# NTSB ATL95FA087: Duke, Clarence E. Lancair 360, N360BJ, Hampton, GA, April 18, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 18, 1995, 14:13 local (18:13 UTC) - Place: Hampton, GA - Coordinates: 33.379417, -84.280258 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.3794&lon=-84.2803&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report November 30, 1995 - Report: Approved by Office Director - ADs cited in the narratives: [AD 90-04-06 R1](https://openairdocs.org/ad/90-04-06-R1) (OpenAirDocs) - NTSB case key (mKey): 3477 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL95FA087 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3477/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=3477 - Page: https://openairdocs.org/ntsb/ATL95FA087 ## Probable cause The loss of engine power for undetermined reasons. A factor in the accident was the pilot's lack of recent flying experience. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, approach - vfr pattern - downwind - reason for occurrence undetermined - Forced landing, emergency landing - Loss of control - in flight, emergency landing - aircraft control - not maintained, pilot in command (cause) - lack of recent experience, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE PILOT/BUILDER HAD JUST COMPLETED CONSTRUCTION OF THE EXPERIMENTAL HOMEBUILT AIRCRAFT. THIS WAS THE FIRST FLIGHT OF THE AIRCRAFT AFTER CONSTRUCTION. WITNESSES STATED THAT THE AIRCRAFT ENGINE SOUNDED LIKE IT LOST POWER DURING THE DOWNWIND PHASE OF THE VFR APPROACH. THE AIRCRAFT MADE A SHARP TURN TOWARD THE AIRPORT, AND IMPACTED THE TERRAIN ABOUT 600 FEET WEST OF THE APPROACH END OF RUNWAY 6. THE WITNESSES STATED THAT, AS A RESULT OF THE WIND DIRECTION, THE RUNWAY THE AIRCRAFT WAS MAKING AN APPROACH TO WAS NOT THE RUNWAY IN USE AT THE TIME. THE PILOT'S SON-IN-LAW STATED THAT THE PILOT HAD NOT DONE ANY FLYING FOR ABOUT 10 YEARS PRIOR TO THE ACCIDENT, EXCEPT FOR ABOUT 5 HOURS OF TRAINING IN A LOW PERFORMANCE AIRCRAFT JUST PRIOR TO THE ACCIDENT. ## Factual narrative HISTORY OF FLIGHT On April 18, 1995 at 1413 eastern daylight time, a Clarence E. Duke Lancair 360, N360BJ was destroyed following a collision with terrain during a forced landing attempt near Hampton, Georgia. The commercial pilot was fatally injured in the accident. The aircraft was being operated under the provisions of 14 CFR Part 91 by the pilot. Visual meteorological conditions existed at the time of the accident, and no flight plan had been filed for the personal flight. The flight departed Stockbridge, Georgia at 1330. According to witnesses, the flight was the first flight of the aircraft following certification. The aircraft was reported on downwind for landing. Witnesses stated that the engine sounded as if it were sputtering. The aircraft nose was observed to drop, and the engine sounded as if it went to full power and remained at full power until impact with the terrain. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with airplane single engine, multiengine, and instrument airplane ratings. He held a second class (limited) medical certificate, with a restriction for the use of glasses, issued December 28, 1994. No record of the pilot's flight experience could be located, however, on his FAA application for medical certificate in December of 1994, he listed his flight experience as 1,975 total hours. The pilot's son-in-law stated that the pilot had done a lot of flying many years ago, but that he had not done any flying in about 10 years prior to his starting work on this aircraft. After beginning work on this aircraft, he estimated that the pilot had flown about five hours.(See Record of Conversation With Mr. O'Conner Attached to this Report.) Additional personnel information may be obtained in this report on Page 3 under section titled First Pilot Information. AIRCRAFT INFORMATION The Duke Lancair 360 is a two place, single engine, retractable tricycle landing gear airplane. The aircraft is amateur built from a kit, and is certificated under an experimental airworthiness certificate. According to the owners work log, construction of the aircraft began in July of 1992.