ERA11FA285

NTSB accident investigation · Hebert Peter J Lancair Legacy · Richlands, NC · May 6, 2011

Accident · FatalField investigationFinal report
Date
May 6, 2011, 12:57 local (16:57 UTC)
Place
Richlands, NC
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N23PHHebert Peter J Lancair Legacy
Defining event
Enroute-cruise: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report November 5, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors, FAA/FSDO
FAA report
20110506008209A
Case key
79050

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

On this page

Probable cause

The pilot's improper in-flight fuel management, which resulted in a loss of engine power due to fuel starvation.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementHebert Peter J LANCAIR LEGACY: 1 caseAll aircraft: 1,695 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

About 3 hours 39 minutes into a cross-country flight, the pilot declared an emergency to an air traffic controller due to low fuel pressure. The controller vectored the flight to the nearest airport; however, the airplane impacted a field about 3 miles short of the runway. Examination of the wreckage did not reveal any preimpact mechanical malfunctions, and the fuel selector valve was found positioned to the left main fuel tank. Data recovered from the airplane's engine data monitor revealed that at the time of the emergency, no fuel remained in the left main fuel tank; however, approximately 20 gallons of fuel remained in the right fuel tank. The investigation could not determine why the pilot did not position the fuel selector handle to the right main fuel tank. The airplane held 67 gallons of fuel and the pilot fully fueled the airplane with 46.1 gallons prior to departure.

