WPR14FA135

The pilot's reconfiguration of the fuel venting system, which resulted in a loss of engine power and subsequent loss of aircraft control.

The instructor was taking the student on an introductory instructional flight in a special light-sport weight-shift-control aircraft (trike). After departure, the instructor maneuvered the trike over the ocean and along the coast at an altitude of about 1,000 ft above ground level. About 20 minutes into the flight, the trike descended into terrain, impacted in a near vertical attitude, and was consumed by fire. Although the pilot was in radio communication with another trike, he did not report that he was having any difficulties. The pilot had recently experienced a problem with the trike's fuel system: during a previous flight, fuel was streaming out of the vent line due to suction created by its position in the airstream. Although the airframe manufacturer explained that this can be normal, the pilot decided to reposition the vent line. Before the accident flight, the pilot had re-routed the clear plastic vent line so that it ran up the mast and aft along the keel (inside the keel pocket) and then bent 180-degrees upward and around to face into the airstream. The severe impact and fire damage to the trike precluded determination of the events that led to the departure from controlled flight. However, the rerouted vent line may have become constricted due to the rerouted configuration, either by the tie wraps securing it to the keel or by the keel tube riding tightly against the keel pocket in flight. Such a constriction would lead to the fuel system becoming fully depressurized and the engine experiencing a loss of power due to fuel starvation. It is likely that the pilot became distracted by the loss of power and subsequently lost control of the trike.