(See Copy of Owners Lancair Kit Work Log Attached to This Report.) METEOROLOGICAL INFORMATION Weather conditions in the area at the time of the accident were reported to be sufficient for flight under visual flight rules. Witnesses in the area stated that the winds at the time of the accident were strongly favoring runway 24. Additional meteorological information may be obtained in this report on page 3 under section titled Weather Information. WRECKAGE AND IMPACT INFORMATION The wreckage was distributed over an area approximately 375 feet in length, and the wreckage path began about 900 feet west of the approach end of Runway 06 at Tara Field in Hampton, Georgia.(See Wreckage diagram Attached to this Report for Details of Wreckage Distribution.) There was a post crash fire, and most of the composite aircraft fuselage, cockpit area, and wings were consumed in the fire. Confirmation of control continuity was not possible, due to the consumption of components in the post crash fire. The aircraft propeller was constructed of composite materials, and fractured during impact with the terrain. The accessory section of the engine was severely damaged from heat and fire. The magneto's could not be tested due to the fire damage. The engine was rotated, and continuity was confirmed through the engine, including the accessory drive train. Thumb compression was confirmed on all of the cylinders. All of the valves opened and closed during rotation. Inspection of the rocker box area revealed that the rocker arms were installed incorrectly. The exhaust rocker arms were installed on the intake side, and the intake rocker arms were installed on the exhaust side of the cylinders. A hose had been used for the propeller governor oil line. The hose was tight at both ends, and the hose was not ruptured. The hose was not properly secured as per AD 90-04-06 R1 Appendix 2. Disassembly of the carburetor revealed that the main fuel nozzle, accelerator pump, and venturi were in place. The float was made of metal, and the float bowl contained a small amount of fluid. A test of the fluid from the carburetor float bowl using water finding paste was positive for the presence of water in the fluid. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was conducted on April 18, 1995, by Dr. Gerald Gowitt of the Henry County, Georgia Medical Examiners Office. The autopsy report lists the cause of death of the pilot as blunt head trauma. A toxicology examination of the pilot was conducted by the Federal Aviation Administration Toxicology and Accident Research Laboratory of Oklahoma City, Oklahoma. The toxicology report was negative for the use of alcohol. The report showed that there was 0.046 (ug/ml, ug/g) Diphenhydramine detected in the blood, Diphenhydramine was detected in the urine, and 59.300 (ug/ml, ug/g) Salicylate detected in the urine.( See Forensic Toxicology Fatal Accident Report Attached to this Report.) Dr. Canfield of the Research Laboratory stated that Diphenhydramine was an antihistamine, and that the levels reported in the report were less than therapeutic. ADDITIONAL INFORMATION The aircraft wreckage was released to Mr. Harry Brooks, the owners insurance representative, on April 20, 1995. ## Aircraft - Registration: [N360BJ](https://openairdocs.org/deregistered/N360BJ-1997-03-12), registration cancelled 1997-03-12, S/N 51925 (OpenAirDocs) - Reported make and model: DUKE, CLARENCE E. LANCAIR 360 (LANCAIR 36) - Registry model: [Duke Clarence LANCAIR 360](https://openairdocs.org/model/duke-clarence-lancair-360) (registry code 05625J3) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 51925 - Engines: LYCOMING O-360 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Duke, Clarence E. Jr. - Airworthiness certificate: Special, Experimental (Special) - Departed: 4A0, STOCKBRIDGE, GA - Airport: 4A7, Tara Field, runway 6, 3,375 × 40 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,975 total ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: MCN, 60 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950418008269A](https://openairdocs.org/incident/19950418008269A), Apr 18, 1995: Amtr LANCAIR, Hampton, GA, Destroyed, 1 fatal. First flight after certification. Engine missed. Plane stalled. Crashed. Rocker arms installed incorrectly. ## Docket (21 files) The files NTSB released with the investigation on November 8, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=3477. 