# NTSB CEN11LA374: Malkin Roy K Searey, N242RM, Minneapolis, MN, June 4, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 4, 2011, 18:37 local (23:37 UTC) - Place: Minneapolis, MN - Coordinates: 45.061943, -93.353889 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.0619&lon=-93.3539&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report December 27, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Admininstration - NTSB case key (mKey): 79310 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA374 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79310/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79310 - Page: https://openairdocs.org/ntsb/CEN11LA374 ## Probable cause The pilot's failure to maintain adequate airspeed during takeoff, which resulted in an inadvertent stall. Contributing to the accident was the degraded engine performance due to the improper servicing and maintenance of the fuel system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Damaged/degraded; cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=05619RK), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition; cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05619RK), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not serviced/maintained (probable cause); cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05619RK), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=05619RK), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05619RK), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05619RK), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Malkin Roy K SEAREY, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05619RK), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to an air traffic controller, shortly after takeoff, approximately 50 to 100 feet above ground level, the pilot contacted the tower controller and stated "...we're gonna," and the transmission ended. The tower controller said that when the airplane reached the departure end of the runway, the airplane entered a left bank and impacted terrain. The airplane came to rest inverted, adjacent to the runway. A postaccident examination of the airplane revealed that the engine's fuel system contained brownish fluid, consistent with old and dirty automotive fuel. The pilot stated that he did not service the airplane with fuel prior to takeoff and that the airplane hadn’t been flown in at least 6 months. A postaccident examination revealed that the fuel system hoses were cracked and degraded, and one fuel line was improperly modified. Further, a conditional inspection of the airplane had not been completed in the previous 3 years. The engine was test run postaccident with fresh automotive fuel, and it ran normally for about 5 minutes at various power settings. Based on the tower controller's description of the accident sequence, it is likely the airplane entered an aerodynamic stall shortly after takeoff. It is also likely that the improper servicing and maintenance of the fuel system could have contributed to degraded engine performance. ## Factual narrative On June 4, 2011, at 1837 central daylight time, a Malkin SeaRey experimental amateur-built airplane, N242RM, sustained substantial damage when it impacted terrain shortly after takeoff from Crystal Airport (MIC), Minneapolis, Minnesota. The commercial pilot and passenger sustained serious injuries. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The local flight was originating at the time of the accident. According to air traffic control communications and witness information, at 1833, the pilot contacted the MIC air traffic control tower (ATCT) for taxi clearance to runway 32R for takeoff. The pilot stated his intentions were to remain in the traffic pattern and perform some touch and go's, then possibly depart the MIC area to the west. Shortly after takeoff, approximately 50 to 100 feet above ground level, the pilot contacted the ATCT and stated, "...we're gonna" and the transmission ended. The MIC local controller observed the airplane not producing the normal amount of lift, and when the airplane reached the departure end of runway 32R, the airplane entered a left bank and impacted terrain. The airplane came to rest inverted adjacent to the runway. During a telephone conversation with the pilot, he reported that he had very little recollection of the events prior to and during the accident flight. The pilot did not fuel the airplane prior to the flight, and he estimated the fuel tank contained approximately 6 gallons of fuel. The accident flight was the pilot and airplane's first flight in the calendar year 2011. The pilot stated he typically obtained fuel from a local automotive gas station near MIC. A review of the aircraft logbooks showed the most recent conditional inspection was completed on May 3, 2008, at a total time of 93.8 hours. The pilot confirmed this was the most recent conditional inspection. On June 21, 2011, a postaccident examination of the airframe and engine was conducted by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), two Federal Aviation Administration inspectors, and a representative from engine manufacturer. The forward fuselage was crushed and fragmented. The outboard two-thirds of the left wing was crushed upward and aft. The outboard one-third of the right wing was crushed downward and aft. The flap handle was found in the first detent position. Flight control continuity was established from the cockpit controls to the flight control surfaces. Approximately 40 pounds of lead weight ballast were found within the wreckage, which the pilot reported he typically used when he flew the airplane solo. The Rotax 912ULS-2 engine remained attached to the airframe, and the three blade composite propeller remained attached to the engine. One of the blades was fractured at mid-span and the other two blades remained intact. The propeller wasrotated by hand and thumb