Accident Details
Probable Cause and Findings
fuel starvation due to the mechanic's failure to properly tighten a fuel line fitting on the engine driven fuel pump, which led to a depletion of the fuel in the header tank. The mechanic's self induced pressure to complete the job prior to leaving on vacation was a factor in the accident.
Aircraft Information
Registered Owner (Historical)
Analysis
1.1 HISTORY OF FLIGHT
On May 11, 2002, at 1242 Pacific daylight time, a Ercoupe (Engineering & Research Corp.) 415C, N2948H, collided with obstacles and the ground on a freeway in El Cajon, California, during an attempted forced landing following a loss of engine power. No automobiles were involved on the ground. The airplane was owned and operated by the pilot under the provisions of 14 CFR Part 91 of the Federal Aviation Regulations. The airplane was destroyed in the collision sequence. The private pilot, the sole occupant, sustained serious injuries. Visual meteorological conditions prevailed at the time and no flight plan had been filed. The local area post maintenance test flight originated at the Gillespie Field airport, El Cajon, at 1140.
According to controllers at the Federal Aviation Administration (FAA) Air Traffic Control Tower at Gillespie Field, when the pilot departed he informed them that he would be breaking in a new engine and would be orbiting northeast of the airport. About 1240, the pilot radioed the local controller and declared an emergency, noting that he had a rough-running engine. At the time he stated his position as 5 miles east of the airport. The local controller cleared the pilot to land on runway 27R. Shortly after that, the pilot stated "mayday mayday." The controller stated that he saw the airplane on final approach and it "nose dived" out of his sight.
The airplane collided with the eastern most fence bordering the freeway right of way, then the ground in the northbound lanes of highway 67 about 1/2 mile from the approach end of runway 27R. The airplane came to rest inverted on the freeway.
A post accident investigation disclosed that the recently overhauled engine had just been installed in the airframe and this was the first flight following this maintenance activity. The mechanic who installed the engine was initially interviewed on site by a responding FAA inspector. During the interview, he provided the airframe and engine maintenance records to investigators. He stated that the Teledyne Continental C-75 engine had been overhauled and he completed the reinstallation that morning. Following installation, he performed a 20-minute ground run of the engine. A fuel leak was noted in a fitting in the line to the carburetor and that was tightened. There were no other discrepancies noted in the engine indications. The pilot then took the airplane for a post maintenance test flight and engine break-in. The mechanic noted that the carburetor was overhauled at the same time as the engine.
1.1 Pilot's Statement
The pilot, who is also the owner of the airplane, was interviewed at his residence following release from the hospital. He said that he did not participate in any of the maintenance activities associated with the removal or installation of the engine. The mechanic who installed the engine is the one who does all of the maintenance on the airplane and has a key to the hangar where the airplane is kept.
He noted that it was in late November 2001 that he first became aware of a low oil pressure and a high oil temperature condition. This first manifested itself during a video taping flight over the southern San Diego area. The readings were of such concern that he diverted the flight to Brown Field and landed. The mechanic was contacted by telephone and he came out to troubleshoot the problem. Over a week-long period the mechanic attempted to resolve the problem without success. Eventually he determined that it was safe to move the airplane back to Gillispie Field. The pilot stated that the mechanic telephoned an engine overhaul shop, Barkhorn Precision Engines, and the resulting recommendation was for an overhaul, which the pilot agreed to. He denied that he instructed the mechanic to do only a "bottom end overhaul."
He could not recall the date of the last fueling on the airplane, however, he acknowledged that it could have been in early December.
While he is unsure of the dates, he believes that the engine was removed in the early December time frame for the overhaul. The overhaul seemed to take a long time and they were anxious to have their airplane back, but he did not pressure the mechanic to get the airplane back quickly. He was advised when the engine was delivered on May 6, and then the mechanic telephoned on May 10 and said the airplane would be ready the next day. The pilot arrived at the airport after the mechanic had performed the ground run of the engine. He was not present during any of the final installation or test run processes.
