# NTSB CEN11FA537: Morrison E-RACER, N345JM, Big Rock, IL, July 31, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 31, 2011, 07:48 local (12:48 UTC) - Place: Big Rock, IL - Coordinates: 41.759166, -88.514442 - Nearby events: https://openairdocs.org/map.md?lat=41.7592&lon=-88.5144&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 5, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - DuPage FSDO - NTSB case key (mKey): 81338 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11FA537 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81338/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81338 - Page: https://openairdocs.org/ntsb/CEN11FA537 ## Probable cause The pilot's failure to maintain airplane control after experiencing excessive engine cylinder head temperatures during the initial flight test of the experimental amateur-built airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Morrison John K E-RACER, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05625QT), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Morrison John K E-RACER, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05625QT), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Morrison John K E-RACER, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05625QT), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The accident occurred during the first flight test of the recently completed experimental amateur-built airplane. The tower controller cleared the flight to orbit the airport at 2,500 feet mean sea level (msl) and to make left turns. As the airplane was completing its first orbit of the airport, the pilot told the tower controller that the airplane was experiencing excessive engine cylinder head temperatures and that he would like to land. According to radar track data, the airplane was at 2,700 feet msl and had a ground speed of about 145 knots at that time. The tower controller replied that the wind was calm and that the flight was cleared to land. The pilot acknowledged the landing clearance, and no additional communications were received from the pilot. Radar track data indicated that the airplane began a left descending turn as its ground speed decreased from about 170 to 105 knots, and its descent rate increased from 650 to 2,400 feet per minute. The last radar return was about 2 miles west-southwest of the airport about 400 feet above the ground. A witness observed the accident airplane traveling about 125 feet above the ground at a high speed while in a slight left turn with its landing gear retracted. The airplane leveled its wings momentarily before it entered a left-wing-low, wings-near-vertical descent and then collided with power lines and a cornfield. The postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. No evidence of an in-flight fire was found. The extent of damage to the engine compartment and associated baffling precluded a determination of why the engine developed excessive cylinder head temperatures during the accident flight. However, excessive engine cylinder head temperatures would not have resulted in a flight controllability issue and, therefore, the pilot should have been able to maintain control of the airplane throughout the flight. The pilot had accumulated about 365 hours of flight experience in a comparable airplane. ## Factual narrative The accident airplane was a 2011 Morrison model E-Racer amateur-built airplane, serial number 186. The plans-built composite airframe was equipped with a forward canard and a rear-mounted engine. A modified 350-horsepower Lycoming model O-540-A1D5 reciprocating engine, serial number L-1135005-40, powered the airplane. The stock Lycoming O-540-A1D5 engine had been modified with a fuel injection system and an electronic coil-on-plug ignition system. These engine design modifications resulted in an experimental engine classification. The airplane was equipped with a fixed pitch, three blade, Catto Propellers wood propeller. The accident airplane was issued an experimental airworthiness certificate on July 8, 2011. The accident occurred during the airplane's first flight. A postaccident review of the available maintenance records found no history of unresolved airworthiness issues. The Aurora Municipal Airport (ARR), located about 1 mile northwest of Sugar Grove, Illinois, was served by three runways: 9/27 (6,501 feet by 100 feet, concrete); 15/33 (5,503 feet by 100 feet, concrete); and 18/36 (3,198 feet by 75 feet, asphalt). The airport elevation was 712 feet mean sea level (msl). On July 31, 2011, at 0748 central daylight time, an experimental amateur-built Morrison model E-Racer airplane, N345JM, was destroyed when it collided with power lines and terrain while maneuvering during a test flight near Big Rock, Illinois. The pilot was fatally injured. The airplane was registered to and operated by the private