# NTSB ERA13LA406: Engineering & Research 415-D, N3940H, Beaver Falls, PA, September 6, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 6, 2013, 17:54 local (21:54 UTC) - Place: Beaver Falls, PA - Coordinates: 40.77, -80.391387 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.7700&lon=-80.3914&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: No injuries - Injuries: 2 uninjured - Status: Completed, report June 22, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 88010 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA406 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88010/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88010 - Page: https://openairdocs.org/ntsb/ERA13LA406 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=0420306), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=0420306), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=0420306), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=0420306), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=0420306), [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: [Engineering & Research 415-D, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=0420306), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Engineering & Research 415-D, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0420306), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N3940H-2017-09-27), registration cancelled 2017-09-27, S/N 4641, built 1947 (OpenAirDocs) - Reported make and model: ENGINEERING & RESEARCH 415-D - Registry model: [Engineering & Research 415-D](https://openairdocs.org/model/engineering-research-415-d) (registry code 0420306) (OpenAirDocs) - Registry engine: [Continental A&C75 series](https://openairdocs.org/engine/continental-a-c75-series) (registry code 17005, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4641 - Year built: 1947 - Airframe hours: 2219 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: none; 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 ## 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 20130906023679A](https://openairdocs.org/incident/20130906023679A), Sep 6, 2013: Engineering & Research 415-D, Beaver Falls, PA, Substantial damage. The pilot of N3940H experienced a rough running engine after takeoff from kbvi runway 28 that continued during the departure climb out. The pilot contacted… ## Docket (11 files) The files NTSB released with the investigation on May 14, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88010. 3.8 MB in all. - Beaver County Sheriff's Report (item 1, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426468&FileExtension=.PDF&FileName=Beaver%20County%20Sheriff%27s%20Report-Redacted.PDF - Record of Conversation - Ferren (item 2, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426469&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Ferren-Master.PDF - FAA Inspector's Statements (item 3, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426470&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statements-Redacted.PDF - Champion Check-A-Plug Chart (item 4, .PDF, 360 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426471&FileExtension=.PDF&FileName=Champion%20Check-A-Plug%20Chart-Master.PDF - Continental Motors Safety Bulletin M77-3 (item 5, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426472&FileExtension=.PDF&FileName=Continental%20Motors%20Safety%20Bulletin%20M77-3-Master.PDF - CE-09-35 Carb Icing Bulletin (item 6, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426473&FileExtension=.PDF&FileName=CE-09-35%20Carb%20Icing%20Bulletin-Master.PDF - Photo 1 - Wreckage (Photo Courtesy of FAA) (item 7, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426474&FileExtension=.PDF&FileName=Photo%201%20-%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Right Wing (Photo Courtesy of FAA) (item 8, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426475&FileExtension=.PDF&FileName=Photo%202%20-%20Right%20Wing%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Left Wing (Photo Courtesy of FAA) (item 9, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426476&FileExtension=.PDF&FileName=Photo%203%20-%20Left%20Wing%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 4 - Valve Stem Carbon Build-up (Photo Courtesy of FAA) (item 10, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426477&FileExtension=.PDF&FileName=Photo%204%20-%20Valve%20Stem%20Carbon%20Build-up%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 5 - Valve Guide Choking (Photo Courtesy of FAA) (item 11, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426478&FileExtension=.PDF&FileName=Photo%205%20-%20Valve%20Guide%20Choking%20(Photo%20Courtesy%20of%20FAA)-Master.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.