# NTSB CEN21LA243: Phillips Ralph W Vans RV8, N274CV, San Angelo, TX, May 27, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: May 27, 2021, 18:25 local (23:25 UTC) - Place: San Angelo, TX - Coordinates: 31.358029, -100.50069 - Nearby events: https://openairdocs.org/map.md?lat=31.3580&lon=-100.5007&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 103180 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA243 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103180/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103180 - Page: https://openairdocs.org/ntsb/CEN21LA243 ## Probable cause The loss of engine power due to fuel starvation. Contributing to the accident was the installation of a reduced flow fitting in the fuel line to the carburetor by maintenance personnel. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05619RA), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect service/maintenance; cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=05619RA), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Incorrect service/maintenance; cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05619RA), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05619RA), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05619RA), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Takeoff: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Phillips Ralph W VANS RV8, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=05619RA), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) ## Analysis Shortly after takeoff, the pilot reported an “engine failure” to the airport tower controller. The airplane impacted terrain off the end of the runway. The airplane came to rest upright, with substantial damage to the fuselage and wings during the accident. The airplane had undergone maintenance with the installation of a new glass panel system, and the accident flight was the first flight after the installation. The avionic shop drained about 40 gallons of fuel from the tanks and added the fuel back for calibration. The installation of the glass panel also added a fuel flow transducer tothe fuel line, between the pressure side of the engine driven fuel pump and carburetor. The engine-driven fuel pump outflow fitting had two fittings installed. The 3/8’s port was capped off with an AN929 fitting. The other port had a number 4 reduced flow fitting installed in the fuel line leading to the carburetor (through the fuel flow transducer). The reduced flow fitting would have prevented sufficient fuel flow to the carburetor once the fuel in the carburetor was consumed. The accident is consistent with the loss of engine power due to fuel starvation. ## Factual narrative On May 27, 2021, about 1825 central daylight time, a Vans RV-8 airplane, N274CV, was substantially damaged when it was involved in an accident near San Angelo, Texas. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations personal flight. Shortly after takeoff, the airplane came to rest upright, with substantial damage to the fuselage and wings. The responding Federal Aviation Administration (FAA) inspector reported that the fuel tanks seemed empty but appeared to have been breached in the accident. The airplane had undergone maintenance with the installation of a Garmin G3 system, and the accident flight was the first flight after the installation. He also noted that the avionic shop drained about 40 gallons of fuel from the tanks and added the fuel back for calibration. The airplane was recovered to a salvage yard, where the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) conducted an examination. The top set of sparkplugs were removed from each cylinder, and the engine rotated by hand. Continuity through the valve train and to the accessory section was noted. The left and right magnetos were removed and, when rotated, produced a spark on each terminal. The fuel system was equipped with a fuel flow transducer located in the fuel line between the pressure side of the engine-driven fuel pump and carburetor (see figure 1). The addition of the fuel flow transducer was required to provide fuel flow reading on the new panel. Figure 1: “Red Cube” Fuel Flow Transducer The pressure side of the engine driven fuel pump outflow fitting had two fittings installed. The 3/8’s port was capped off with an AN929 fitting. The other port had a number 4 fitting installed in the fuel line (which ran to the fuel flow transducer – see figure 2 & 3). Figure 2: Fuel Line as it exited to the Engine Driven Fuel Pump Figure 3: Fuel Pump Fittings ## Aircraft - Registration: [N274CV](https://openairdocs.org/deregistered/N274CV-2023-01-14), registration cancelled 2023-01-14, S/N 81039 (OpenAirDocs) - Reported make and model: PHILLIPS RALPH W VANS RV8 - Registry model: [Phillips Ralph W VANS RV8](https://openairdocs.org/model/phillips-ralph-w-vans-rv8) (registry code 05619RA) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1A](https://openairdocs.org/engine/lycoming-o-360-a1a) (registry code 41594, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 81039 - Airframe hours: 600 - Engines: Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, September 3, 2020 - Airport: SJT, Mathis Field, runway 18, 8,054 × 75 ft, asphalt - Equipment: ADS-B, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: serious; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; seat: front ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 64 °F - Altimeter: 29.87 inHg - Observed at: KSJT - METAR: SPECI KSJT 272343Z 19003KT 10SM CLR 32/18 A2987 RMK AO2 LTG DSNT NW T03170183 ## 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 20210527009389A](https://openairdocs.org/incident/20210527009389A), May 27, 2021: Phillips Ralph W VANS RV8, San Angelo, TX, Substantial damage. On may 27, 2021, about 1825 central daylight time, a vans RV-8 airplane, N274CV, was substantially Damaged when it was involved in an accident on departure… ## Docket (5 files) The files NTSB released with the investigation on December 20, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103180. 16.9 MB in all. - Memo (item 1, PDF, 1 page, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12470932&FileExtension=pdf&FileName=Memo-Rel.pdf - Engine examination (item 2, PDF, 4 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12468907&FileExtension=pdf&FileName=Examination%20Summary%20--Rel.pdf - Maintenance records (excerpts) (item 3, PDF, 4 pages, 8.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12471130&FileExtension=pdf&FileName=Mx%20records_Redacted-Rel.pdf - Photos (item 4, PDF, 6 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12468917&FileExtension=pdf&FileName=Photo%201-Rel.pdf - Photo (item 5, PDF, 1 page, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13027299&FileExtension=pdf&FileName=Photo%202-Rel.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.