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NTSB investigation record

WPR16FA091

Completed

Nokes matthew Lancair iv p· N438Y

Date
April 2, 2016
Location
Fallbrook, CA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

A loss of engine power during cruise for reasons that could not be determined because examination of the airplane did not reveal any anomalies that would have precluded normal operation.

Investigator assessment

Analysis narrative

About 15 minutes after departing on the cross-country flight, the experimental, amateur-built airplane experienced a loss of engine power, and the private pilot considered landing on a 550-ft-long airstrip for remote-controlled aircraft. After observing numerous people on and near the runway, he subsequently decided to land on an interstate highway. Upon touching down with the landing gear retracted, the airplane slid into a car parked on the paved shoulder of the highway, fatally injuring one of the car's occupants. Video footage captured by a cell phone inside the airplane showed normal engine indications before the accident. A video taken shortly thereafter did not capture the instrument panel or engine indications; however, the engine could be heard surging. The airplane was equipped with fuel tanks in the left and right wings, as well as a fuselage tank. The right and left wing tanks each had a capacity of 52 gallons, and the capacity of the fuselage tank was 33 gallons. The fuel system was configured so that the left wing tank connected to the fuselage tank, and the engine would draw from the fuselage tank. The fuselage tank did not have a dedicated fuel quantity gauge; the pilot stated that he knew it was full when the wing tank gauge began to indicate above zero. The pilot stated that before departing on the accident flight, the left fuel tank quantity gauge indicated 1 gallon, which corresponded to 34 gallons available. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. A test run of the engine at low, intermediate, and high power settings was successful. The fuselage tank was breached during the accident, and an undetermined quantity of fuel leaked out. The gascolator did not contain any fuel, and the line from the gascolator to the engine-driven fuel pump, as well as the fuel inlet line to the fuel manifold, contained no fuel. The lack of fuel in these areas, coupled with the engine surging heard on video, may be an indication of fuel starvation; however, since the investigation was unable to determine the total quantity of fuel on board the airplane, the reason for the loss of power and engine surging could not be determined.

