Accident Details
Probable Cause and Findings
A total loss of engine power due to fuel starvation because of a blocked fuel line that resulted from the pilot’s improper maintenance practices and the pilot’s subsequent failure to maintain adequate airspeed while attempting a forced landing, which led to the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn May 31, 2014, about 1620 Pacific daylight time, a single-engine experimental Nebert Vans RV-10, N62DN, experienced a loss of power and departed controlled flight while the pilot was maneuvering for a forced landing in Toledo, Oregon. The airplane was substantially damaged. The private pilot and four-year old passenger were fatally injured; the adult passenger sustained serious injuries. The airplane was registered to and being operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The personal cross-country flight departed Newport Municipal Airport, Newport, Oregon, with a planned destination of Seattle, Washington. Visual meteorological conditions prevailed and no flight plan had been filed.
Numerous witnesses located in Toledo reported observing the airplane flying at a low altitude from the north. The witnesses reported hearing no sound from the airplane's engine and saw it progressively descend in altitude. The airplane approached the Georgia Pacific paper mill and made a steep turn to the left. The airplane subsequently made a rapid descent and impacted terrain in a nose-low, near-vertical attitude.
The surviving passenger recalled the flight, although was heavily medicated during the recounting of the events that transpired. She stated that she was in the aft right seat and her daughter was buckled in a car seat positioned in the aft left seat. Luggage was strapped in the front right seat in an effort to compensate for the aft weight. The departure seemed normal and the pilot commented that the engine sounded better than it had in awhile. The airplane continued the takeoff climb through some cloud wisps and ascended above a lower cloud cover, with an overcast layer above.
The passenger further stated that suddenly the engine experienced a total loss of power, which she described as the airplane stopping forward motion, and there was no engine sound. An alarm sounded, and shortly thereafter all of the airplane's electrical system failed. She recalled observing the screen in front of the pilot flickered and then went blank. The pilot was busy pressing buttons and maneuvering levers, and indicated that they were going to land at the closest airport [which was the Toledo State Airport]. The airplane descended through clouds heading toward the airport. The pilot stated that they were going to make it to the airport, and that he was looking for a place to land. The airplane made an alert sound, which she thought indicated the airplane was moving too slow. The pilot made a left turn and tried to pull up, but the airplane spiraled down harder to the ground. PERSONNEL INFORMATIONA review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the pilot, age 51, held a private pilot certificate with airplane rating for single-engine land, which was issued in March 2008. He additionally held a Repairman Experimental Aircraft certificate. His most recent third-class medical was issued on January 04, 2013, with no limitations.
According to the pilot's flight logbook he had about 785 hours of total flight experience, of which about 375 was amassed in the accident airplane. Based on the airport identifiers listed in the logbook for flight origin and destination points, the pilot accumulated the majority of his flying hours around Newport, his home airport and where the airplane was based. The pilot recorded having flown 6.4 hours in the preceding 30 days, which was accumulated over 6 different flights.
The pilot was a member of the Experimental Aircraft Association (EAA) since August 1991, and had numerous EAA technical counselor visits during the building process. AIRCRAFT INFORMATIONThe Vans RV-10 is an amateur-built experimental airplane that is sold as a kit. The low-wing airplane was equipped with four seats, fixed tricycle landing gear, and traditional flight control surfaces. The accident airplane, serial number (s/n) 40546, received a special airworthiness certificate in the experimental category for the purpose of being operated as an amateur-built aircraft in August 2010; the pilot purchased the kit in October 2009. The airplane was equipped with a Lycoming O-540-B4B5 engine, s/n L-7862-40C, and, according to the manufacturer, is rated at 235 shaft horse power (SHP). The powerplant contained a data tag labeling it as a Lycoming O-540-B1AB, which contained the vibropeened identification next to the stamp of "B4B5."
The airplane's test flight hours were completed in September 2010. Thereafter, the logbooks indicated that the pilot estimated that the airplane's stalling speed in the landing configuration (Vso), at a weight of 1,858 lbs and a CG of 108.5 inches aft of datum, was 58 knots.
