WPR12FA089

A loss or commanded reduction of engine power during the initial climb for reasons that could not be determined because of postaccident impact damage and fire destruction to engine systems and components. Also causal were the pilot's failure to maintain adequate airspeed and airplane control while attempting to return to the runway despite unpopulated, flat terrain immediately ahead that was suitable for an emergency landing; his decision to take off again with a known problem; and his lack of training in the make and model airplane.

The amateur-built, experimental, high-performance airplane was fueled to capacity and the pilot had planned a cross-country flight. During an initial takeoff, the airplane climbed to about 60 feet above ground level (agl) before touching back down; the pilot transmitted to the air traffic controller that he had a problem. The controller asked if the pilot needed any assistance, and the pilot responded that he was going to taxi back and "see if I can figure it out," indicating that there was not a catastrophic failure and the pilot was intending to troubleshoot the problem. The pilot then taxied to a ramp area where the airplane was stationary for almost a minute and a half. Although the pilot's actions during this period are not known, it is likely that he was attempting to troubleshoot a problem with the airplane because the recorded engine parameters are consistent with the pilot cycling the propeller. Thereafter, the pilot stated his intention to stay in the traffic pattern, and he taxied the airplane back to the runway. The airplane became airborne about 18 seconds into the takeoff; the pilot then made a request to turn back to land. The airplane turned to the left and continued to climb until it reached its peak altitude of about 320 feet agl. Witnesses indicated that the airplane then entered a spin, completed about one revolution, and impacted terrain in a nose-low attitude before coming to rest in a dirt area between the parallel runways. A fire started upon impact. At the peak of the airborne portion of the first rejected takeoff, about 5,860 feet of runway remained. When the pilot made the request to turn back to land during the second takeoff, over 5,160 feet of runway remained, but because the airplane was 260 feet higher and had a higher airspeed than previously, the pilot likely thought he would not be able to land on the runway surface straight ahead. A performance study indicated that the airplane experienced a loss of thrust during the accident takeoff about 1 second before the pilot's request to return. Postaccident examination revealed no evidence of a preimpact uncontained engine failure, inflight fire, or flight control system malfunction. Fuel system continuity could not be confirmed due to thermal damage incurred during the postcrash fire. Review of the engine parameters revealed that, during the accident takeoff, the greatest anomaly in the airplane's parameters was that the fuel pressure dropped to a minimum psi while the fuel flow increased and the torque delivered to the engine shaft (Q) increased excessively. Shortly thereafter, fuel pressure recovered when the fuel flow reduced and Q retarded to an idle setting. Q also dropped to an idle setting during the previous takeoff. The reason for these variations could not be explained. In comparing prior flights to the accident flight, the maximum Q attained during takeoff climb was lower than the Q for the accident takeoff, and the fuel pressure did not drop to the same level as during the accident flight, which are indicative of a problem with the airplane. The airplane was equipped with a Turbine Starter Limiting/Monitoring System, capable of limiting power by restricting fuel flow, which was designed to act as a start sequence controller, an engine protection limiter, and an engine monitor/recorder. It is possible that this system/installation malfunctioned and engaged during the accident takeoff; however, the system was destroyed in the postcrash fire and could not be examined. Consequently, no determination regarding its performance during the accident flight is possible. The data showed that the pilot's most recent flight in the airplane was 6 days before the accident, at the same airport. During that flight, he also performed an initial rejected takeoff, suggesting that he was possibly having problems at that time; he made a successful flight thereafter, but remained in the traffic pattern. A simulation of the accident flight indicated that, during the airplane's left turn, the angle of attack at which the wing stalls was exceeded. A former engineer and general manager of the kit manufacturer stated that if the engine failed during takeoff, the airspeed would rapidly decay, and the pilot would have to push the nose down to maintain flying speed. He noted that following a loss of power, the nose would remain in a nose-up attitude, and unless the pilot made corrective pitch inputs (reducing the angle of attack) within about 4 to 5 seconds, the airplane would rapidly reach a critical angle of attack and stall, which would result in the wing simultaneously dropping. It would not be possible to recover from the stall at altitudes below 1,500 ft agl. Based