# NTSB ERA11FA222: Replogle Lancair 360, N164T, Chesapeake, VA, April 3, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 3, 2011, 16:30 local (20:30 UTC) - Place: Chesapeake, VA - Coordinates: 36.658889, -76.330276 - Nearby events: https://openairdocs.org/map.md?lat=36.6589&lon=-76.3303&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 27, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 78741 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11FA222 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78741/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78741 - Page: https://openairdocs.org/ntsb/ERA11FA222 ## Probable cause The pilot did not maintain airspeed following a loss of engine power, which resulted in an aerodynamic stall and spin. Contributing to the accident was the pilot's selection of the wrong fuel tank at takeoff, which resulted in fuel starvation and the total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05626JX), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=05626JX), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid management (probable cause); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05626JX), [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. - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=05626JX), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05626JX), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05626JX), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Replogle Tom 360, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05626JX), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot had earlier flown to the airport and was taking his sister on a short familiarization flight. Witnesses reported that, after takeoff, when the airplane was beyond the departure end of the runway and about 200 to 300 feet above the ground, the engine began sputtering and backfiring. The airplane then turned sharply to the right (back toward the runway), stalled, and spun. It began to recover, and, as it did, several witnesses heard a brief reestablishment of power before impact. An examination of the wreckage indicated that, at the time of impact, the airplane was in an approximate 20-degrees-nose-down left rotation. No preexisting mechanical anomalies were noted with the engine or the airplane. Both fuel tanks were found empty but compromised. Areas of browned vegetation at the crash site indicated that, although specific fuel amounts could not be determined, very little fuel had been in the left fuel tank and far more fuel had been in the right tank. Although the fuel selector was found in the right tank position, its position prior to the loss of engine power could not be determined. If the fuel selector had been selected to the right tank while the airplane was in its initial climb attitude, it is possible that there was an insufficient quantity of fuel in the tank to cover the port that supplied the engine and that, when the nose of the airplane subsequently fell during the stall, fuel moved forward to cover the port and resupply fuel to the engine, resulting in the restored power heard by witnesses. A more likely scenario is that the pilot took off with the fuel selected to the left tank, and, once the loss of engine power occurred, he selected the right tank, which resupplied fuel to the engine before impact. ## Factual narrative HISTORY OF FLIGHT On April 3, 2011, about 1630 eastern daylight time, an experimental amateur-built Lancair 360, N164T, was substantially damaged when it impacted terrain shortly after taking off from Chesapeake Regional Air port (CPK), Chesapeake, Virginia. The certificated commercial pilot/owner and the passenger were fatally injured. Visual meteorological conditions prevailed. The airplane was not operating on flight plan during the 14 Code of Federal Regulations Part 91 local personal flight. Family members reported that the pilot initially flew the airplane from Williamsburg-Jamestown Airport (JGG), Williamsburg, Virginia, where it was hangared, to CPK with his son onboard to meet family members for lunch. The pilot subsequently offered to take his sister on a short familiarization flight. According to one witness, he saw the airplane take off from runway 23. The landing gear retracted, and about ¼ mile beyond the departure end of the runway, the engine began "missing and sputtering." The witness saw the airplane then turn sharply to the right while losing altitude. After 90 to 110 degrees of turn, the nose of the airplane "dropped sharply, perhaps borderline inverted. Rotation stopped, and the nose began to recover from vertical" before the airplane impacted the ground. Another witness stated that at the departure end of the runway or a "little beyond," and about 150 to 200 feet above the ground, there was a loud backfire, followed by several smaller backfires. The airplane "started turning back towards the airport and stalled" before descending behind a hangar. A third witness noted that after the airplane took off from the airport, about 200 feet of altitude, the engine began to "sputter." The airplane's nose attitude lowered slightly, and the airplane began a right turn. The sputtering seemed to decrease, but the airplane entered a spin and disappeared behind a hangar. With the engine still sputtering, the witness heard the sound of an impact, and the engine noise stopped. Additional witness statements were consistent, except that one thought that the airplane reached an altitude between 300 and 400 feet, and another stated that the airplane rolled 90 degrees, then headed "straight down," but continued rolling until it was upright again, and further noted that the pilot "tried pulling up but did not have sufficient altitude." Another witness stated that "the airplane appeared to enter a classic 'stall/spin' and rolled inverted." One witness also noted that after the airplane entered the spin, the "engine came back to life too late," while another witness stated that just after he lost site of the airplane behind a hangar, he heard the engine at full power for a split second before impact. An addtional witness heard the engine sputtering after he lost sight of the airplane. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot, age 45, held a commercial pilot certificate, with ratings for airplanesingle engine land, single engine sea, multi-engine land, glider, rotorcraft-helicopter, and instrument airplane and helicopter. He also held a flight instructor certificate for airplane single engine and multi-engine, rotorcraft-helicopter, and instrument airplane and helicopter. The pilot's latest FAA second medical certificate was issued on February 11, 2009. The pilot was an active duty U.S. Army aviator, who, according to a recent, undated resume, was also an Army standardization instructor pilot, an instrument flight examiner, and a graduate of the U.S. Navy Test Pilot School. The resume indicated that the pilot had accrued 4,533 hours of flight time. The pilot's Army flight time and latest annual checkride date were requested from Army personnel, but not provided. Sales documents indicated that the pilot had purchased the airplane from the builder in February 2008. The pilot's personal logbook documented flights through January 24, 2011. The logbook indicated that he had accrued over 150 hours in the airplane. Logbook remarks for a May 20, 2010, 2.7-hour flight include: "left tank run dry landed w/3 gallons in right." AIRCRAFT INFORMATION According to its aircraft log, the airplane was fabricated from a Lancair II factory "fast-build" kit with some modifications, including permanent wet wing tip extensions which allowed an additional 5 gallons of fuel to be carried in each wing. The airplane was issued a special airworthiness certificate on May 26, 1998. The airplane was powered by an overhauled, intercooled Lycoming TIO-360 engine that was converted from an IO-360 engine during the July 1995 overhaul. The airplane's latest condition inspection was completed by the builder on October 1, 2010, at 242.0 hours of tachometer time. A fuel receipt indicated that the pilot had purchased 39.7 gallons of fuel on March 8, 2011. The amount of engine operating time from the last refueling until the accident could not be determined. The port to supply fuel from each wing fuel tank to the engine was located about 2 inches aft of the tanks' leading edges. AIRPORT INFORMATION Runway 23 was 5,500 feet long and 100 feet wide. Agricultural fields were located to the right of the departure end of runway 23, with the largest in excess of about ½ mile by ½ mile in size. METEOROLOGICAL INFORMATION Weather, recorded at the airport at 1620, included winds from 280 degrees true at 7 knots, clear skies with visibility 10 statute miles, temperature 16 degrees C, dew point -2 degrees true, and an altimeter setting of 30.07 inches Hg. WRECKAGE AND IMPACT INFORMATION The wreckage was located at the edge of a grassy field, on airport property, next to an undamaged perimeter fence. It was about 1,200 feet, 310 degrees magnetic from the departure end of runway 23, in the vicinity of 36 degrees, 39.54 minutes north latitude, 076 degrees, 19.82 minutes west longitude. There were no ground scars leading to the wreckage, and the angle of the partially buried engine, relativeto the level terrain, was an estimated 20 degrees nose-down. The engine compartment heading was 200 degrees magnetic, while the rest of the airplane fuselage aft of the engine compartment was oriented toward a 190-degree heading. The left wing was separated in an aft direction at the wing root, the tail was broken off to the right, and the right wing was fractured forward, about mid-span, all of which was consistent with left-turning rotation at ground impact. In addition, the autopilot turn coordinator, which did not provide pitch information, was frozen in a left turn indication. All flight control surfaces were located at the accident scene. Control continuity was confirmed from the pilot's control stick to the ailerons, and aft through the flight control tubes to the elevator. Impact damage precluded movement of the rudder controls. The landing gear and flaps were up. Both wet wings' fuel tanks were compromised, with the right wing/tank fractured from the wing leading edge to the aft spar, about 1/3 of the wing span from the wing root. There was no fuel in left fuel tank, and when the wing was moved, there was only one spot of browned vegetation under it with a diameter of about 1 foot. There was also no fuel in the right tank; however, there was a square area about 9 feet by 9 feet with browned vegetation under, and extending outward from where the wing came to rest. The fuel selector was found in the right tank position. The lines leading to and from the selector were compromised and empty, as were the lines leading to and departing from the fuel filter. However, about 1 cup of fuel that was clear, blue in color, and absent of debris, was drained from the fuel filter itself. The throttle was full aft, but could have been displaced during the impact. The mixture and propeller were full forward. The boost pump switch had been dislodged from its housing. One of the three-bladed, wooden-core, composite propeller blades came to rest sticking up and undamaged. The two remaining blades were in the ground, and when the engine was lifted, both blades were found to be broken off at the hub, with one fractured into multiple pieces. The wreckage was transferred to a storage facility in Delaware where the engine was further examined. Crankshaft continuity was confirmed to the accessory section. The top spark plug electrodes were gray in color. Compression was confirmed for all four cylinders, and the insides of all four fuel injectors were observed to be free of debris. The four cylinders were borescoped, with no anomalies noted, and the number 1 cylinder, which had been overhauled in 2009, was removed for further examination, again