ERA13LA406

NTSB accident investigation · Engineering & Research 415-D · Beaver Falls, PA · September 6, 2013

Accident · No injuriesLimited investigationFinal report
Date
September 6, 2013, 17:54 local (21:54 UTC)
Place
Beaver Falls, PA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N3940HEngineering & Research 415-D
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 22, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20130906023679A
Case key
88010

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

The owner/pilot’s failure to follow engine manufacturer recommendations for engine oil changes and spark plug cleaning and rotating when operating the airplane with 100 low lead fuel, which resulted in carbon buildup in the engine and the total loss of engine power due to the No. 3 cylinder exhaust valve being stuck open.

Findings · 3

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.

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

According to the pilot, he departed for a flight to his home base airport, and, while the airplane was climbing through 200 ft above ground level, the engine began to run roughly. While he was attempting to turn back toward the airport, the engine experienced a total loss of power, and he subsequently made an emergency landing in a nearby field. No anomalies were noted with the carburetor or the induction, ignition, and fuel systems; 100 low lead fuel was found in the header tank. A postaccident examination of the engine revealed that the No. 3 cylinder exhaust valve was stuck in the "open" position and that the Nos. 2 and 4 cylinder spark plugs were carbon fouled. Although an engine manufacturer service bulletin (SB) stated that 100 low lead fuel was an acceptable alternative fuel, it also indicated that "the amount of tetraethyl lead in these higher grade fuels has increased the lead build up and fouling of spark plugs." The SB noted that, when this type of fuel is used, "exhaust valve sticking could result from lead salt accumulation in the lubricating oil," and it recommended that "regular 50 hour oil changes be implemented to reduce such accumulation." The SB also recommended that the spark plugs be rotated every 50 hours of operation and cleaned and rotated every 100 hours. A review of the engine maintenance logbooks revealed that the airplane's most recent annual inspection was completed about 60 hours before the accident. No record was found indicating that the oil was changed after the annual inspection. Based on the condition of the exhaust valve and the spark plugs and the maintenance records, it is likely that the pilot did not follow the SB-recommended procedures, which resulted in the engine carbon buildup and the exhaust valve being stuck open.

Factual narrative

On September 6, 2013, about 1754 eastern daylight time, an ERCO Ercoupe 415-D, N3940H, was substantially damaged during a forced landing near Beaver County Airport (BVI), Beaver Falls, Pennsylvania. The airline transport pilot and passenger were not injured. The airplane was registered to and operated by a private individual under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight was originating at the time of the accident and was destined for North Central West Virginia Airport (CKB), Clarksburg, West Virginia.According to the pilot, he had flown in from his home base earlier that day uneventfully. The pilot conducted a preflight before his return back to CKB and noted no anomalies. After takeoff while climbing though 200 feet above ground level (agl) the engine "began to run rough." The pilot attempted to turn back towards the airport and halfway through a 180-degree turn, the engine had a loss of total power. The pilot was unable to maintain altitude and executed a forced landing to a field, resulting in substantial damage to both wings. An examination of the engine assembly by a Federal Aviation Administration (FAA) inspector revealed no anomalies were noted within the induction, carburetor and fuel systems. The airplane was equipped with a Continental C75 series 75-hp engine and according to the FAA inspector it flew approximately 60 hours since the last inspection. The logbooks were not available for review by the NTSB. During the examination approximately 18 gallons of blue fluid, similar in color to 100LL aviation fuel, was discovered in the header tank. Further examination of the engine revealed that the number 3 exhaust valve was stuck in the open position and an engine run was not performed. No internal engine damage was noted as a result of the stuck valve. Internal examination of the engine revealed that the valve train was intact and rotation of the crankshaft by hand achieved valve train continuity and compression on cylinders number 1, 2 and 4. Examination of the magnetos revealed that spark was obtained on all ignition leads. The top and bottom spark plugs were removed and it was noted that the numbers 2 and 4 cylinder spark plugs were carbon fouled. The other spark plugs exhibited normal wear signatures when compared to the champion spark plug chart. The number 3 cylinder was removed and an excessive amount of coking was noted on the mid-span of the bore of the valve guide. An examination of the engine oil revealed that the oil was free of debris and the quantity was at the operational level. A review of the Continental Motors safety bulletin (SB) M77-3 stated that "100LL was an acceptable alternative fuel and continued on to indicate that the amount of tetraethyl lead in these higher grade fuels had increased the lead build up and fouling of spark plugs along with valve erosion incidents reported on some lowercompression engines. When using this fuel, exhaust valve sticking could result from lead salt accumulation in the lubricating oil. Under such circumstances, an exhaust leak between the exhaust elbow flange and the exhaust port face was possible, which resulted in localized cylinder head overheating and subsequent exhaust valve and guide distress." Further review of SB M77-3 revealed that it is recommended that regular 50 hour oil changes be implemented to reduce such accumulation. No record of 50 hour oil changes were noted in the engine logbook book as stated by the FAA inspector. It was also recommended that spark plugs should be rotated every 50 hours of operation and cleaning/rotation every 100 hours. A review of the FAA chart, titled "Conditions Favoring Carb Ice Formation," indicated that with the ambient temperature and dew point, "serious icing at glide power" was probable at the time of the accident."

Aircraft

Registration
N3940H
Reported as
Engineering & Research 415-D
Category
Airplane
Serial number
4641
Built
1947
Airframe hours
2,219
Engine
Cont Motor A&C75 SERIES, 75 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Ferren Larry
Registered owner
Ferren Larry
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 2, 2012 · 60 hours before
Departed
BVI · Beaver Falls, PA
Destination
CKB · Clarksburg, WV
Airport
BVI · Beaver County Airport
Equipment
Stall warning system

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
72
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 10, 2012
Seat
Left
Restraint
Lap only
Flight hours
31,603 total · 31,603 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 37 °F
Altimeter
30.18 inHg
Observed at
BVI

Docket · 11

The files NTSB released with the investigation on May 14, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.8 MB in all.

FAA reports on this event · 1

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