CHI04FA203

NTSB accident investigation · Knoepflein Lancair Legacy 2000 · Madison, WI · August 1, 2004

Accident · FatalField investigationFinal report
Date
August 1, 2004, 18:49 local (23:49 UTC)
Place
Madison, WI
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N98SNKnoepflein Lancair Legacy 2000
Weather
Visual (VMC) · Day
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
Continental, FAA, MKE FSDO
FAA report
20040801026859A
Case key
59807

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A loss of engine power due to high engine temperatures which resulted in a failure of the number three piston, the pilot's continued operation of the airplane with known high temperature problems, the pilot's poor inflight planning, and the pilot's failure to maintain a proper emergency descent rate. A factor associated with the accident was the light pole that the airplane contacted.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,cylinder - overtemperatureCause
Operation with known deficiencies in equipment - continuedPilot in commandCause
Engine assembly,piston - failure,totalCause
Forced landingDescent - emergency
In flight collision with objectEmergency descent/landing
Object - poleFactor
In-flight planning/decision - poorPilot in commandCause
Clearance - not maintainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - roadway/highway

Analysis

The amateur-built airplane was destroyed when it impacted a light pole and terrain during an off airport landing following a loss of engine power. The airplane was at an altitude of 8,000 feet mean sea level (msl), 15 miles southeast of the airport, when the pilot informed air traffic control (ATC) that he was having an engine problem and he needed to land. The controller cleared the airplane to land on either runway 32 or runway 21. The pilot told the controller, "Alright uh if you don't mind I'm going to circle around up here and uh see if I can iron out the problem and then uh I'll try to let you know what I need to do." Two minutes later, the controller informed the pilot that he was now eight miles from the airport. The pilot responded that he had the airport in site. The controller informed the pilot that runway 32 was the closest runway to his present position to which the pilot responded that he would enter a left base for runway 21. Nineteen seconds later, the pilot reported he was "really having problems" and he was going to land on runway 32. The pilot then stated that he was losing altitude "really bad" and he did not think he was going to make it to the airport. The airplane contacted a light pole and the terrain along a 4-lane divided roadway. The pilot was also the aircraft builder. He installed a supercharger system on the Continental IO-550 engine. Acquaintances of the pilot reported he told them he was experiencing problems with high oil temperatures and high cylinder head temperatures on the number one and number three cylinders. One acquaintance stated the pilot mentioned the problem approximately 10 months prior to the accident and others stated the pilot talked about the continuing problem on the day prior to the accident. Post accident inspection of the engine revealed a hole in the top of the engine case near the number two cylinder. An engine teardown revealed the engine had suffered internal heat and impact damage. Metal debris was found throughout the engine. All of the pistons and cylinders sustained heat and/or impact damage. The number three piston head was burned through along an approximate 60 degree arc around the circumference and down the side of the head past the rings The piston head was black in color. The piston rings were distorted and were out of their grooves. The airplane was equipped with an electronic flight instrument system (EFIS). The EFIS data showed the engine oil pressure was at its maximum of 69 pounds per square inch (psi) prior to takeoff and it decreased throughout the flight as the oil temperature increased. The data also indicated that after the pilot informed ATC of the engine problem, the airplane's rate of descent varied between 100 and 4,000 feet per minute.

Factual narrative

History of flight

On August 1, 2004, at 1849 central daylight time, a Knoepflein Lancair Legacy 2000, N98SN, collided with a light post and terrain during an off airport landing in Madison, Wisconsin, following a loss of engine power. The private pilot was fatally injured. The airplane was destroyed by impact and post impact fire. The 14 CFR Part 91 personal flight was operating in visual meteorological conditions and no flight plan was filed for this leg of the cross country flight. The accident occurred as the pilot was returning home after attending AirVenture 2004 at the Wittman Regional Airport (OSH) Oshkosh, Wisconsin. The pilot departed OSH around 1823 with an intended destination of Rockford, Illinois.

At 1843, the pilot contacted the air traffic control tower at the Dane County Regional Airport (MSN), Madison, Wisconsin, stating that he was having an engine problem and he needed to land. The controller asked the pilot what his position was, and the pilot responded that he thought he was about 15 miles east of the airport. The controller issued a squawk code and asked the pilot what his altitude was. The pilot responded that he was at 8,000 feet.

At 1844, the controller identified N98SN on radar as being 15 miles southeast of MSN. The controller cleared the pilot to fly straight to the airport and to land on either runway 32 or runway 21. The pilot replied, "Alright uh if you don't mind I'm going to circle around up here and uh see if I can iron out the problem and then uh I'll try to let you know what I need to do." The controller instructed the pilot to keep him advised of his intentions.

