to a pathologist from the same office who reviewed the slides, the stenosis within the left anterior descending measured at least 80%. Fueling info According to fueling records provided by RUQ, the pilot purchased 51 gallons of 100LL aviation fuel on June 19, 2012. He additionally purchased 41 gallons of 100LL aviation fuel on June 23, 2012. Additionally, examination of a security video from RUQ recorded the pilot servicing the airplane from the self-serve fuel station on the above-documented dates. The video showed the pilot fueling both wing tanks and placing the fuel hose inside the cabin of the airplane. The weather recorded at 0355, at Rowan County Airport (RUQ), 13 miles to the northwest, included calm winds, and ½ mile visibility in fog, with an indefinite cloud ceiling at 500 feet. The temperature was 20 degrees C, the dew point was 18 degrees C, and the altimeter setting was 29.89 inches Hg. The weather recorded at 0355, at Stanly County Airport (VUJ), Albemarle, North Carolina, 10 nm to the southeast, included calm winds, 10 miles visibility, overcast clouds at 900 feet, temperature 22 degrees C, dew point 21 degrees C, and altimeter setting of 29.93 inches Hg. The pilot called FSS on the morning of the accident at 0341 and requested an abbreviated weather briefing for the flight. He was informed by the briefer that an icing AIRMET had been issued for the part of his flight over Maryland and Pennsylvania. The freezing level was predicted between 9,000 and 11,000 feet. There were several convective SIGMETS issued for the route of flight as well as IFR AIRMETs for ceilings below 1,000 feet and visibility below 3 miles with mist, in the vicinity of the route. The initial impact point was at the top of an approximately 60-foot-tall tree, where a portion of the left wing was wrapped around the tree. At the base of the tree, the left flap was observed, separated into two sections. The wreckage path continued on a heading of about 270 degrees magnetic for approximately 150 feet to the main wreckage. Several pieces of 90-degree cut wood, with black paint transfer were located along the wreckage path. The main wreckage was oriented on an approximate heading of 090 degrees magnetic and nearly completely consumed by fire. The flight control tubes were all accounted for at the accident site. The tubes to the tail section were separated in several sections and melted in the cockpit area. Both aileron tubes were separated from their respective wing sections. The trim and flap settings could not be determined to due impact and fire damage. The engine came to rest separated from the firewall and resting nose-down against a tree (the number 1 cylinder being the lowest point). The propeller remained attached to the engine; one blade was relatively straight and one blade was bent forward about 10 degrees at mid-span. Located in the vicinity of the engine was a non-approved fuel line and valve. Additionally, about 15 feet from the engine, an aluminum can was observed, which was safety-wired to the outlet of the air-oil separator. After removal from the accident site, the engine was further examined. It was rotated at the propeller flange, and valve train continuity was confirmed on all cylinders. Thumb compression was also confirmed on all cylinders, with the exception of the No. 2 cylinder, which displayed severe heat damage. The turbocharger was separated from the engine. The compressor shaft rotated freely by hand, the hoses were burned, and the controllers were separated and fire damaged. Additionally, the exhaust bypass valve was in the "open" position, and displayed impact damage. The dual-magneto ignition system was separated and consumed by fire. Examination of the spark plugs exhibited a "worn, but normal condition." The vacuum pump remained attached to the engine. The drive coupling was melted; however, the vanes remained intact. The fuel flow divider remained attached to the engine. The diaphragm was charred; however, examination of the fuel nozzles revealed Nos. 2, 3, 5, and 6 were unobstructed, and Nos. 1 and 4 contained some particulates. The engine-driven fuel pump remained attached to the engine and could not be rotated by hand due to severe fire damage. The spline remained intact (not fractured). No fuel was observed in any of the fuel system components. The pilot held a private pilot certificate with an instrument rating. His most recent FAA third-class medical certificate was issued on December 16, 2011. At that time, he reported 2,200 hours of total flight experience. A pilot flight log was provided by the pilot's wife after the accident. It contained entries from August 23, 2007 to October 31, 2010. During that period, the pilot logged 1,917 hours of total flight experience. A more recent logbook could not be located by the pilot's wife. Documentation provided by the insurance company revealed the pilot's most recent BFR was completed on May 4, 2012. The airplane was manufactured in 1989, and received its first airworthiness certificate from the FAA the same year. According to the pilot's wife, he had owned the airplane since approximately 2005. The logbooks for the airplane could not be located by the pilot's wife. An interview with a mechanic at the local airport revealed he completed the most recent annual inspection on March 4, 2012. However, he did not have a copy of the logbook signoff and did not recall how many hours the airplane had accumulated at the time of the inspection. The mechanic did remember that the engine was past the recommended TBO time, which he mentioned to the pilot. He did not recall any other anomalies with the airplane or engine. According to interviews with friends and family of the pilot, he routinely performed his own maintenance on the airplane. Several friends and the pilot's wife confirmed that he installed an auxiliary fuel tank in the cabin of the airplane during the weeks prior to the accident. One friend, who observed the installation, described the fuel tank as a plastic white tank in the backseat, which was not aviation-approved. It appeared to be an "herbicide-type tank, similar to a tank you would see on a riding lawnmower." In addition, the fuel line installed was too small (1/4 inch in diameter, compared to 3/8 or 1/2 inch), and the system was vented into the cabin. Maintenance personnel at Stanly County Airport (VUJ) reported that the pilot arrived at their facility on June 22, 2012 and requested an oxygen fill. The system was "topped off" with 1800 psi. The mechanic reported that when he added the oxygen, he noticed water coming out of the v