# NTSB CEN17LA009: Aero Smart Solutions Lancair Evolution, N38DM, Iola, KS, October 1, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: October 1, 2016, 17:35 local (22:35 UTC) - Place: Iola, KS - Coordinates: 37.924446, -95.400001 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.9244&lon=-95.4000&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report August 3, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 94133 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA009 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94133/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94133 - Page: https://openairdocs.org/ntsb/CEN17LA009 ## Probable cause Water contamination of the fuel due to the pilot’s inadequate preflight inspection, which led to a total loss of engine power. Contributing to the accident was the pilot’s failure to complete the engine-out checklist, which resulted in an excessive loss of altitude and the inability to glide to the intended airport. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=056322V), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=056322V), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Engine (turbine/turboprop)](https://openairdocs.org/ntsb-findings/01057200): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/01057200/cases.md?model=056322V), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01057200/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=056322V), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=056322V), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=056322V), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Enroute-climb to cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=056322V), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aero Smart Solutions LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056322V), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was flying the airplane in cruise flight at 11,000 ft when the engine lost power. He attempted to restart the engine by switching fuel tanks, turning on the igniters, and holding down the start button but was unsuccessful. He elected to turn back toward the departure airport and feathered the propeller. During the descent, the pilot decided he was unable to make it back to the airport and conducted a forced landing on a dirt road. During the landing rollout, both wings struck trees, which resulted in substantial damage. Examination of the flight controls, engine, and fuel systems revealed no mechanical malfunctions or failures that would have precluded normal operation. However, fuel samples recovered from the airplane tested positive for water. Data recovered from the engine monitor showed an abrupt power loss that coincided with a loss of fuel flow. The flight instructor who completed transition training with the pilot reported the pilot did not sump the fuel before every flight. Thus, it is likely that the pilot did not perform an adequate preflight inspection and water remained in the fuel system, which led to a total loss of engine power. The pilot's operating handbook (POH) recommended that the configuration for a forced landing is landing gear up, flaps up, propeller feathered, and airspeed at 110 knots to achieve maximum glide performance. This configuration provides a maximum glide performance of about 500 ft per minute (fpm) descent and about 3.5 nautical miles glide distance per 1,000 ft of altitude lost. Data from the engine monitoring system revealed that, about 3 minutes after the fuel flow stopped and about 2-3 minutes before the accident, the flaps were extended to takeoff position, the airplane achieved 110 kts, and the propeller was feathered. During this time, the rate of descent exceeded 1,000 fpm and was, at times, in excess of 4,000 fpm. The pilot did not mention of the use of an emergency engine-out checklist or consultation of the POH during the event. The pilot's failure to accomplish all of the steps in the emergency engine-out checklist promptly after the loss of engine power led to an accelerated loss of altitude and the subsequent inability to glide to the airport. ## Factual narrative According to the POH, the recommended configuration for a forced landing is landing gear up, flaps up, propeller feathered, and airspeed at 110 knots. This configuration provides a maximum glide performance of about 500 fpm descent, an 18:1 glide ratio, and about 3.5 nm glide distance per 1,000 ft of altitude lost. Pratt & Whitney Service Bulletin 12144, Turboprop Engine Fuels and Additives - Requirements and Approved Listing, states, "Fuel shall consist solely of hydrocarbon compounds except as otherwise specified herein. It shall be free from water, sediment, and suspended matter, and shall be suitable for use in aircraft turbine engines." The Lancair Evolution Pilot Operating Handbook (POH) highlights the importance of sumping fuel and checking