pilot under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the local flight that departed the Aurora Municipal Airport (ARR), Sugar Grove, Illinois, at 0744. The accident occurred during the airplane's first flight since being issued an experimental category airworthiness certificate. According to air traffic control data, the pilot contacted ground control at 0739:33 (hh:mm:ss) for a taxi clearance to runway 27. The pilot told the ground controller that it was the airplane's first flight and that he wanted to orbit the airport at 2,500 feet mean sea level (msl). At 0742:27, the pilot contacted the control tower for a takeoff clearance on runway 27. The tower controller cleared the flight for takeoff on runway 27 and to orbit the airport at 2,500 feet msl, making left turns. Radar track data initially depicted the airplane at 900 feet msl, west of the departure end of runway 27, in a climbing left turn. The airplane climbed to 2,600 feet msl while maintaining a 1 to 2 mile radius from the airport. At 0747:29, as the airplane was completing its first orbit of the airport, the pilot told the tower controller that the airplane was experiencing excessive engine cylinder head temperatures and that he would like to land. According to radar track data, the airplane was at 2,700 feet msl and had a ground speed of about 145 knots at that time. The tower controllerreplied that the wind was calm and that the flight was cleared to land on either runway 27 or runway 9. At 0747:42, the pilot replied that he would land on runway 27. There were no additional communications received from the pilot. After the pilot reported having excessive engine cylinder head temperatures, radar track data indicated that the airplane began a descending left turn about 1.5 miles from the airport. The airplane's ground speed decreased from about 170 knots to 105 knots during the final 18 seconds of recorded radar data. During the same time period, the airplane descent rate increased from 650 feet per minute to 2,400 feet per minute. At 0748:10, the last radar return was recorded about 2.2 miles west-southwest of ARR at 1,100 feet (about 400 feet above the ground). A witness, who was also a certificated pilot, observed the airplane flying at a low altitude, between 100 to 150 feet above the ground, immediately north of Granart Road. The airplane was traveling at a high ground speed in a slight left turn with its landing gear retracted. The airplane leveled its wings momentarily before it entered a left wing low, wings near vertical, descent. The airplane collided with power lines and a cornfield while in the near vertical descent. On June 30, 2011, an autopsy was performed on the pilot by the Kane County Coroner's Office located in Geneva, Illinois. The cause of death for the pilot was attributed to multiple blunt-force injuries sustained during the accident. The FAA's Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on samples obtained during the pilot's autopsy. No ethanol was detected. Diphenhydramine was detected in liver and kidney samples. Diphenhydramine, trade name Benadryl, is an over-the-counter sedating antihistamine used to treat seasonal allergies. Famotidine was detected in kidney samples. Famotidine, trade name Pepcid, is an over-the-counter histamine that inhibits stomach acid production. Quinine was detected in liver samples. Quinine is an anti-malarial used in the treatment of malaria and leg cramps; however, it is also an additive used in tonic water and in over-the-counter nutritional supplements. At 0752, the ARR automated surface observing system (ASOS) reported: calm wind, visibility 7 miles, clear sky, temperature 23 degrees Celsius, dew point 20 degrees Celsius, and an altimeter setting of 30.13 inches of mercury. According to Federal Aviation Administration (FAA) records, the pilot, age 73, held a private pilot certificate with a single engine land airplane rating. His last aviation medical examination was completed on July 6, 2011, when he was issued a third-class medical certificate with a restriction for corrective lenses. The most recent pilot logbook entry was dated July 15, 2007. At that time, the pilot had accumulated 382 hours total flight time. The logbook indicated that all of his flight experience had been completed in single-engine land airplanes.The last documented flight review was completed on November 18, 2006, in a Cessna 172. On September 12, 2000, the pilot had a forced landing accident in another Morrison model E-Racer, serial number 113 (not the accident airplane). The National Transportation Safety Board (NTSB) final report attributed the loss of engine power to the pilot/builder's modification of the engine air intake system that resulted in an excessive fuel flow to the manifold. The pilot reported having accumulated 191 hours total time in all aircraft and 24 