compression and suction was noted on all four cylinders. Both carburetor bowls were removed and a brownish fluid was noted in each bowl. The fluid was tested with a water finding paste and the test results were negative for water content. The float bowl gaskets were made of original cork material. Replacement gaskets supplied by the manufacturer were a paper type material, and the gaskets are recommended by the manufacturer to be changed during a conditional or 100-hour inspection. Both carburetor slides were manipulated by hand and were free to move. Both carburetor air inlet filter elements displayed a brownish color rather than their normal pink color. The engine was not equipped with carburetor heat system. The mechanical pump inlet fuel hose was found to have the last 5 inches reduced from a 5/16 inch inner diameter hose to a 1/4 inch inner diameter hose. The manufacturer required a uniform 5/16 inch fuel hose. The reduced hose section was found crazed and cracked in multiple locations. The fuel pump was removed and a small amount of brownish fluid was noted within the pump, consistent with the carburetor float bowl fluid. The engine coolant expansion cap rubber seal was dislodged and found folded over. Fresh auto fuel was added to the carburetor bowls, a slave fuel tank was connected to the fuel inlet line, and an engine start was attempted. Prior to the engine test run, the propeller blades were cut near the blade root for safety precautions. The engine was test run at various power settings for approximately 5 minutes with no anomalies noted. The cockpit engine controls were used to control the engine power settings during the engine test run. The pilot did not submit a completed Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1) as requested by the NTSB IIC. ## Aircraft - Registration: [N242RM](https://openairdocs.org/deregistered/N242RM-2017-04-24), registration cancelled 2017-04-24, S/N 1MK369C, built 2005 (OpenAirDocs) - Reported make and model: MALKIN ROY K SEAREY - Registry model: [Malkin Roy K SEAREY](https://openairdocs.org/model/malkin-roy-k-searey) (registry code 05619RK) (OpenAirDocs) - Registry engine: [Rotax SEE BOMBADIER](https://openairdocs.org/engine/rotax-see-bombadier) (registry code 55555, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1MK369C - Airframe hours: 94 - Engines: ROTAX 912ULS-2 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Malkin Roy K - Registered owner: Malkin Roy K - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, May 3, 2008 - Departed: MIC, Minneapolis, MN - Destination: MIC, Minneapolis, MN - Airport: MIC, Crystal Airport, runway 32R, 3,263 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; flight instructor, commercial; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3; last flight review December 2, 2010; seat: left; flight hours: 3,800 total, 100 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 48 °F - Altimeter: 30.10 inHg - Observed at: MIC ## 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 20110604012039A](https://openairdocs.org/incident/20110604012039A), Jun 4, 2011: Malkin Roy K SEAREY, Crystal, MN, Destroyed. Arrived on scene 06/04/2011 at 1915. Took numerous photos of experimental Searey in an inverted position located in between the parallel runways on 32R/L at… ## Docket (13 files) The files NTSB released with the investigation on November 14, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79310. 4.4 MB in all. - Record of Conversation - Pilot (item 1, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356171&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Summary of ATCT Communications Audio File (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357777&FileExtension=.PDF&FileName=Summary%20of%20ATCT%20Communications%20Audio%20File-Master.PDF - Excerpts of Police Report (item 3, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356174&FileExtension=.PDF&FileName=Excerpts%20of%20Police%20Report-Redacted.PDF - Maintenance Logbook Entry (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356175&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Entry-Redacted.PDF - Engine Manufacturer Report (item 5, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356177&FileExtension=.PDF&FileName=Engine%20Manufacturer%20Report-Master.PDF - Photo 1 - View of Aircraft Wreckage (item 6, .PDF, 496 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356178&FileExtension=.PDF&FileName=Photo%201%20-%20View%20of%20Aircraft%20Wreckage-Master.PDF - Photo 2 - View of Left Wing (item 7, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356179&FileExtension=.PDF&FileName=Photo%202%20-%20View%20of%20Left%20Wing-Master.PDF - Photo 3 - View of Right Wing (item 8, .PDF, 359 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356191&FileExtension=.PDF&FileName=Photo%203%20-%20View%20of%20Right%20Wing-Master.PDF - Photo 4 - View of Carburetor Filters (item 9, .PDF, 296 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356181&FileExtension=.PDF&FileName=Photo%204%20-%20View%20of%20Carburetor%20Filters-Master.PDF - Photo 5 - View of Carburetor Fuel Bowl (item 10, .PDF, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356182&FileExtension=.PDF&FileName=Photo%205%20-%20View%20of%20Carburetor%20Fuel%20Bowl-Master.PDF - Photo 6 - View of Mechanical Fuel Pump and Fuel (item 11, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356183&FileExtension=.PDF&FileName=Photo%206%20-%20View%20of%20Mechanical%20Fuel%20Pump%20and%20Fuel-Master.PDF - Photo 7 - View of Fuel Line (item 12, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356184&FileExtension=.PDF&FileName=Photo%207%20-%20View%20of%20Fuel%20Line-Master.PDF - Photo 8 - View of Engine Coolant Cap (item 13, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356186&FileExtension=.PDF&FileName=Photo%208%20-%20View%20of%20Engine%20Coolant%20Cap-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.