fuel quality on preflight and after refueling. The POH states, "The fuel system feeds fuel to the engine through a fuel screen pickup, fuel selector, gascolator/fuel filter, electric boost pump ad finally a fuel control unit. The fuel tanks should be sumped at regular intervals." Fuel sumping is also called for in the preflight inspection checklist contained in the POH. On October 1, 2016, about 1735 central daylight time, an Aero Smart Solutions Lancair Evolution airplane, N38DM, experienced a total loss of engine power during cruise flight. The pilot made a forced landing onto a roadway near Iola, Kansas. The private pilot was not injured and the passenger suffered minor injuries. The airplane was registered to, and operated by, Aero Smart Solutions, Inc. under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and an instrument flight rules flight plan was filed. The pilot stated he had just departed after stopping to refuel at Allen County Airport (K88) in Iola, Kansas. Shortly after departure, air traffic control (ATC) cleared the pilot to his destination of Ogden-Hinckley Airport (OGD) in Ogden, Utah. The pilot reported he switched from the left fuel tank to the right fuel tank, he did not recall when he made the switch. Around 11,000 ft, the pilot heard the pitch of the engine "drastically change." Immediately following that, the pilot heard an alarm from the engine monitoring instrument which showed the oil pressure had decreased to "0." The pilot did not notice any instrument indications before the engine lost power. The pilot pushed the nose over, and switched fuel tanks from the right to the left. He turned on the igniters and held the start button down but there were no changes to the engine power. The pilot called ATC and declared an emergency. He used his GPS to return directly back to K88, and the controller also provided a vector. The pilot feathered the propeller and it completely stopped rotating; the pilot noticed a billow of smoke out of the right exhaust pipe. At that time, the airplane was about 6,500 ft and 8-9 miles from the airport. About 6 miles from the airport, the pilot decided hewas unable to make it back to the airport. He saw an open dirt road and decided to conduct a forced landing on the road. During the landing rollout, the roadway became tree-lined and both wings were substantially damaged due to impact with trees. The raw, unsmoothed data from the engine monitoring system indicated normal flight parameters until 17:29:35 when the fuel flow abruptly dropped to zero. The flaps were extended at 17:32:33 to about 16°, or takeoff position, and remained at 16° until the end of the flight. The airplane achieved 110 knots, best glide speed, at 17:32:35. The propeller was feathered at 17:33:10. Figure 1 depicts these events during the flight. From 17:29:48 until 17:33:18 the rate of descent exceeded 1,000 ft per minute (fpm) and was, at times, in excess of 4,000 fpm. During that 3.5-minute period, the airplane descended from about 11,900 ft to about 3,560 ft, an average descent rate of nearly 2,300 ft per minute. In multiple statements provided by the pilot, there was no mention of the use of an emergency engine out checklist or consultation of the pilot operating handbook (POH) during the event. Figure 1: Plot of Flight Track with Control Inputs Depicted The pilot's flight instructor who completed transition training with the pilot stated the pilot did not sump the fuel before every flight. The instructor also explained that he advised his students that the engine can tolerate some water. The instructor did not mention addressing the pilot's lack of a proper preflight inspection or advise the pilot that sumping the fuel was necessary. The airplane came to rest on the side of a tree-lined dirt roadway with substantial damage to both wings, the engine, and the empennage from tree strikes. The left wingtip separated about 9 ft outboard of the fuselage. The right wingtip separated just outboard of the fuel cap. The engine mounts were separated from the firewall, and the propeller blades had separated from the hub. The main and nose landing gear were separated. Fuel samples were collected from 4 locations within the fuel system: the fuel control unit, fuel/oil heat exchanger, fuel lines to/from the fuel pump, and the fuel filter. Federal aviation Administration (FAA) inspectors performed testing on the fuel samples collected from the fuel control and fuel filter using a Kolor Kut water finding paste. All 4 samples tested positive for water contamination. The fuel control unit (FCU) and fuel pump were examined and tested by the engine manufacturer. The FCU test results were consistent with typical field adjustment for operation. Corrosion was noted on the fuel pump; however, it performed satisfactorily during testing. An examination revealed no preimpact anomalies with the flight controls, engine, or fuel system