with no anomalies noted. The single-drive duel magneto was removed, and subsequently sparked on all eight leads. The engine driven fuel pump was also removed, and when the input shaft was rotated, it pumped out about two teaspoons of fuel. Engine fuel distribution was located below the cylinders, where most of the impactdamage occurred. The fuel manifold was fractured, and there was no fuel in the lines to the cylinders. There was, however, fuel in the line leading to the fuel injection servo, and about 5 teaspoons of fuel that was clear, blue in color and absent of debris, were drained from the unit. The fuel injector servo, which exhibited impact damage, was partially disassembled to reveal that the internal bellows was intact. The GPS (global positioning system), engine monitor, and fuel system monitor units were retained for non-volatile memory download; however, no useful information could be obtained. There was no stall warning system installed in the airplane, and the installed angle of attack indicator was destroyed. MEDICAL AND PATOLOGICAL INFORMATION An autopsy was conducted on the pilot by the Virginia Department of Health, Office of the Chief Medical Examiner, Norfolk, Virginia, with the cause of death determined to be "multiple blunt force trauma." Subsequent toxicological testing was conducted by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, with no anomalies noted. ## Aircraft - Registration: [N164T](https://openairdocs.org/deregistered/N164T-2017-09-18), registration cancelled 2017-09-18, S/N 509-320-247-FB, built 1968 (OpenAirDocs) - Reported make and model: REPLOGLE LANCAIR 360 - Registry model: [Replogle Tom 360](https://openairdocs.org/model/replogle-tom-360) (registry code 05626JX) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 509-320-247-FB - Airframe hours: 242 - Engines: Lycoming TSIO-360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, October 1, 2010 - Departed: CPK, Chesapeake, VA - Destination: CPK, Chesapeake, VA - Airport: CPK, Chesapeake Regional Airport, runway 23, 5,500 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane, helicopter; medical: class 2, without waivers/limitations; seat: left; toxicology performed; flight hours: 4,533 total, 150 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 27 °F - Altimeter: 30.06 inHg - Observed at: CPK ## 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 20110403004719A](https://openairdocs.org/incident/20110403004719A), Apr 3, 2011: Replogle Tom 360, Chesapeake, VA, Destroyed, 2 fatal. Aircraft was seen taking off on runway 23, and when it reached about 250 ft altitude, the engine was heard backfiring several times, and then stopping… ## Docket (16 files) The files NTSB released with the investigation on January 31, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78741. 33.2 MB in all. - Witness Statements (item 1, .PDF, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361047&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Pilot Resume (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361433&FileExtension=.PDF&FileName=Pilot%20Resume-Redacted.PDF - Excerpt, Pilot Logbook (item 3, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361437&FileExtension=.PDF&FileName=Excerpt,%20Pilot%20Logbook-Redacted.PDF - Toxicology Report (item 4, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361048&FileExtension=.PDF&FileName=Toxicology%20Report-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361632&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1- Wreckage Side View (As Found) (item 6, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360774&FileExtension=.PDF&FileName=Photo%201-%20Wreckage%20Side%20View%20(As%20Found)-Master.PDF - Photo 2 - Wreckage Front View (item 7, .PDF, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360775&FileExtension=.PDF&FileName=Photo%202%20-%20Wreckage%20Front%20View-Master.PDF - Photo 3 - Right Wing (Broken Forward; Browned Grass) (item 8, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360776&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20Wing%20(Broken%20Forward;%20Browned%20Grass)-Master.PDF - Photo 4 - Right Wing (Browned Vegetation both Forward and Aft) (item 9, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361430&FileExtension=.PDF&FileName=Photo%204%20-%20Right%20Wing%20(Browned%20Vegetation%20both%20Forward%20and%20Aft)-Master.PDF - Photo 5 - Wreckage Removed; Browned Vegetation in Area of Right Wing (item 10, .PDF, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361431&FileExtension=.PDF&FileName=Photo%205%20-%20Wreckage%20Removed;%20Browned%20Vegetation%20in%20Area%20of%20Right%20Wing-Master.PDF - Photo 6 - Ground Imprint of Removed Left Wing; Small Area of Browned Vegetation Near Wing Root Area (item 11, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361432&FileExtension=.PDF&FileName=Photo%206%20-%20Ground%20Imprint%20of%20Removed%20Left%20Wing;%20Small%20Area%20of%20Browned%20Vegetation%20Near%20Wing%20Root%20Area-Master.PDF - Photo 7 - Fuel Selector Valve (item 12, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360778&FileExtension=.PDF&FileName=Photo%207%20-%20Fuel%20Selector%20Valve-Master.PDF - Photo 8 - Right Fuel Tank (item 13, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360779&FileExtension=.PDF&FileName=Photo%208%20-%20Right%20Fuel%20Tank-Master.PDF - Photo 9 - Instrument Panel (item 14, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361434&FileExtension=.PDF&FileName=Photo%209%20-%20Instrument%20Panel-Master.PDF - Photo 10 - Throttle Quadrant (item 15, .PDF, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361435&FileExtension=.PDF&FileName=Photo%2010%20-%20Throttle%20Quadrant-Master.PDF - Photo 11 - Pilot Instruments (item 16, .PDF, 438 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361436&FileExtension=.PDF&FileName=Photo%2011%20-%20Pilot%20Instruments-Master.PDF From the NTSB's public API. 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