Source record

Factual narrative

The IIC and an investigator from CMI examined the wreckage at Air Transport, Phoenix, Arizona, on April 26, 2016. A full report is contained within the public docket for this accident. The wreckage examination revealed no anomalies that would have precluded normal operation of the airframe or engine. Airframe The airplane was equipped with a belly tank, but it was ground down and breached. The belly drain was scraped. The fuel selector valve (FSV) was labeled L, R, and OFF/OFF. The fuel line from the left wing fuel tank was connected to the belly tank, which in turn was connected by a separate line to the FSV. The right wing tank fuel line connected directly to the FSV. The outlet from the FSV connected to an electric fuel pump located on the right side wall of the cabin. A line went through the firewall to connect the electric fuel pump to the gascolator, which had a line connecting it to the engine. The return line from the engine was connected directly to the FSV, which had a separate line going directly to each (left and right) wing fuel tank. The fuel quantity gauge had two indicators ranging from E to F on the left and right sides of the gauge. The air filter was clean. Engine There were no holes in the crankcase or cylinders that indicated a catastrophic failure of the engine. Investigators left the engine in place on the airframe. They manually rotated the crankshaft with the propeller. The crankshaft rotated freely; the valves moved approximately the same amount of lift in firing order, and the gears in the accessory case turned freely. A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. The inlet for each turbocharger compressor was clear, and the rotors for each one turned freely. Investigators disconnected the fuel line from the gascolator to the engine driven fuel pump, and nothing drained from the line. They then disconnected the fuel inlet line to the fuel manifold valve on top of the engine, and nothing drained from the line. Recovery personnel installed a two-bladed propeller on the engine, and made other modifications to facilitate an attempt to run the engine (see the follow-up exam notes in the public docket). The engine was started and run at low, intermediate, and finally at a high power setting. The engine was run a total of several minutes with no anomalies noted. Propeller All three propeller blades remained attached at the hub, but were loose, and rotated in the hub. They were all bent aft, and all three tips curled aft. Fuel System A detailed examination of the fuel system was completed on June 28, and the examination report is in the public docket; no anomalies were noted. The aft portion of the belly tank had a vent line going to a solenoid valve, which in turn was connected to a line exiting the belly skin of the airplane aft of the belly tank. Blowing into the vent with electrical power off, air could be heard going into the belly tank. Video Study A cell phone in the airplane contained media recordings of portions of the flight. An NTSB recorder's specialist in the Office of Research and Engineering viewed the images, and provided a written report, which is in the public docket for this accident. Pertinent parts of the report follow. The phone captured 42 relevant media files, 23 still images and 16 video files. In some media files, the entire instrument panel was captured; in others, only portions of the instrument panel were captured. Only events pertinent to the accident were summarized. The video files included start, taxi, takeoff, and cruise. Videos showed the airplane at different altitudes increasing from 1,500 feet up to 3,500 feet. A still file showed the airplane in nearly level flight about 3,000 feet msl. Airspeed was 175 knots, heading was 315 degrees, manifold pressure was 26.8 psi, rpm was 2,480, fuel pressure 11 psi, oil pressure 55 psi, fuel flow 18.1 gph, and oil temperature was 178° F. The cylinder head temperature (CHT) was within that particular instrument's green limits. A clock showed a time of 19 minutes and 35 seconds. Another still taken several minutes later showed the airplane at 3,500 feet, on a direct route GPS track to French Valley Airport, which was 27.4 nm away. A video began 28 minutes after startup; 3 seconds into that recording, the engine was heard making a surging noise. The pilot's hand was on the throttle then moved away as if to manipulate something on the instrument panel. No engine instruments were captured in the recording, and the GPS showed that the airplane was no longer on a direct track to the programmed waypoint. Eight seconds into the recording, the passenger appeared to put the phone down. No other useful visual information was captured; the recording ended 4 seconds later, and the engine was still surging. Radar Study Recorded radar data tracked the flight from about 1 minute after departure until the airplane approached the accident site. The airplane turned to the north, and remained to the east of Interstate 15. About 5 minutes prior to the accident, the airplane was nearly abeam the accident site at a mode C reported altitude of 3,700 feet msl. About 1 minute later, the target began a left 100-degree turn at 3,900 feet. About 1 minute later, it was descending to the west as it crossed Interstate 15 below 3,600 feet, and continued a descending turn to the south to parallel the freeway. It continued descending on a straight southerly course for about 1 minute; it then began a left turn, crossing the freeway at 1,700 feet. The turn was over 180 degrees, and the last data point was near the accident site with the target at 600 feet. Amateur Built According to FAA Advisory Circular AC 20-27F, Certification and Operation of Amateur-Built Aircraft, "Amateur builders are free to develop their own designs or build from existing designs. We do not approve these designs and it would be impractical to develop design standards for the wide variety of design configurations, created by designers, kit manufacturers, and amateur builders." An automated surface weather observation at Camp Pendleton Marine Corps Air Station (KNFG), Oceanside, California (elevation 78 feet msl, 10 miles southwest of the accident site) was issued at 0854 PDT. It indicated wind from 180 degrees at 3 knots, 5 miles visibility with haze, sky clear, temperature 13 degrees C, dew point 09 degrees C, and an altimeter setting at 30.18 inches of mercury. The pilot stated that he had adequate sleep, had not consumed alcoholic beverages, and was not taking any medications or supplements. The 62-year-old pilot reported that he held a private pilot certificate with a rating for airplane single-engine land. The pilot held a third-class medical certificate issued on August 18, 2015. It had the limitation that the pilot must wear corrective lenses. He had a Statement of Demonstrated Disability (SODA) 30D09235 dated October 9, 1992, for no useful vision in the left eye. The SODA was issued on October 21, 1992, after the pilot successfully completed a medical flight test. The pilot held a Repairman Experimental Aircraft Builder certificate. The pilot reported that he had a total flight time of 4,750 hours, and had logged 0 hours in the previous 90 days. He reported 1,200 hours in this make and model. He completed a flight review on November 11, 2015. The four-seat low-wing retractable-gear airplane, serial number LIV-298, had an original special airworthiness certificate issued on January 29, 2000. A special airworthiness certificate was issued to the pilot/current owner on February 2, 2010. Federal Aviation Administration (FAA) records indicated that the registration on the airplane was issued on February 2, 2010, with an expiration date of December 31, 2013. The registration and airworthiness certificate were not identified in the wreckage. Maintenance logbook

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