At 1846, the controller informed the pilot that the airport was eleven o'clock and eight miles from his position. The pilot responded that he had the field in sight. The controller informed the pilot that runway 32 was the closest runway to his position and that the winds were from 225 degrees at 5 knots. The pilot then asked the controller what runway was being used as the active runway. The controller responded they were using runways 21, 18, and 14, but with the light winds the pilot could use runway 32.

At 1847, the pilot responded that he would enter a left base for runway 21. The controller cleared the pilot enter a left base to land on runway 21. Nineteen seconds later the pilot stated "alright eight sierra November is going to go straight in to three two we're really having problems." The controller responded by clearing the pilot to land on runway 32.

At 1848, the pilot stated, "and Madison eight sierra November I'm not sure that I'm going to make the runway." The controller informed the pilot that the airport was at eleven o'clock and two and a quarter miles. The pilot responded, "I have the field but I'm just losing altitude really bad I'm not sure I'm going to make it."

The last transmission from the pilot was at 1849, when he stated that he was not going to make it to the airport.

Several witnesses reported seeing the airplane flying at a low altitude prior to the accident. Some of these witnesses described the airplane as being out of control with the wings "wobbling" back and forth. One of these witnesses reported the propeller was not turning, and another witnesses reported hearing the engine running prior to impact. Witnesses reported the airplane contacted a light pole and burst into flames when it contacted the ground. One witness reported the airplane was inverted when it contacted the ground prior to sliding across the road.

Aircraft information

N98SN was an amateur-built Knoepflein Lancair Legacy 2000, serial number L2K-189. The airplane was a two-place, low-wing airplane equipped with retractable tricycle landing gear. The accident pilot was the aircraft builder.

The Federal Aviation Administration issued an experimental airworthiness certificate for N98SN on June 17, 2003. The pilot's logbook indicates the airplane's first flight was on June 24, 2003. The pilot's logbook shows he had accumulated a total of 235 hours of flight time in N98SN.

According to the aircraft logbooks, the next condition inspection was due to be completed by June 17, 2004. There was no entry in the logbook to show that this inspection was accomplished. The last entry in the aircraft logbook was dated May 26, 2004, at which time the aircraft hobbs time was listed as 205.5 hours.

The airplane was fueled with 33.6 gallons of 100LL aviation fuel at OSH on July 30, 2004. According to a witness, the pilot also added 3 quarts of oil to the engine at the same time.

The airplane was equipped with a Continental IO-550-N17 engine. The engine was rated to 310 horsepower. The pilot modified the engine by adding an Aero Supercharger system. The system contained a belt driven centrifugal Vortech supercharger, model V-7 JT, with an altitude compensating relief valve. It is controlled by a butterfly valve on the inlet manifold in conjunction with the relief valve.

Several acquaintances of the pilot contacted the National Transportation Safety Board following the accident and reported the pilot had concerns regarding high engine temperatures on N98SN. One person stated the pilot discussed the high temperatures with him approximately 10 months prior to the accident. Two others stated they had conversations with the pilot on the day prior to the accident. The pilot mentioned his concern about high oil temperatures and high cylinder temperature on the number 1 and 3 cylinders.

N98SN was equipped with a Chelton electronic flight instrument system (EFIS) 2000 which monitors and logs the flight conditions and engine parameters. The system records data points once every second. This information is stored as non-volatile memory on the flash card.

Personnel information

The pilot held a commercial pilot certificate with airplane single-engine and instrument airplane ratings which was issued on June 4, 2004. The pilot received his private pilot certificate with a single engine land rating on May 16, 2002. The instrument rating was added to the certificate on October 1, 2002. The pilot held a third-class medical certificate which was issued on June 17, 2004. This certificate did not contain any limitations.

The pilot also held a Repairman Experimental Aircraft Builder certificate which was issued on May 21, 2004. The repairman certificate contained the following limitation: "Inspection certificated for experimental aircraft make Model Lancair Legacy 2000, serial number L2K-189, certification date : 17 Jun 2003."

According to the pilot's last logbook, he had a total flight time of 705.2 hours, of which 703.7 hours were in single-engine land airplanes. The pilot's logbook showed he had a total of 235 hours of flight time in the accident airplane. The last flight listed in the logbook was dated July 24, 2004. The pilot's last flight review was completed on March 5, 2003.