3.4 MB in all. - Supplement A (item 1, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034328&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034329&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement K (item 3, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034330&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Photo 1 - Aircraft Empennage and Remainder of Aircraft (Except for Engine and Propeller) Inside Boxes on Trailer. Photo Furnished Without Negative by Lycoming. (item 4, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034331&FileExtension=.PDF&FileName=Photo%201%20-%20Aircraft%20Empennage%20and%20Remainder%20of%20Aircraft%20(Except%20for%20Engine%20and%20Propeller)%20Inside%20Boxes%20on%20Trailer.%20%20Photo%20Furnished%20Without%20Negative%20by%20Lycoming.-Master.PDF - Photo 2 - Aircraft Propeller (Note Composite Blades) (item 5, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034332&FileExtension=.PDF&FileName=Photo%202%20-%20Aircraft%20Propeller%20(Note%20Composite%20Blades)-Master.PDF - Photo 3 - Water Finding Paste After Test For Water (Note Red Color Denotes Positive for Water) (item 6, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034333&FileExtension=.PDF&FileName=Photo%203%20-%20Water%20Finding%20Paste%20After%20Test%20For%20Water%20(Note%20Red%20Color%20Denotes%20Positive%20for%20Water)-Master.PDF - Photo 4 - Photo of Engine Rocker Arms (Note Rocker Arms Installed Incorrectly). (item 7, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034334&FileExtension=.PDF&FileName=Photo%204%20-%20Photo%20of%20Engine%20Rocker%20Arms%20(Note%20Rocker%20Arms%20Installed%20Incorrectly).-Master.PDF - Statement of Mr. Julien (item 8, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385745&FileExtension=.PDF&FileName=Statement%20of%20Mr.%20Julien-Redacted.PDF - Statement of Mr. Price (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385746&FileExtension=.PDF&FileName=Statement%20of%20Mr.%20Price-Redacted.PDF - Statement of Mr. Asbill (item 10, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385748&FileExtension=.PDF&FileName=Statement%20of%20Mr.%20Asbill-Redacted.PDF - Record of Conversation with Mr. O'Conner (item 11, .PDF, 370 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385749&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Mr.%20O%27Conner-Redacted.PDF - Wreckage Diagram of N360BJ (item 12, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034339&FileExtension=.PDF&FileName=Wreckage%20Diagram%20of%20N360BJ-Master.PDF - Copy of Application for Airworthiness Certificate Filed by Mr. Duke (item 13, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385750&FileExtension=.PDF&FileName=Copy%20of%20Application%20for%20Airworthiness%20Certificate%20Filed%20by%20Mr.%20Duke-Redacted.PDF - Copy of Weight and Balance Sheet Filed by Mr. Duke (item 14, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034341&FileExtension=.PDF&FileName=Copy%20of%20Weight%20and%20Balance%20Sheet%20Filed%20by%20Mr.%20Duke-Master.PDF - Copy of Eligibility Statement Amateur-Built Aircraft Filed by Mr. Duke (item 15, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385751&FileExtension=.PDF&FileName=Copy%20of%20Eligibility%20Statement%20Amateur-Built%20Aircraft%20Filed%20by%20Mr.%20Duke-Redacted.PDF - Copy of Mr. Duke's Lancair Kit Work Log (item 16, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40034343&FileExtension=.PDF&FileName=Copy%20of%20Mr.%20Duke%27s%20Lancair%20Kit%20Work%20Log-Master.PDF - Copy of FAA Inspector's Conformity Inspection Record for N360BJ (item 17, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385752&FileExtension=.PDF&FileName=Copy%20of%20FAA%20Inspector%27s%20Conformity%20Inspection%20Record%20for%20N360BJ-Redacted.PDF - Copy of Experimental Operating Limitations for N360BJ (item 18, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385754&FileExtension=.PDF&FileName=Copy%20of%20Experimental%20Operating%20Limitations%20for%20N360BJ-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 19, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385755&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 20, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385756&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 21, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385757&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF 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. --- 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.