that would have precluded normal operation. ## Aircraft - Registration: [N38DM](https://openairdocs.org/deregistered/N38DM-2022-12-31), registration cancelled 2022-12-31, S/N EVO-0047, built 2013 (OpenAirDocs) - Reported make and model: AERO SMART SOLUTIONS INC LANCAIR EVOLUTION (NO SERIES) - Registry model: [Aero Smart Solutions LANCAIR EVOLUTION](https://openairdocs.org/model/aero-smart-solutions-lancair-evolution) (registry code 056322V) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-42](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-42) (registry code 52062, turbo-prop) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: EVO-0047 - Year built: 2013 - Airframe hours: 442 - Engines: P&W CANADA PT6A-42 850 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Aero Smart Solutions Inc - Registered owner: Aero Smart Solutions Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 24, 2016 - Departed: K88, IOLA, KS - Destination: OGD, OGDEN, UT - Flight plan: IFR - Equipment: ADS-B, Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review October 17, 2015; seat: left; restraint: 3-point; flight hours: 1,660 total, 359 in this make and model, 1,660 as pilot in command, 95 in the last 90 days, 37 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Temperature: 73 °F, dew point 48 °F - Altimeter: 30.04 inHg - Observed at: K88 ## 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 20161001021179A](https://openairdocs.org/incident/20161001021179A), Oct 1, 2016: Aero Smart Solutions Inc LANCAIR EVOLUTION, Iola, KS, Substantial damage. On oct 1st 2016 while enroute from raleigh north carolina to huntsville Utah, [privacy data omitted] of Lancair Evolution sn EVO-0047/N38DM with one passenger… ## Docket (15 files) The files NTSB released with the investigation on June 2, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94133. 19.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484047&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement from Lancair Enthusiasts Blog (item 2, .PDF, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484048&FileExtension=.PDF&FileName=Pilot%20Statement%20from%20Lancair%20Enthusiasts%20Blog-Master.PDF - Photographs of the Accident Site and Fuel Sample Testing Results (item 3, .PDF, 2 photos, 521 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484049&FileExtension=.PDF&FileName=Photographs%20of%20the%20Accident%20Site%20and%20Fuel%20Sample%20Testing%20Results-Master.PDF - GPS track (Plot) (item 4, .PDF, 459 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484050&FileExtension=.PDF&FileName=GPS%20track%20(Plot)-Master.PDF - Memorandum of Record for Wreckage Exam (item 5, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484051&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20for%20Wreckage%20Exam-Master.PDF - Memorandum of Record with Pilot's CFI (item 6, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484052&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20with%20Pilot%27s%20CFI-Master.PDF - Multiple Electronic Devices - Specialist's Factual Report (item 7, .PDF, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484053&FileExtension=.PDF&FileName=Multiple%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Multiple Electronic Devices - Attachment 1 (MVP-50P) - Tabular Data (CSV) (item 8, .CSV, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484054&FileExtension=.csv&FileName=Multiple%20Electronic%20Devices%20-%20Attachment%201%20(MVP-50P)%20-%20Tabular%20Data%20(CSV)-Master.csv - Multiple Electronic Devices - Attachment 2 (Garmin G900X SD Card) - Tabular Data (CSV) (item 9, .CSV, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484055&FileExtension=.csv&FileName=Multiple%20Electronic%20Devices%20-%20Attachment%202%20(Garmin%20G900X%20SD%20Card)%20-%20Tabular%20Data%20(CSV)-Master.csv - Relevant POH Sections for Fuel Sumping, Engine Failures, and Forced Landings (item 10, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484056&FileExtension=.PDF&FileName=Relevant%20POH%20Sections%20for%20Fuel%20Sumping,%20Engine%20Failures,%20and%20Forced%20Landings-Master.PDF - Fuel Debris Examination (item 11, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484057&FileExtension=.PDF&FileName=Fuel%20Debris%20Examination-Master.PDF - Lancair Owners and Builders Organization Factual Report (item 12, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484058&FileExtension=.PDF&FileName=Lancair%20Owners%20and%20Builders%20Organization%20Factual%20Report-Master.PDF - Pratt & Whitney Engine Report (item 13, .PDF, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484059&FileExtension=.PDF&FileName=Pratt%20%26%20Whitney%20Engine%20Report%20-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484060&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 15, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40484061&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.