Factual narrative

HISTORY OF FLIGHT On May 6, 2011, at 1257 eastern daylight time, an experimental amateur-built Lancair Legacy, N23PH, registered to and operated by the private pilot, collided with terrain during a forced landing near Richlands, North Carolina. The personal flight was operated under the provisions of 14 Code of Federal Regulations Part 91 with an instrument flight rules flight plan filed. Visual meteorological conditions prevailed. The private pilot and passenger were fatally injured and the airplane received substantial damage. The flight departed Morrisville-Stowe Airport (MVL), Morrisville, Vermont, at 0857. According to Wilmington International Airport (ILM), Wilmington, North Carolina approach control, the pilot checked in on the controller’s frequency and was instructed to descend to 4,000 feet. He was informed that automated terminal information service Oscar was current and to expect runway 24. Seven miles west-southwest of Jacksonville, North Carolina, descending out of 6,000 feet, the pilot declared an emergency due to low fuel pressure. The controller asked the pilot for number of people on board and fuel remaining, and the pilot responded 1 hour and two people onboard. The pilot asked for the closest airport and was advised that Albert J. Ellis Airport (OAJ), Jacksonville, North Carolina was the closest. The airplane was vectored from a 200-degree heading to a 050-degree heading, and the pilot reported the airport in sight. The controller cleared the airplane for a visual approach and advised the pilot that runway 5/23 was available. The ILM facility advised Jacksonville, North Carolina emergency services of the situation, and approximately 15 minutes later the 911 operator advised ILM approach control that the airplane had crashed in a cornfield southwest of the airport. The wreckage was located in a field approximately three miles southwest from OAJ. PERSONNEL INFORMATION The pilot, age 52, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, updated on September 11, 2009, and a third-class airman medical certificate issued on July 26, 2009, with limitations for corrective lenses. A review of the pilot's logbook revealed that the last recorded entry was on March 1, 2009; at a total of 1,027.5 flight hours in the current airplane. On the pilot's July 26, 2009, application for his medical certificate, he reported 1,100 total civilian flight hours with 85 flight hours accrued during the past 6 months. The pilot also held a repairman experimental aircraft builder certificate. AIRCRAFT INFORMATION The experimental two-seat, low-wing, retractable-gear airplane, serial number 163, was manufactured in 2004. It was powered by a Continental IO-550 experimental engine and equipped with an Aerocomposits model AC1-02023 controllable-pitch propeller. Review of copies of maintenance logbook records showed an annual condition inspection in accordance with Appendix D, Part 43 was completed April 30,2010, at a recorded tachometer reading of 459.2 hours, airframe and engine time. According to MVL personnel, the pilot pumped 46.1 gallons of 100 low-lead aviation gasoline himself on May 6, 2011, at 0800. The airplane was equipped with a left and right main fuel tank, each with a capacity of 33.5 gallons. METEOROLOGICAL INFORMATION A review of recorded weather data from OAJ, elevation 93 feet, revealed at 1255 conditions were wind 270 degrees at 6 knots, visibility of 10 miles, cloud conditions scattered at 7,500 feet above ground level, temperature 23 degrees Celsius, dew point temperature 6 degrees Celsius, and altimeter 30.06 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage debris path was on a heading of 062 magnetic degrees. A ground scar revealed that the airplane traveled approximately 54 feet before coming to rest. The airframe was intact and crushed upward; all flight control surfaces were accounted for at the accident site. Examination of the wreckage revealed that the wooded propeller assembly remained attached to the propeller crankshaft flange. Two of the propeller blades were broken and one blade remained attached to the propeller flange. The two broken blades were found splintered in the wreckage debris path. The spinner was fragmented along the debris path. The upper and lower cowlings remained attached to the airframe. The lower cowling was crushed and broken away from the underside of the engine. The engine was displaced aft towards the firewall and downward into the ground. All engine accessories remained attached to the engine. The nose wheel assembly remained attached to the nose gear trunnion and was in the retracted position. The cabin area from the engine firewall extending aft to the empennage was crushed from the floor upwards. The instrument panel was intact and damaged. The fuel selector handle was broken away from the fuel selector valve. Continuity of the flight control system was confirmed from the control yoke aft to all flight control surfaces. The right wing was crushed upwards and was fragmented throughout the wing span. The right wing remained attach to main spar. The outboard section of the wing was broken aft and remained attached by the aileron control tube. The right main fuel tank was ruptured and no signs of fuel were noted. The fuel cap was secure with a tight seal. The right flap was in the retracted position and attached to the wing at all the hinge points. The right aileron was attached at all the hinge points. The right main landing gear assembly was in the retracted position. The empennage was intact and separated from the main fuselage. The control tubes for the rudder and elevators were still attached. The rudder was attached to the vertical stabilizer at the attachment hinges. The elevators were attached to the horizontal stabilizers at the attachment hinges. The left wing was crushed upwards from the underside of the wing. The left main fuel tank was ruptured and no signs offuel were noted. The fuel cap was secure with a tight seal. The left flap was in the retracted position and attached to the wing at the hinge points. The left aileron was attached at the hinge points. The left main landing gear assembly was in the retracted position. Examination of the airframe and flight control system components did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The engine remained attached to the engine mounts. The left and right exhaust pipes and muffler were crushed upwards. The oil sump was ruptured crushed upwards towards the engine casing. A small amount of oil was observed in the oil sump. The engine was partially disassembled and it was noted the camshaft gear was impact damaged. Due to the broken camshaft gear, the engine could only be rotated approximately 100 degrees in either direction. The engine was rotated by hand and all pistons were observed moving. The oil pump gears were also observed rotating. The top sparkplugs were removed and examined and revealed normal wear when compared to the Champion Check- A- Plug chart. Examination of the fueling system revealed that the fuel pump was in place and not damaged. The drive coupling was intact and not damaged. The drive shaft was free to rotate and fuel was observed in the inlet line. The mixture control was free to move, and the pump was tested using an electric drill. The fuel pump operated normally pumping fuel from a five gallon container filled with aviation gasoline to an open five gallon bucket. All fuel nozzles were free and clear of debris. The fuel manifold was in place and not damaged. The fuel manifold was dissembled and the fuel screen was clean and free of debris. A small amount of fuel was observed in the manifold. The fuel selector valve was examined and found in the left tank position. Examination of the engine and its components did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on May 9, 2011, by Coastal Pathology Associates, P.A., Jacksonville, North Carolina, as authorized by the Onslow County Coroner. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the liver or the muscle, and no drugs were detected in the liver. An autopsy was performed on the passenger on May 9, 2011, by Coastal Pathology Associates, P.A., Jacksonville, North Carolina, as authorized by the Onslow County Coroner. Forensic toxicology was performed on specimens from the passenger by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the liver or the muscle, and no drugs were detected in the liver. RECORDERS The airplane was equipped with an engine data monitor(EDM) device, J.P. Instruments EDM-900. The EDM was panel-mounted and allowed the operator to monitor and record up to 24 parameters related to engine operations, depending on the installation. The unit can also calculate, in real time, percent of maximum horsepower, fuel used, shock cooling rate, and exhaust gas temperature (EGT) differentials between highest and lowest cylinder temperatures. The calculations are also based on the aircraft installation. The unit contains non-volatile memory for data storage of the parameters recorded and calculated. The EDM unit was removed from the airplane and sent to the NTSB Vehicle Recorder Laboratory, Washington, DC, for data extraction from the last recorded session on May 6, 2011. The parameters provided by this EDM device are as follows: • Time –time recorded by the device (hh:mm:ss) • Batt-1(V)-battery voltage (volts DC) • Eng1 CHT#-1 (deg F)-cylinder head temperature cylinder# (degrees Fahrenheit) • Eng1 EGT#-1 (deg F)-exhaust gas temperature cylinder# (degrees Fahrenheit) • Eng1 RPM (RPM)- engine revolutions per minute • Eng1 MAP (in Hg)- engine manifold air pressure (inches of mercury) • Eng1 HP(%hp)-engine horsepower (percent of total horsepower) • Eng1 Fuel Flow (GPH)-engine fuel flow (gallons per hour) • Eng1 Oil temp(deg F)-engine oil temperature (degrees Fahrenheit) • Temp OAT (deg F)-outside air temperature (degrees Fahrenheit) • Eng1 Fuel Used (GAL)-engine fuel used (gallons) • Right/Left Fuel Level (GAL)-right or left side fuel level (gallons) Review of the EDM data revealed that approximately 3 hours and 39 minutes into the flight the left main fuel tank was depleted. The Eng1 EGT revealed that the temperature decreased from 1,300 to 200 degrees Fahrenheit, and the Eng1 fuel flow went to 0 GPH. The EDM recorded approximately 49.2 gallons were used by the end of the flight, and approximately 20 gallons remained in the right fuel tank. This value was reset at the beginning of the flight and the unit calculates gallons used from fuel flow. The fuel flow usage calculated by the EDM during the flight was approximately 13.7 GPH.