on the results of the simulation for the accident flight, witness statements, statements from a former employee of the kit manufacturer, it is likely that pilot was attempting to return to a runway (either the takeoff runway or the parallel runway). The pilot did not push the nose down to maintain flying speed and stalled the airplane well below 1,500 ft agl, and the airplane was spinning when it impacted the ground. Although beyond the end of the takeoff runway was flat, unpopulated hard-dirt surface, suitable for a straight-ahead emergency landing, it is unknown why they pilot chose to return to the airport rather than lower the nose and land there. Twenty-six percent of Lancair airplanes have been involved in accidents, and 19 percent have been involved in fatal accidents. In 2008 and 2012, the FAA convened two safety groups specifically to address the airplane's "unusually high accident and fatality rate compared to other amateur-built aircraft." The study noted that based on the statistics, the kit was involved in fatal accidents at "a rate that is disproportionate to their fleet size." As a result of studies developed by these safety groups, the FAA acknowledged that accidents would continue to occur if no action was taken. Thus, the FAA issued a notice that Lancair pilots should "review and thoroughly understand all information regarding stall characteristics and obtain specialized training regarding slow flight handling characteristics, stall recognition, and stall recovery techniques;" install an angle-of-attack indicator to better predict a stall; and have their airplane evaluated by an experienced type-specific mechanic to ensure proper rigging, wing alignment, and weight and balance. The notice was recalled shortly after its release and another notice was released later to include other high-performance experimental amateur-built aircraft. When asked about what he disliked about the flight characteristics of the airplane, the pilot had told a technician who refueled the airplane that it was "squirrelly." According to the FAA, depending on the complexity of the systems installed, pilots likely will require orientation and specially-tailored training to operate this airplane safely. Although the pilot was properly certificated in accordance with existing Federal Aviation Regulations and his estimated flight experience in the airplane was 13 hours 40 minutes, no evidence was found indicating that the pilot had received flight instruction in the accident airplane model, even though he was aware that insurance companies required him to do so in order to receive coverage.

1.0 HISTORY OF FLIGHTOn February 03, 2012, at 0856 mountain standard time, an experimental amateur-built Lancair IV-TP, N321LC, impacted terrain following a loss of control while on the initial takeoff climb from Gowen Field, Boise, Idaho. The airline transport pilot, the sole occupant, was fatally injured, and the airplane was destroyed. The airplane was owned and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The local personal flight was originating from Boise when the accident occurred. Visual meteorological conditions prevailed and no flight plan had been filed. Numerous witnesses located at the airport observed the airplane on an initial rejected takeoff and on the subsequent accident flight. A majority of them stated that, during the initial rejected takeoff, the airplane departed 10R and climbed to about 5 to 10 feet (ft) above ground level (agl) before touching back down on the runway. The pilot taxied back toward the west end of the airport. Shortly thereafter, the airplane departed 10R again and climbed to about 100 to 200 ft agl. It then began to roll to the left while rapidly losing altitude. The airplane completed about one revolution and impacted terrain in a nose-low attitude. The airplane came to rest in a dirt area between runways 10R and 10L, and a fire started upon impact. Airport personnel responded to the accident and extinguished the fire with a fire suppressant. The Boise Air Traffic Control (ATC) Facility provided the recorded radio communications between the pilot and controllers. The pilot was initially cleared onto runway 10R and instructed to "line up and wait." About 1 minute later, he was cleared for a departure to the south, and the airplane took off from the 9,760 ft long runway about 0846:38. He transmitted to the controller 40 seconds later that he was going to "land here and stop… we got… we got a problem." An ATC controller asked if he needed any assistance to which he responded by saying, "negative, I'm going to taxi back and see if I can figure it out." About 9 minutes later, he told the controller that he would like to depart and stay in the traffic pattern for a "couple laps." The tower controller cleared the pilot for takeoff at 0854:40, and at 0855:44, the pilot made his last intelligible transmission when he requested that he would "like to turn back in and…uh…land… coming back in…uh…three." An indiscernible transmission was made 9 seconds later that may have been the pilot saying "Boise." Flight track data recorded from the airplane's onboard global positioning system (GPS) by the onboard Aerosonic Op Technologies Electronic Flight Instrumentation