# Accident 20040801026859A: Amtr LANCAIRLEGAY, Madison, WI, August 1, 2004 - Type: FAA accident report (Accident/Incident Data System), as reported - Date: August 1, 2004, 18:50 local time - Place: Madison, WI - Airport: Dane Co Regional-Truax Field - Damage: Destroyed - Phase of flight: Fcd/Prec Ldg From Cruise - Operating rules: General operating rules (Part 91) - Location: 43.1397° N, 89.3375° W: From the FAA - Nearby events: https://openairdocs.org/map.md?lat=43.1397&lon=-89.3375&mi=10 - Aircraft: N98SN, a cancelled registration (https://openairdocs.org/deregistered/N98SN-2017-03-24) (OpenAirDocs) - Registry model: Knoepflein Shannon LANCAIR LEGACY 2000 (registry code 05615HS, https://openairdocs.org/model/knoepflein-shannon-lancair-legacy-2000) (OpenAirDocs) - Registry engine: Continental IO-550 series (registry code 17042, https://openairdocs.org/engine/continental-io-550-series) (OpenAirDocs) - Reported make and model: AMTR LANCAIRLEGAY - Reported engine: CONT IO520* - People aboard: 1 - Fatal injuries: 1 - Pilot flight hours: 704 total, 209 in this make and model, 47 in the last 90 days - NTSB investigation: [NTSB CHI04FA203](https://openairdocs.org/ntsb/CHI04FA203) (OpenAirDocs) - FAA source: FAA Aviation Safety Information Portal (https://asip.faa.gov/) - Page: https://openairdocs.org/incident/20040801026859A ## Narrative As the FAA filed it, in capitals; the FAA replaces private details with ^PRIVACY DATA OMITTED^. (-23) I WAS CONTACTED BY ROC AT APPROXIMATELY 1850 THAT A SMALL AIRCRAFT, A LANCAIR LEGACY 2000, N98SN HAD CRASHED SHORT OF THE MADISON WISCONSIN AIRPORT (KMSN) WHILE IN ROUTE FROM THE OSHKOSH AIRPORT (OSH) ATTEMPTING AN EMERGENCY LANDING. IT WAS UNKNOWN AT THE INITIAL NOTIFICATION WHAT THE INTENDED POINT OF LANDING WAS OR WHO THE PILOT WAS. I ARRIVED ON SCENE AT APPROXIMATELY 2030. THE MADISON POLICE AND FIRE DEPARTMENTS HAD SECURED THE AREA. THE LOCAL FBI WAS HANDLING THE CRASH SITE UNTIL I ARRIVED AT WHICH TIME IT WAS TURNED OVER TO ME. THE AIRCRAFT HAD ATTEMPTED TO MAKE AN EMERGENCY LANDING ON HIGH POINT CROSSING, AN EAST WEST STREET, (WHICH IS A FOUR LANE STREET DIVIDED WITH A MEDIAN AND LIGHT POLES) APPROXIMATELY ONE MILE SOUTH EAST OF KMSN. THE AIRCRAFT HAD ATTEMPTED TO MAKE A LANDING ON THE EASTBOUND LANES. WHILE ATTEMPTING THE EMERGENCY LANDING THE AIRCRAFT IMPACTED APPROXIMATELY 8 FEET UP FROM THE GROUND WITH ITS LEFT WING A STREETLIGHT. A THREE-FOOT SECTION OF THE OUTBOARD WING WAS SEPARATED FROM THE AIRCRAFT ATOMIZING THE FUEL, WHICH WAS HELD IN THE WING, IN THE DIRECTION OF THE AIRCRAFT TRAVEL. THE FUEL WAS THEN IGNITED (ASSUMING BY AN ELECTRICAL ARC CAUSED FROM THE COLLISION WITH THE LIGHT POLE). THE BURN PATTERN WAS TRIANGULAR IN SHAPE STARTING AT THE LIGHT POLE WITH THE NARROWEST PORTION AND SPREADING WIDER TOWARD THE FINAL RESTING PLACE OF THE AIRCRAFT. IT APPEARS THAT THE AIRCRAFT AFTER HITTING THE LIGHT POLE RAPIDLY ROLLED LEFT AND IMPACTED THE WEST BOUND LANES OF THE STREET. THE AIRCRAFT THEN IMPACTED SOME OTHER ROAD SIGNS AND SLID UPSIDE DOWN UNTIL COMING TO REST AT THE BASE OF A SIGN