The trike came to rest at the base of a ridgeline about 1 nautical mile east of Polihale State Park. The main wreckage was consumed by fire but all major structural components were located within the wreckage debris area. According to the airframe manufacturer, the position of the haul-back latch and the damage signatures of the cross tubes were consistent with the wing impacting terrain in a near vertical attitude. There was no evidence of any system malfunction. The end portions of the keel and the fuel vent line were found in the wreckage. The vent line was still secured to the keel tubing with black tape. A complete pictorial diagram is contained in the public docket for this accident. Data Upon arrival at the NTSB Vehicle Recorder Laboratory, an exterior examination revealed that the GoPro Camera had sustained significant impact damage. The camera's glass element lens was shattered; the battery and memory card were not seated in the appropriate locations. A crack in the memory chip that corresponded to the crack in the card's external plastic casing was discovered. Despite numerous attempts, the mechanical damage to the chip precluded any data from being recovered. Use of Special Light Sport Aircraft for Revenue Sightseeing There were three prior fatal weight-shift trike accidents in Hawaii during instructional flights: WPR10FA211, WPR11FA138, and WPR11FA225. According to Federal Aviation Administration regulations, Title 14: Aeronautics and Space, Part 91.327, Aircraft having a special airworthiness certificate in the light-sport category: Operating limitations in part: (a)No person may operate an aircraft that has a special airworthiness certificate in the light-sport category for compensation or hire except- (1)To tow a glider or an unpowered ultralight vehicle in accordance with 91.309 of this chapter; or (2)To conduct flight training. Birds in Paradise utilized SLSAs to conduct introductory flights and advertised itself as an "Intro Flight School." According to the factual report on a pervious accident that occurred in an SLSA in December 2012 (WPR11LA081), the FAA was aware that operators were "conducting flight tours under the guise of flight instruction," and the operators' "flight records show hundreds of flights listed" as introductory flights. During that investigation, an FAA inspector noted that there was no follow-up training or any repeat students. He further stated that the operators did not conduct any ground school training, nor did they have the facilities to do so. That investigation also found that these types of operations were common knowledge to inspectors at the Honolulu Flight Standards District Office (HNL FSDO). The HNL FSDO maintained files on those operators and attempted to monitor them. However, because the operators were not certificated revenue sightseeing flight providers, limited FSDO resources constrained the ability of the inspectors to conduct regular surveillance on those operators. Maintenance of Special Light Sport Aircraft According to the FAA, maintenance, repair and alterations on an SLSA may be performed by the following: -LSA Repairman with Maintenance rating (as authorized by manufacturer) -A&P or FAA-certificated repair station (as authorized by manufacturer) An autopsy was performed on the pilot by Pan Pacific Pathologists, LLC in Lihue, Hawaii. The Forensic Pathologist reported that the cause of death of the pilot was due to multiple traumatic injuries. Toxicological tests on specimens from the pilot were performed by the FAA Civil Aeromedical Medical Institute. Analysis revealed no ethanol or tested drugs in the muscle. The closest aviation weather observation station was located at Barking Sands Pacific Missile Range Facility Airport, Kekaha, Kauai, about 2 nm south from the accident site. That facility issued an automated surface weather observation at 0856 (about 15 minutes prior to the accident) reporting the following: the wind was calm; 10 miles or greater visibility; sky conditions clear, temperature 21 degrees Celsius; dew point 19 degrees Celsius; and an altimeter setting of 30.05 inches of mercury. A review of Federal Aviation Administration (FAA) airman records revealed that the 54 year-old-pilot held a certified flight instructor sport-pilot certificate. The pilot's partner reported that he had amassed 19,000 flight hours and was renowned in the trike community. The pilot never had a medical certificate and was not required to have a medical certificate to be a Sport Pilot or a Sport Flight Instructor pilot. He held a light-sport repairman certificate. The pilot's partner reported that the pilot had flown four flights on March 8, 2014, totaling 5.5 hours of flight time. On March 10, the day before the accident, the pilot awoke early and made several flights before coming back home at 1600. The pilot received his normal 7-8 hours of sleep and arrived at the flight school about 0600. Customers would usually arrive about 0645, with the first flight starting at 0700. The flights were either 60 or 90 minutes long and would always be conducted as a tandem flight for a safety precaution, with both pilots staying in radio communication with one another. The trike was a special light sport (SLSA) weight-shift-control Evolution Trikes, Revo, serial number 000551, and equipped with a Rotax, 912ULS, serial number 6775546. A review of the trike's maintenance logbooks revealed that the last airframe conditional inspection was dated December 19, 2013, with an airframe total time of 1,427 hours. The last engine conditional inspection was dated January 03, 2014, with an engine total time of 1,442 hours. The same trike and pilot were involved in an accident in April 2010 (NTSB number WPR10CA224) where a loss of engine power resulted from fuel exhaustion due to the pilot's improper decision to continue the flight after the low fuel warning. The trike had 24 hours of total flight time when the accident occurred and was rebuilt shortly thereafter. Recent History The pilot had recently experienced problems with the trike's fuel system. He reported to the second pilot that during flight, he had noticed that fuel was being suctioned out of the main vent line located in the belly of the aircraft. On a recent flight, the pilot landed in Princeville, Kauai, to assess the problem and refuel. He determined that the fuel was streaming out of the vent line because of suction created due to its position in the airstream. This flight occurred about one month prior to the accident equating to about 25 flights and it is unknown when this began because the vent line position was not changed according to records. The accident pilot spoke with a representative from Evolution Trikes about a week prior to the accident expressing concern with fuel being syphoned out of the trike during flight. He stated that the fuel level was diminishing quickly and another pilot could see fuel streaming out. The representative told him that it was likely due to the fuel heating inside the tank due to the nature of its position adjacent to the radiator and exhaust. He explained to the pilot that the fuel will expand as it gets warmer which could result in about a half-gallon streaming out of the vent line. The pilot explained that he had re-run the vent line up the mast, and it was still leaking fuel even with the vent being higher than the tank. The representative stated that all of the fuel vent lines on the company's REVOs showed signs of fuel leakage. On the morning of the accident, the second pilot noticed as he was taking his trike out of the hangar, that the accident pilot was on a ladder routing compressed air into the accident-trike's fuel vent line. The second pilot commented to the accident pilot that the fuel cap was still affixed on the tank and removed it for him, which produced a "pop" sound as the compressed air escaped the system. The pilot had re-routed the clear plastic