System (EFIS) was extracted from compact flash memory cards recovered from the wreckage. The EFIS data consisted of 23 parameters with 1 sample taken every 5 to 7 seconds. The recorded data covered the last 14 start cycles of the EFIS, and the last start cycle included data from the accident flight and the rejected takeoff immediately preceding the accident flight. The EFIS data for the last start cycle spanned from 0838:03 to 0856:00, or 25 minutes 57 seconds, with the airborne portion of the accident flight consisting of the last 28 seconds, from 0855:32 to 0856:00. Comparing the times of the pilot's radio transmissions (as recorded in the ATC transcript) to the times of events recorded in the EFIS data revealed that the ATC transcript time lags the EFIS time by about 23 seconds. The EFIS times are used in this report, and the times of radio transmissions recorded in the ATC transcript have been adjusted accordingly (by subtracting 23 seconds). A review of the data (see Figures 01 and 02 in the public docket) revealed that after the engine started at 0838:39, the airplane made a continuous taxi (as indicated by variations in groundspeed and heading) from 0844:18 to 0846:07, at which point the nose was aligned with the runway heading (around 100 degrees). From 0846:07 to 0846:32, the airplane remained stationary on the centerline about 270 ft from the approach end of the runway with the torque delivered to the engine shaft (Q) remaining around between 13 to 14 percent, consistent with an idle setting. The airplane began the takeoff roll at 0846:32 and became airborne about 0846:59. The airplane climbed 60 ft over the next 10 seconds to 2,845 ft msl, which was the highest attained altitude on that flight and corresponded to about 3,900 ft from the arrival end of the runway, which equates to about 40-percent down the runway with 5,860 ft remaining. At this time, 0847:09, the airplane had reached 108 kts (the highest airspeed of the flight); the pitch attitude had decreased from 8.1 to 4.4 degrees nose-up; the Interstage Turbine Temperature (ITT) had decreased from 581 degrees to 376 degrees Celsius (C); Q had dropped from 89.6 to 13 percent; and fuel flow dropped from 56 to 20 gph. The pilot transmitted that he was going land, and the airplane touched down around 0847:21. The pilot made a right turn to the south to exit onto taxiway D. The airplane continued northwest along taxiway B, made a turn west to taxiway F, north onto taxiway J, and taxied on the ramp toward the pilot's hangar. When the airplane was adjacent to the hangar (about 175 ft north of the hangar door), the pilot maneuvered to have the nose on a heading of about 060-degrees. From about 0852:25 to 0853:51, the airplane was stationary, and it is unknown what the pilot's actions were during that 1 minute 26 second period. The engine parameters indicated that the propeller rotation speed (Np) fluctuated from about 1,140 rpm, down to 490 rpm, and then up to 1,614 rpm, which corresponded to Q values of about 14, 29 and 34 percent, respectively. Thereafter, the pilot taxied back to runway 10R (a 1 minute 4 second trip to the hold-short line) and turned on the centerline about 110 ft from the arrival end of the runway, where the arrival threshold makings were located. The airplane began the takeoff roll at 0855:14 and became airborne about 18 seconds later at 0855:32, which corresponds to being positioned about 1,780 ft from the arrival end of the runway (see Figure 02 in the public docket). Immediately after becoming airborne, between 0855:32 and 0855:44, the fuel pressure dropped from 26 to 15 psi and then to 14 psi; fuel flow increased from about 54 to 65 gph; the airspeed increased from 99 to 104 kts; and Q increased from 104 to 113 percent torque. At 0855:44, the pilot made his request to turn back to land, and the data began to show significant changes in the recorded parameters at this time. The airplane was in a 12-degree nose-up pitch attitude and had climbed to about 205 ft agl, corresponding to about 4,150 ft from the arrival end of the runway and about 200 ft right of the runway's centerline. The airplane rolled from 1.7 degrees right to 1.6 degrees left; the airspeed increased from 124 to 132 kts; the fuel flow decreased from 65 to 56 gph; the fuel pressure increased from 14 to 31 psi; Q decreased from 113 to 66 percent; and a drop in Np of about 70 rpm was recorded. The airplane continued to climb for 10 seconds until 0855:54, when it reached about 320 ft agl, the highest altitude attained during the flight. The data revealed that at this point, the airplane was in a 16-degree bank to the left, and it continued to roll to 49 degrees within 6 seconds. Additionally, Q had reduced to 16 percent; ITT dropped to 379 degrees C, the lowest during the entire flight; fuel flow had reduced to 19 gph; the fuel pressure remained around 32 psi; and the gas generator speed (Ng) had reduced to around 62 percent. The last 4 data points, encompassing the last approximate 16 seconds of the flight, revealed that the heading changed from 107 to 21 degrees, with Q decreasing from 16 to 14 percent. The accident site was located about 400 ft north of the last recorded position. 1.1 PERSONNEL INFORMATION A review of Federa