AT CAPITAL FORD, WHERE THE AIRCRAFT BURNED. IT WAS BURNED AFT OF THE ENGINE COMPARTMENT AND THE FUSELAGE AND EMPENNAGE, AS WELL AS THE WINGS ARE TOTALLY DESTROYED BY FIRE. THE PILOT WAS STILL IN THE AIRCRAFT STRAPPED IN HIS SEAT WITH HIS SEAT BELT FASTENED ABOUT HIM. THE AIRFRAME HAD COLLAPSED AROUND THE PILOT AS A RESULT OF THE FIRE. THE TAIL OF THE AIRCRAFT HAD BEEN SEPARATED AND WAS LAYING APPROXIMATELY 100 FEET FROM IT. FOUND IN THE DEBRIS FIELD WAS A LAPTOP COMPUTER AND DISPLAY SCREEN ALONG WITH BACKPACK SOME PERSONAL BELONGINGS AND AIRCRAFT LOG BOOKS AND A FLIGHT MANUAL. THE DEBRIS AND THE AIRCRAFT WERE RECOVERED BY THE SUN PRAIRIE FIRE DEPARTMENT ALONG WITH THE CITY OF MADISON FIRE DEPARTMENT AND TRANSPORTED TO A NATIONAL GUARD HANGAR AT THE KMSN AIRPORT FOR SECURE STORAGE. DURING THE ONSITE INVESTIGATION I WAS ABLE TO DETERMINE THAT THE AIRCRAFT DID HAVE AN IFR FLIGHT PLAN FILED, THAT WOULD BEGIN AT THE ROCKFORD IL. AIRPORT (RFD), AND WOULD TERMINATE AT LEBANON-SPRINGFIELD KY (6I2). WE WERE UNABLE TO DETERMINE THE IDENTITY OF THE PILOT, HOWEVER THE FLIGHT PLAN SHOWED A MR. SHANNON K. KNOEPFLEIN AS THE PILOT IN COMMAND ON THE RFD PORTION OF THE FLIGHT. THE CLOTHING WERE BURNED OFF OF THE PILOT AND WE WERE UNABLE TO FIND ANY IDENTIFICATION ON HIS BURNED. IT WAS DETERMINED HOWEVER THAT THERE WAS ONLY ONE PILOT. THE PILOT WAS REMOVED FROM THE AIRCRAFT UTILIZING AN AUTOMOBILE WRECKER TO PICK UP THE BOTTOM HALF OF THE AIRCRAFT AND TAKEN TO THE MORGUE FOR AUTOPSY AND POSITIVE IDENTIFICATION. THE AIRCRAFT PANEL WAS PHOTOGRAPHED FOR SWITCH POSITION, ALTHOUGH VERY BADLY DAMAGED. ROBERT K. GESSERT, INSPECTOR. BELOW IS A SUMMARY OF FACTS BASED ON INFORMATION WHICH WAS RETRIEVED FROM THE AVIONICS SYSTEM INSTALLED IN THE AIRCRAFT. IT WAS POSSIBLE TO RETRIEVE THE DATE FROM THE LAST 4 FLIGHTS AS WELL AS THE FLIGHT THAT ENDED IN THE CRASH IN MADISON, WISCONSIN AUGUST 1, 2004. THIS INFORMATION IS FROM THE FLIGHT THAT DAY. THE AIRCRAFT DEPARTS KOSH AT 23:34:00 AND PROCEEDS SOUTH WHILE CLIMBING TO 12,368 FT MSL. AT 23:30:25 AN "OIL TEMPERATURE CAUTION" SHOULD HAVE BEEN DISPLAYED AT THE TRIGGER TEMPERATURE OF 220 DEGF. OIL PRESSURE HAS BEEN DECAYING SINCE TAKEOFF (69 PSI MAXIMUM) AND IS NOW AT 35 PSI (45-60 PSI IS NORMAL). AT 23:42:01 THE AIRCRAFT IS APPROXIMATELY 20.3 NM WSW FROM KMSN AND STARTS A RIGHT TURN TOWARDS KMSN. ALTITUDE IS 12,368 MSL ( 11,600 AGL). GLIDE RATIO (AS ENTERED IN THE EFIS LIMITS FILE IS 12:1 GIVING A MAXIMUM ZERO WIND GLIDE OF 22.9 NM. AVERAGE HEADWIND AS CALCULATED FROM THE AVERAGE TAS (169 KTS) MINUS THE AVERAGE GROUND SPEED (161 KTS) WAS 8 KNOTS. 8 KTS MULTIPLIED BY THE TIME FROM THE TURN TO THE LAST DATA POINT (7:57) EQUALS 1.06 NM. THE AVERAGE RATE OF CLIMB FROM THE TURN TO THE LAST DATA POINT IS -1525 FPM AND THE AVERAGE TAS IS 17144 FT/MIN GIVING AN ACTUAL GLIDE RATIO OF 11.2:1. AT 23:45:22 THE PLANE PASSES OVER 87Y BLACKHAWK AIRPORT AT 7000 AGL AT AIRSPEED OF 196 KIAS. MANIFOLD PRESSURE IS 31.8 INHG, OIL PRESSURE IS 17 PSI AND OIL TEMPERATURE IS 228 DEGREES F. BETWEEN 23:47:00 AND 23:48:00 THE OIL PRESSURE