Aircraft

Registration
N23PH
Reported as
Hebert Peter J Lancair Legacy
Category
Airplane, amateur-built
Serial number
163
Airframe hours
459
Engine
Cont Motor IO-550 SERIES, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Hebert Peter J
Registered owner
Hebert Peter J
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · April 30, 2010
Departed
MVL · Morrisville, VT
Destination
ILM · Wilmington, NC
Flight plan
IFR

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
52
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
1,100 total

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 43 °F
Altimeter
30.05 inHg
Observed at
OAJ, 3 nm away

Docket · 22

The files NTSB released with the investigation on August 1, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 36.5 MB in all.

Non-Volatile Memory Devices - Specialist's Factual ReportItem 1 · .PDF · 915 KBNon-Volatile Memory Devices - Specialist's Factual Report - Attachment 1Item 2 · .CSV · 210 KBReports from Federal Agencies-ATC Accident Package-Wilmington ATC TowerItem 3 · .PDF · 11.2 MBAircraft logbook pages excerptsItem 4 · .PDF · 7.7 MBExcerpts From Pilot LogbookItem 5 · .PDF · 8.9 MBOther Pertinent Forms and Reports - N23PH Refueling ReceiptItem 6 · .PDF · 107 KBOther Pertinent Forms and Reports - Fueling Facility ChecksItem 7 · .PDF · 163 KBOther Pertinent Forms and Reports - N23PH Operating LimitationsItem 8 · .PDF · 246 KBOther Pertinent Forms and Reports - Excerpt From Pilot's Operating HandbookItem 9 · .PDF · 54 KBReports from State Agencies - North Carolina State Highway Patrol Incident ReportItem 10 · .PDF · 1.8 MBToxicological Report - HerbertItem 11 · .PDF · 140 KBToxicological Report - RoweItem 12 · .PDF · 141 KBStatement of Party Representatives to NTSB Investigation-ContinentalItem 13 · .PDF · 250 KBRetention / Release of Wreckage FormItem 14 · .PDF · 136 KBPhoto 1: Front View of Main WreckageItem 15 · .PDF · 500 KBPhoto 2: Leftside main wreckage aft viewItem 16 · .PDF · 723 KBPhoto 3:Wreckage aft viewItem 17 · .PDF · 695 KBPhoto 4: Right wing main wreckageItem 18 · .PDF · 698 KBPhoto 5: Propeller two broken bladesItem 19 · .PDF · 513 KBPhoto 6: Front view engineItem 20 · .PDF · 456 KBPhoto 7:Underside view of engineItem 21 · .PDF · 515 KBPhoto 8:Aft view of engine acessoriesItem 22 · .PDF · 535 KB

FAA reports on this event · 1

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