The mechanic told him that the airplane was ready for a test flight and that he should take it up for about an hour, changing the rpm setting every 5 minutes. The pilot said he did a preflight inspection, which included sump checking the fuel tanks. As for determination of quantity, the fuel gage in the cockpit read 3/4ths and the sight gage on the header tank was showing about 6 gallons. He explained that the one fuel gage combines the readings for both wing tanks. He interpreted the readings to mean that he had 6 gallons in each of the wing tanks and 6 gallons in the header tank, for a total of about 18 gallons. On the subject of the fuel tanks, he said that he was under the impression that the mechanic removed the header tank during the engine removal process.
After the preflight, he started the engine and taxied down to the runway where he did his normal run-up process, which included two separated magneto checks. He was number 5 for takeoff and was on the ground for about 10 minutes until he received his takeoff clearance. After takeoff he flew out about 3 miles and orbited while varying the rpm every 5 minutes. During the entire flight from engine start, the power plant performed perfectly with no abnormal engine indications. At the end of 1 hour, he reported to the Gillispie Field control tower that he was ready to land and turned inbound toward the runway. On final approach, the engine just quit without any precipitating roughness or engine spool down. He said it was "like someone just turned off the key." He did not have enough altitude to make the runway and did not want to take the chance of injuring someone on the ground by landing in a residential area or on the freeway. He selected a Christmas tree farm and set up to land there; however, he was slightly high and decided to "pancake it into the trees." After the airplane hit, it bounced back into the air and hit a fence. He does not remember anything after that.
1.2 PERSONNEL INFORMATION
Review of the records maintained by the FAA in the airman and medical records section disclosed that the pilot held a private pilot certificate with category ratings for airplanes single engine land and gliders. The most recent third-class medical certificate was issued on November 2, 2001, and contained the limitation that correcting lenses be worn for near vision.
The pilot supplied his most recent personal flight record logbook for review by investigators. The numeral 3 was written on the outside cover. The book encompasses entries from February 1992 to December 2001. (Note that the engine overhaul began in January 2002 and was completed on May 2, and that this was the first flight since December).
The estimated total time is 750 hours, with 70 at night. No determination could be made as to the total time in the airplane; however, all flights listed in this book were in the accident airplane. The pattern of activity averages about 5 hours per month over the course of the logbook entries, with the typical flight lasting around 0.5-hours.
A Biennial Flight Review endorsement was dated August 8, 2000, and was completed in the accident airplane.
1.3 AIRCRAFT INFORMATION
1.3.1 General Information
Review of FAA Aircraft Registry files disclosed that the airframe, an Ercoupe 415C, serial number 3573, was manufactured in 1946. A Continental C75-12 engine, serial number 3796-6-12, was installed in the airframe.
The fuel system in the airplane consists of a 6-gallon tank in each wing and a 6-gallon header tank, which is mounted in front of the cockpit. Fuel is supplied to the engine's carburetor via gravity fed line only from the header tank. The engine driven fuel pump moves fuel from the wing tanks to the header tank to replenish that supply as the engine uses it. According to the Teledyne Continental operating manual for the "C" series engines, the typical cruise fuel consumption rate of the C75 engine is between 5 and 6 gallons per hour.
Review of the fueling records at the Gillespie Field airport disclosed that the last documented fueling of the airplane occurred on December 7, 2002, with the addition of 10.0 gallons of 100LL aviation gasoline.
1.3.2 Airframe Logbook
This record begins with an entry dated January 3, 1972, with a notation that the annual inspection date was taken from "FAA Form 8320-3". A total airframe time was "estimated" at 1,407 hours, with a new recording tachometer reading of zero hours. At the accident site, the recording tachometer displayed 550.11 hours.
The most recent annual inspection was entered and dated May 11, 2002, with a recording tachometer time of 549.16. This entry was not signed by the completing mechanic/IA. In a subsequent interview with investigators, the completing mechanic/IA said that he wanted to wait until after the test flight to sign the return to service endorsement.
The annual inspection prior to this one was dated May 13, 2001, at a recording tachometer time of 538 hours.
1.3.3 Engine Logbook
As with the airframe record, the engine book begins in January 1972 with the same entry, citing FAA Form 8320-3 as the source for the total time. The estimated total time since new is the same as was listed for the airframe, 1,407 hours.
A "top" overhaul was listed on October 23, 1998, at a tachometer time of 451.1 hours. Between the "top" overhaul and t...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX02FA157