FALLS FROM 15 PSI TO 0 PSI. OIL TEMPERATURE CLIMBS FROM 270 DEG F TO 303+ DEG F WHERE IT SATURATES (SENSOR LIMIT). RPM FALLS FROM 2340 TO 1520 RPM AND THEN IMMEDIATELY TO 0, INDICATING THE MAGNETO IS TURNED OFF. THE MAGNETO IS TURNED ON 3 SECONDS LATER. THE ENGINE CONTINUES TO WINDMILL AT 1540 RPM. THE LAST ENTRY IS AT 23:49:48 AND POSSIBLY SHOWS THE NOSE PITCHES DOWN FROM +13.1 TO -16 DEGREES AND THE PLANE ROLLS LEFT FROM -35.5 TO -111.1 DEGREES (76 DEGREES/SECOND) IN 1 SECOND. THIS WAS THE IMPACT POINT WHERE THE AIRCRAFT HIT THE FIRST LIGHT POLE DURING THE EMERGENCY LANDING WITH THE LEFT WING TIP EXPOSING THE FUEL TO THE ATMOSPHERE AND IGNITING THE FUEL AS A RESULT OF ARCING AS A RESULT OF THE COLLISION WITH THE LIGHT POLE. CONTRIBUTING FACTORS: 1. AIRCRAFT WAS OPERATED IN AN EXTREME LEAN CONDITION "WAS FLOWN AGRESSIVELY" BASED ON DATA RETRIEVED FROM THE AVIONICS. 2. THE AIRCRAFT HAD INSTALLED AN UNAPPROVED SUPER CHARGER. 3. PILOT FAILED TO ESTABLISH BEST GLIDE AT THE FIRST DISCOVERY OF AN OIL PRESSURE/TEMPERATURE PROBLEM. 4. PILOT DID NOT HAVE GOOD POSITION AWARENESS AND OVER FLEW AT LEAST ONE AIRPORT THAT WOULD HAVE BEEN SUFFICIENT FOR MAKING AN EMERGENCY LANDING. 5. PILOT FAILED TO RECOGNIZE A DETERIORATING CONDITION OF HIS AIRCRAFT ENGINE EVEN AS EARLY AS THE PRECEDING FLIGHT BASED ON WITNESS STATEMENTS. 6. ENGINE EXPERIENCED PREIGNITION/DETONATION. 7. PILOT FAILED TO FOLLOW "ACCEPTED EMERGENCY PROCEDURES" FOR THIS TYPE OF EMERGENCY. IE: FAILED TO MAINTAIN BEST GLIDE AND OVER AIRPORT CIRCLE DOWN FOR THE EMERGENCY LANDING IN AN ENVIRONMENT RELATIVELY FREE OF OBSTACLES. 8. AIRCRAFT HAD NOT HAD AN ANNUAL CONDITION INSPECTION SINCE 06/17/2003, WHICH MADE IT OVER A MONTH OUT OF INSPECTION. IT MAY HAVE BEEN POSSIBLE THAT HAD THE INSPECTION BEEN ACCOMPLISHED A LOW COMPRESSION READING OF THE #3 CYLINDER MAY HAVE BEEN DISCOVERED AND REPAIRS MADE. CONTINENTAL 10-550 EXPERIMENTAL NOTABLE FINDINGS: ENGINE IS EQUIPPED WITH A "UNAPPROVED, ROLLING" TYPE BELT DRIVEN SUPERCHARGER. #3 CYLINDER TOP SPARK PLUG HAD A PIECE OF CENTER ELECTRODE PORCELAIN MISSING.#3 PISTON TOP AND SKIRT AREA WERE BURNED THRU. CONNECTING RODS FAILED AS A RESULT OF OIL STARVATION. (CRANKCASE WAS PRESSURIZED CAUSING OIL TO BE FORCED OUT THE CRANKCASE VENT). THIS IS A CLASSIC EXAMPLE OF PREIGNITION/DETONATION. ## The NTSB's investigation of this event (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB CHI04FA203](https://openairdocs.org/ntsb/CHI04FA203), Aug 1, 2004: Knoepflein Lancair Legacy 2000 (N98SN), Madison, WI, destroyed, 1 fatal. Probable cause: A loss of engine power due to high engine temperatures which resulted in a failure of the number three piston, the pilot's continued operation of the airplane with known high temperature problems,… From the FAA Accident/Incident Data System. Reports are matched to registry aircraft by N-number and event date, checked against the reported make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. For accidents, the NTSB's own investigation is the fuller record. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.