Wreckage and impact information

The accident site was located near the intersection of High Crossing Boulevard and Wayne Terrace in Madison, Wisconsin. High Crossing Boulevard is a 4-lane road with a grass median which contains light poles. The airplane impacted a street light at a point approximately 8 feet above the ground. Pieces of the outboard section of the left wing were located on the ground near the street light. The ground/pavement was burned in a triangular pattern starting just after the light pole and ending at the main wreckage. The airplane continued across the westbound lanes of High Crossing Boulevard coming to rest on the grass in front of the Capitol City Ford Dealership located at 5422 Wayne Terrace.

The wreckage was burned aft of the engine firewall. The fuselage and wings were destroyed by fire. The empennage separated from the airplane during the impact sequence and was located approximately 100 feet behind the main wreckage.

Meteorological information

Aircraft

Registration
N98SN
Reported as
Knoepflein Lancair Legacy 2000
Category
Airplane, amateur-built
Serial number
L2K-189
Airframe hours
205
Engine
Continental IO-550-N17, 310 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Shannon K. Knoepflein
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · June 1, 2003
Departed
OSH · Oshkosh, WI
Destination
6I2 · Lebanon, KY
Flight plan
IFR
Airport
MSN · Dane County Regional

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
28
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
October 1, 2002
Toxicology
Performed
Flight hours
705 total · 235 in this make and model · 625 as pilot in command · 44 in the last 90 days · 11 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 66 °F
Altimeter
29.95 inHg
Observed at
MSN, 2 nm away

Docket · 37

The files NTSB released with the investigation on May 5, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.8 MB in all.

Witness Statements and Record of InterviewsItem 1 · .PDF · 189 KBATC TranscriptItem 2 · .PDF · 69 KBFAA Inspector's StatementItem 3 · .PDF · 77 KBMadison Police Department ReportItem 4 · .PDF · 486 KBFuel LogItem 5 · .PDF · 47 KBRegan Designs ReportItem 6 · .PDF · 371 KBLimitsItem 7 · .PDF · 19 KBLast Flight DataItem 8 · .XLS · 677 KBOil Temp and PressureItem 9 · .PDF · 50 KBFlightpath MapItem 10 · .PDF · 114 KBAero Supercharger InformationItem 11 · .PDF · 502 KBAircraft RecordsItem 12 · .PDF · 573 KBToxicological ReportItem 13 · .PDF · 52 KBStatement of Party Representatives to NTSB InvestigationItem 14 · .PDF · 309 KBLogbook Return InformationItem 15 · .PDF · 79 KBRecord of Return - EFIS DisplayItem 16 · .PDF · 29 KBPhoto 1. Aerial Photo of Accident Site (Madison Fire Dept Photo)Item 17 · .PDF · 3.0 MBPhoto 2. Light Pole That Was Contacted and Initial Ground Impact (Madison Fire Dept Photo)Item 18 · .PDF · 2.9 MBPhoto 3. Empennage and Main Wreckage (Madison Fire Dept Photo)Item 19 · .PDF · 2.9 MBPhoto 4. Main Wreckage (Madison Fire Dept Photo)Item 20 · .PDF · 4.0 MBPhoto 5. Main Wreckage (Madison Fire Dept Photo)Item 21 · .PDF · 4.6 MBPhoto 6. Front View of Engine and Supercharger (Continental Motors Photo)Item 22 · .PDF · 445 KBPhoto 7. Hole in Top of Engine Case (Continental Motors Photo)Item 23 · .PDF · 391 KBPhoto 8. SuperchargerItem 24 · .PDF · 178 KBPhoto 9. Metal Found in EngineItem 25 · .PDF · 209 KBPhoto 10. Metal Found in Oil SumpItem 26 · .PDF · 210 KBPhoto 11. Oil PumpItem 27 · .PDF · 207 KBPhoto 12. Fractured Oil Pump Drive GearItem 28 · .PDF · 162 KBPhoto 13. Rotational Scoring in Oil Pump HousingItem 29 · .PDF · 185 KBPhoto 14. Inside of Engine CaseItem 30 · .PDF · 200 KBPhoto 15. Inside of Engine CaseItem 31 · .PDF · 201 KBPhoto 16. Piston Numbers Three, Five, and Six (Continental Motors Photo)Item 32 · .PDF · 467 KBPhoto 17. Side of Number Three Piston (Continental Motors Photo)Item 33 · .PDF · 454 KBPhoto 18. Number Three, Five, ;and Six Connecting Rods and Bearings (Continental Motors Photo)Item 34 · .PDF · 385 KBPhoto 19. Crankshaft (Continental Motors Photo)Item 35 · .PDF · 455 KBPhoto 20. Camshaft (Continental Motors Photo)Item 36 · .PDF · 474 KBPhoto 21. PropellerItem 37 · .PDF · 186 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.