hours in the Morrison model E-Racer at the time of the September 2000 accident. On June 21, 2008, the pilot experienced an inflight fire accident in the same airplane that was involved in the September 2000 accident. The airplane, serial number 113, was destroyed during the accident. The NTSB final report attributed the inflight fire to an unspecified failure within the high-pressure fuel system. The pilot reported having accumulated 490 hours total time in all aircraft and 365 hours in the Morrison model E-Racer at the time of the June 2008 accident. According to FAA records, on July 6, 2011, the pilot reported having 502 hours total flight experience when he applied for his current medical certificate. Additionally, he reported that he had not flown during the 6 months before the medical examination. The pilot's previous medical certificate was issued on November 4, 2006, at which time he reported having 320 hours total flight experience. A postaccident investigation confirmed that all airframe structural and flight control components were located at the accident site. The initial impact point was beneath a set of power lines, located about 20 feet south of Granart Road. The initial impact consisted of a ground depression that was consistent in size and shape as the leading edge of the outboard section of the airplane's left wing and associated winglet. The ground depression extended about 15 feet into the cornfield and was consistent with the length of the entire left wing. The main impact crater was located in the cornfield, about 40 feet east of power lines. The main wreckage consisted of the entire airframe, flight controls, engine, and propeller. All observed structural component failures were consistent with overstress separation. The entire fuselage was fragmented. Both wings had separated from the fuselage. There were three power lines found entangled with the right wing, which were located 7 inches, 45 inches, and 121 inches outboard of the wing root. The power lines had penetrated the right wing leading edge, and extended aft to the main wing spar. The left wing exhibited leading edge damage. The canard and elevator were found in several pieces. The split-rudder surfaces remained attached to their respective vertical stabilizers. Flight control continuity could not be established due to the extent of the damage; however, all observed flight control system discontinuities were consistent with overstress.There was no evidence of an inflight fire. The engine remained attached to the aft fuselage bulkhead/firewall, which had separated from the fuselage. The engine compartment and associated baffling were destroyed during the accident. Internal engine and valve train continuity was confirmed as the engine crankshaft was rotated. Compression and suction were noted on all cylinders in conjunction with crankshaft rotation. The upper spark plugs were removed and exhibited features consistent with normal engine operation. A functional test of the electronic coil-on-plug ignition system was not possible due to the extent of damage. There were no obstructions between the air filter housing and the fuel servo. The fuel supply line to the fuel servo contained fuel consistent in appearance with 100-low lead aviation fuel. A fuel sample was free of any water or particulate contamination. The fuel inlet screen was free of any particulate contamination. The propeller remained attached to the engine crankshaft. One of the three propeller blades was fractured near the hub. The remaining two propeller blades remained attached to the hub and were undamaged. The postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The extent of damage to the engine compartment and associated baffling precluded a determination of why the engine had developed excessive cylinder head temperatures during the accident flight. Additionally, although the airplane was equipped with an electronic flight information system, the individual components were not configured and/or equipped to record flight data. ## Aircraft - Registration: [N345JM](https://openairdocs.org/deregistered/N345JM-2017-10-25), registration cancelled 2017-10-25, S/N 186, built 2011 (OpenAirDocs) - Reported make and model: MORRISON E-RACER - Registry model: [Morrison John K E-RACER](https://openairdocs.org/model/morrison-john-k-e-racer) (registry code 05625QT) (OpenAirDocs) - Registry engine: [Lycoming O-540-A1D5](https://openairdocs.org/engine/lycoming-o-540-a1d5) (registry code 42324, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 186 - Airframe hours: 0 - Engines: Lycoming (Modified) O-540-A1D5 reciprocating - Damage: Destroyed - Flight: Flight test, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, July 8, 2011, 0 hours before - Departed: ARR, Sugar Grove, IL - Destination: ARR, Sugar Grove, IL - Airport: ARR, Aurora Municipal Airport, runway 