# NTSB ERA12LA285: Willoughby Pete A Streak Shadow, N2828W, Salem, WV, April 15, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 15, 2012, 17:30 local (21:30 UTC) - Place: Salem, WV - Coordinates: 39.283054, -80.614997 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.2831&lon=-80.6150&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report May 23, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 83392 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA285 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83392/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83392 - Page: https://openairdocs.org/ntsb/ERA12LA285 ## Probable cause A total loss of engine power due to a piston seizure that resulted from a fuel system restriction and poorly secured fuel lines. Contributing to the accident were the pilot/builder’s failure to follow the engine manufacturer procedures and his use of nonaviation parts to secure fuel lines. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel flow sensor](https://openairdocs.org/ntsb-findings/01057333): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-findings/01057333/cases.md?model=056055L), [All aircraft, 3 cases](https://openairdocs.org/ntsb-findings/01057333/cases.md) - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=056055L), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Owner/builder (probable cause); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=056055L), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=056055L), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=056055L), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Willoughby Pete A STREAK SHADOW, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056055L), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was attempting the first flight since the airplane was damaged in an accident about 2 years earlier and then “rebuilt.” Shortly after takeoff, the engine sputtered and lost all power. While the pilot was attempting to maneuver for a forced landing, the airplane collided with trees and terrain, resulting in substantial damage to the airframe and serious injuries to the pilot. Examination of the engine and fuel system revealed that the pistons were severely scored, indicative of a seizure. Examinations revealed that nonaviation tie wraps were used to secure the fuel lines to various fittings, and, in one location, no clamp was used. The airplane was equipped with an in-line fuel flow transducer. Disassembly of the engine revealed that the transducer incorporated a 2-millimeter (mm) jet. According to the engine manufacturer, no device with a diameter smaller than 5 mm should be installed anywhere in the fuel system. The transducer was installed on a test engine, and the engine ran normally up to 7,100 rpm with the 2-mm jet. When a small amount of air was introduced into the lines to replicate a poorly secured or unsecured fuel line, low fuel pressure and fluctuating rpm resulted, and subsequent examinations of the pistons showed signs of scoring damage. ## Factual narrative On April 15, 2012, about 1730 eastern daylight time, an experimental, amateur-built Willoughby Streak Shadow, N2828W, was substantially damaged following a loss of engine power and collision with terrain near Salem, West Virginia. The airline transport pilot was seriously injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The local flight was originating at the time of the accident. A Federal Aviation Administration inspector responded to the accident site and examined the wreckage. Structural damage to the wings was evident. The fuel tank was ruptured. No fuel was observed in the in-line fuel filter. The wreckage was recovered to a storage facility where a more detailed examination was conducted. The pilot stated that he was flying the aircraft for the first time since it was “rebuilt” after an accident two years prior. After ground operations, he took off to the west from the grass airstrip at his residence. Shortly after takeoff, above tree top level, approximately 150 feet above the ground, the engine sputtered and stopped running. He attempted a left turn to maneuver for an open area to perform a forced landing. The aircraft collided with trees on a hill adjacent to the airstrip. He did not recall any events after the collision. The engine and fuel system were examined at the pilot’s hangar on August 14, 2012. Partial disassembly of the engine revealed that the pistons exhibited severe scuffing and scoring, consistent with a seizure event. Inspection of the fuel lines revealed that there was a fuel flow transducer, manufactured by MGL, installed in-line, with a 2 millimeter (mm) jet. The fuel lines were secured with plastic tie wraps and in one area no fuel line clamp was used on a fitting. The fuel flow transducer was tested on another engine after the examination. A vacuum and pressure gauge were installed in the fuel system to observe any changes under various running conditions. The engine was started and ran normally up to 7,100 rpm with the fuel flow transducer installed (with the 2mm jet). Another run was attempted with a valve installed between the fuel flow transducer and the fuel pump to allow the introduction of air into the system to replicate unsecured or poorly secured fuel lines. With a small amount of air introduced while the engine was running, fuel flow dropped significantly, resulting in low fuel pressure and fluctuating rpm. After the engine run, the pistons were examined and they exhibited signs of scoring and cylinder polishing. According to the engine manufacturer, although there was no reduction in fuel flow or rpm with a 2mm jet installed in the transducer, there should be no device installed anywhere in the fuel system that is smaller than the minimum fuel line diameter of 5mm. ## Aircraft - Registration: [N2828W](https://openairdocs.org/deregistered/N2828W-2018-01-17), registration cancelled 2018-01-17, S/N OSS912260003, built 2000 (OpenAirDocs) - Reported make and model: WILLOUGHBY PETE A STREAK SHADOW - Registry model: [Willoughby Pete A STREAK SHADOW](https://openairdocs.org/model/willoughby-pete-a-streak-shadow) (registry code 056055L) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: OSS912260003 - Airframe hours: 101 - Engines: Rotax 582 Series 64 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Martin Joseph K - Registered owner: Martin Joseph K - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, April 12, 2012, 1 hours before - Departed: Salem, WV - Destination: Salem, WV - Airport: Private Airstrip ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: serious; airline transport; airplane ratings: single-engine land; instrument ratings: helicopter, airplane; medical: class 2, with waivers/limitations; last flight review June 30, 2011; seat: single; flight hours: 18,000 total, 101 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 50 °F - Altimeter: 30.01 inHg - Observed at: CKB, 35 nm away ## 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 20120415006379A](https://openairdocs.org/incident/20120415006379A), Apr 15, 2012: Willoughby Pete A STREAK SHADOW, Miletus, WV, Destroyed. Experimental amateur built aircraft on first flight following rebuild from July, 2009 incident. Aircraft engine quit after takeoff. Pilot attempted to return… ## Docket (5 files) The files NTSB released with the investigation on March 21, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83392. 681 KB in all. - NTSB Record of Conversation - Morgan (item 1, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384670&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation%20-%20Morgan-Master.PDF - NTSB Record of Conversation - Martin (item 2, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384637&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation%20-%20Martin-Master.PDF - Excerpt from Correspondence with Rotax (item 3, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384638&FileExtension=.PDF&FileName=Excerpt%20from%20Correspondence%20with%20Rotax-Master.PDF - Excerpt from Aircraft Logbook (item 4, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384660&FileExtension=.PDF&FileName=Excerpt%20from%20Aircraft%20Logbook-Redacted.PDF - Fuel Flow Transducer Test Results (item 5, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384778&FileExtension=.PDF&FileName=Fuel%20Flow%20Transducer%20Test%20Results-Redacted.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.