Fuel System Design
The airplane's fuel system was a gravity-fed design where fuel flowed from the metal tanks in the inboard section of each wing, through a selector valve, and continued to a fuel filter. From the filter, the fuel was routed to an electric fuel pump and then to a transducer where it was plumbed through the firewall to the gascolator. Thereafter, the fuel was directed to the engine-driven fuel pump, and finally enter into the carburetor.
The Van's Aircraft build manual states in section 37, Fuel System, "When installing fluid fittings with pipe threads do not use Teflon tape. Use instead, fuel lube or equivalent pipe thread sealing paste."
Maintenance
According to the aircraft maintenance records and the recording tachometer in the cockpit, the airplane had accumulated a total time in service of 375.4 hours. The most recent condition inspection was recorded as completed by the pilot on October 4, 2013, 71.5 hours prior to the accident. Examination of the logbook revealed that the last maintenance that had occurred was an oil change and the tightening of the left magneto on February 09, 2014 at a total time of 354.2 hours.
From the pilot's photographs on his website blog, the original build, the pilot did not install the fuel transducer.
A friend of the pilot, who was also a FAA certified mechanic, stated that about two to three weeks prior to the accident, the pilot had installed the fuel transducer. The pilot commented to him that he had not installed the unit previously because it needed a certain amount of space (needed to be about seven to nine inches from the filter) and he would have to bend some of the fuel lines to make it fit. The pilot borrowed a flaring tool from him to complete the installation. The friend noted that earlier in the year, when the pilot was performing a condition inspection and the airplane's cowling was removed, he observed that the pilot had used heavy applications of red/orange RTV(room temperature vulcanization) silicone to seal everything, including the area around the airbox (oval-shaped) where it attaches to the carburetor (square-box-shaped). He mentioned to the pilot that this was an improper practice.
Another friend of the pilot stated that the pilot had installed a fuel transducer about one to two weeks prior to the accident flight, and noted at the time that the unit did not have a bypass. The friend also observed that the pilot had not connected the electrical wires for the transducer to be operational, but had installed the unit.
Lycoming Manual
According to the engine's maintenance manual, the rated horsepower was 235 at 2,575 rpm. To obtain the maximum recommended service life of the engine, the manual recommends that the cylinder head temperature be maintained below 435 degrees Fahrenheit (F) during high-performance cruise operation, with a maximum temperature of 500 degrees F. The Lycoming manual additionally stated that the fuel pressure requirements were a minimum pressure of .5 psi and a maximum of 8 psi. METEOROLOGICAL INFORMATIONA routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) in Newport reported that at 1635 there was an overcast cloud layer at 1,900 feet above ground level (agl) with 5 miles visibility. It recorded the temperature at 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit. AIRPORT INFORMATIONThe Vans RV-10 is an amateur-built experimental airplane that is sold as a kit. The low-wing airplane was equipped with four seats, fixed tricycle landing gear, and traditional flight control surfaces. The accident airplane, serial number (s/n) 40546, received a special airworthiness certificate in the experimental category for the purpose of being operated as an amateur-built aircraft in August 2010; the pilot purchased the kit in October 2009. The airplane was equipped with a Lycoming O-540-B4B5 engine, s/n L-7862-40C, and, according to the manufacturer, is rated at 235 shaft horse power (SHP). The powerplant contained a data tag labeling it as a Lycoming O-540-B1AB, which contained the vibropeened identification next to the stamp of "B4B5."
The airplane's test flight hours were completed in September 2010. Thereafter, the logbooks indicated that the pilot estimated that the airplane's stalling speed in the landing configuration (Vso), at a weight of 1,858 lbs and a CG of 108.5 inches aft of datum, was 58 knots.
Fuel System Design
The airplane's fuel system was a gravity-fed design where fuel flowed from the metal tanks in the inboard section of each wing, through a selector valve, and continued to a fuel filter. From the filter, the fuel was routed to an electric fuel pump and then to a transducer where it was plumbed through the firewall to the gascolator. Thereafter, the fuel was directed to the engine-driven fuel pump, and finally enter into the carburetor.
The Van's Aircraft build manual states in section 37, Fuel System, "When installing fluid fittings with pipe threads do not use Teflon tape. Use instead, fuel lube or equivalent pipe thread sealing paste."
Maintenance
According to the aircraft maintenance records and the recording tachometer in the cockpit, the airplane had accumula...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# WPR14FA218