27, 6,501 × 100 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 18, 2006; seat: left; restraint: 4-point; toxicology performed; flight hours: 502 total, 365 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 68 °F - Altimeter: 30.12 inHg - Observed at: ARR, 2 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 20110731018279A](https://openairdocs.org/incident/20110731018279A), Jul 31, 2011: Morrison John K E-RACER, Big Rock, IL, Destroyed, 1 fatal. Shortly after departure from the aurora airport (arr) in sugar grove Illinois. The pilot reported high cylinder head temperature and wanted to return to the… ## Docket (22 files) The files NTSB released with the investigation on May 29, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81338. 8.3 MB in all. - ATC Transcripts (Provided by FAA) (item 1, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412821&FileExtension=.PDF&FileName=ATC%20Transcripts%20(Provided%20by%20FAA)-Master.PDF - Radar Data, Overview of Accident Flight (item 2, .PDF, 404 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412822&FileExtension=.PDF&FileName=Radar%20Data,%20Overview%20of%20Accident%20Flight-Master.PDF - Radar Data, Performance Plots (item 3, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412823&FileExtension=.PDF&FileName=Radar%20Data,%20Performance%20Plots-Master.PDF - Witness Statements (item 4, .PDF, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412824&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - FAA Airworthiness Documentation (item 5, .PDF, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412825&FileExtension=.PDF&FileName=FAA%20Airworthiness%20Documentation-Redacted.PDF - Airframe Logbook (item 6, .PDF, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412826&FileExtension=.PDF&FileName=Airframe%20Logbook-Redacted.PDF - Engine Logbook (item 7, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412827&FileExtension=.PDF&FileName=Engine%20Logbook-Redacted.PDF - Photos Taken of Completed Airplane Before Accident (Photos Provided in .pdf by Pilot's Family) (item 8, .PDF, 5 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412828&FileExtension=.PDF&FileName=Photos%20Taken%20of%20Completed%20Airplane%20Before%20Accident%20(Photos%20Provided%20in%20.pdf%20by%20Pilot%27s%20Family)-Master.PDF - Pilot Logbook (item 9, .PDF, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412829&FileExtension=.PDF&FileName=Pilot%20Logbook-Redacted.PDF - Weather Reports (item 10, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412830&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF - Toxicology Report - Pilot (item 11, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412831&FileExtension=.PDF&FileName=Toxicology%20Report%20-%20Pilot-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412832&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Accident Site Overview (item 13, .PDF, 551 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412833&FileExtension=.PDF&FileName=Photo%201.%20Accident%20Site%20Overview-Master.PDF - Photo 2. Accident Site Overview (item 14, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412834&FileExtension=.PDF&FileName=Photo%202.%20Accident%20Site%20Overview-Master.PDF - Photo 3. Accident Site Overview (item 15, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412835&FileExtension=.PDF&FileName=Photo%203.%20Accident%20Site%20Overview-Master.PDF - Photo 4. Wreckage Layout, Forward Right Side (item 16, .PDF, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412836&FileExtension=.PDF&FileName=Photo%204.%20Wreckage%20Layout,%20Forward%20Right%20Side-Master.PDF - Photo 5. Wreckage Layout, Aft Left Side (item 17, .PDF, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412837&FileExtension=.PDF&FileName=Photo%205.%20Wreckage%20Layout,%20Aft%20Left%20Side-Master.PDF - Photo 6. Wreckage Layout, Aft Right Side (item 18, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412838&FileExtension=.PDF&FileName=Photo%206.%20Wreckage%20Layout,%20Aft%20Right%20Side-Master.PDF - Photo 7. Wreckage Layout, Right Wing (item 19, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412839&FileExtension=.PDF&FileName=Photo%207.%20Wreckage%20Layout,%20Right%20Wing-Master.PDF - Photo 8. Engine, Right Side of Airplane (item 20, .PDF, 310 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412840&FileExtension=.PDF&FileName=Photo%208.%20Engine,%20Right%20Side%20of%20Airplane-Master.PDF - Photo 9. Engine, Left Side of Airplane (item 21, .PDF, 310 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412841&FileExtension=.PDF&FileName=Photo%209.%20Engine,%20Left%20Side%20of%20Airplane-Master.PDF - Photo 10. Propeller (item 22, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40412842&FileExtension=.PDF&FileName=Photo%2010.%20Propeller-Master.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.