# NTSB ERA15FA348: Aerofab Lake LA-4-250, N1401P, Somerset, NJ, September 9, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 8, 2015, 20:48 local (Sep 9, 2015, 00:48 UTC) - Place: Somerset, NJ - Coordinates: 40.622222, -74.673332 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6222&lon=-74.6733&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 4, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO, Lycoming Engines - NTSB case key (mKey): 91953 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15FA348 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91953/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91953 - Page: https://openairdocs.org/ntsb/ERA15FA348 ## Probable cause The pilot's attempted 180-degree return to the runway immediately after takeoff in dark night conditions, which resulted in collision with trees and terrain. Also causal was the pilot's inadequate preflight inspection, which resulted in a takeoff with little-to-no fuel on board the airplane. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent rate](https://openairdocs.org/ntsb-findings/01062037): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-findings/01062037/cases.md?model=5110320), [All aircraft, 242 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aerofab LAKE LA-4-250, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=5110320), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=5110320), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Aerofab LAKE LA-4-250, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5110320), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Planning/preparation: fuel planning](https://openairdocs.org/ntsb-findings/02061030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-findings/02061030/cases.md?model=5110320), [All aircraft, 719 cases](https://openairdocs.org/ntsb-findings/02061030/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=5110320), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=5110320), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=5110320), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) (defining event); cases with it: [Aerofab LAKE LA-4-250, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=5110320), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) ## Analysis The pilot departed in dark night conditions without performing a preflight inspection and with an unknown quantity of fuel on board. Surveillance video captured the takeoff, and, about 30 seconds later, a bright light travelled the opposite direction, and descended approximately parallel to the runway into the wooded area of the accident site. There was no fuel, no odor of fuel, and no evidence of fuel spillage at the scene. Examination of the wreckage revealed no mechanical anomalies that would have prevented normal operation, and propeller signatures and angularly-cut wood at the accident site suggested the engine was producing power when it entered the trees. The engine was later placed in a test cell, where it started immediately, accelerated smoothly, and ran continuously without interruption at all power settings. The pilot's most recent logbook entry was for a round trip, 7.45-hour flight 3 weeks before the accident flight. Fuel receipts, performance data, and a partial radar track suggested a 3-hour flight away from his home base where he purchased 45 gallons of fuel to replace the fuel consumed. The return flight was about 4.4 hours in duration, but the pilot's route of flight and the number of takeoffs and landings performed en route could not be determined. Further, the fuel totals found programmed in the digital fuel flow indicator did not correlate to the actual usage of the airplane but rather to a partial fuel-load setting at an interim point of the flight, which could not be explained. The video evidence indicates that the pilot did not complete a preflight inspection before the accident flight. Thus, it is likely that he discovered the airplane's low fuel state at takeoff and performed a turn back to the airport immediately. It is likely that the airplane lost power on takeoff or in the turn, then engine power was restored when the wings were leveled; however, this scenario could not be definitively determined. Further, the pilot was not instrument-rated, and a rapid, steep turn at low altitude in dark night conditions with little or no visual reference greatly reduced the likelihood of a safe return to the runway. ## Factual narrative Previous Flight Activity A portable Garmin GPS unit was recovered from the wreckage and was forwarded to the NTSB Recorders Laboratory for examination and download. The batteries removed from the device were corroded, and no useful flight history data was recovered. Based on a pilot logbook entry, fuel receipts, and data stored on a commercial flight-following website, the airplane completed a flight from SMQ to Yeager Airport (CRW), Charleston, West Virginia on August 16, 2015. Before departing SMQ, the pilot purchased 51 gallons of fuel. It could not be determined if that fuel service filled all of the fuel tanks. The pilot purchased 45.5 gallons of fuel at CRW before the return flight. No fuel purchase was purchased at SMQ after the return flight, and the usage of the airplane between August 16, 2015 and the day of the accident could not be determined. The commercial flight-following website captured only a portion of the flight between SMQ and CRW and did not capture the return flight. Interpolation of the radar data, performance data, and the fuel purchase at CRW revealed an approximate fuel consumption rate of 15 gallons per hour (gph), which was consistent with available performance data for the airplane. A Shadin fuel flow indicator was removed from the airplane and sent to the NTSB Recorders Laboratory for examination. The panel-mounted gauge acted as a digital fuel management system, and had capabilities to interface with other devices via a RS-232 serial connection. It provided endurance (time), fuel flow (gph), fuel used (gallons), and fuel remaining (gallons) when the operator set the initial fuel level correctly before starting the engine. The system included a non-volatile memory that retained fuel remaining and fuel used information when power to the unit was removed. Power was applied, the self-test report was "good," and the gallons-used display showed 44.7 gallons, and the gallons-remaining display showed 21.0 gallons, for an approximate total of 66 gallons. The fuel values displayed could not be directly attributed to a specific flight before the accident flight.. A review of the pilot's logbook revealed that the pilot recorded the flight to CRW, and the return flight to SMQ, as a single entry of 7.45 hours. The four-seat, single-engine, high-wing, retractable-gear, amphibious airplane was manufactured in 1984 and was equipped with a pylon-mounted Lycoming 250-horsepower reciprocating engine. According to the airplane's maintenance records, the most recent annual inspection was completed on April 27, 2015, at 1,612 total aircraft hours. The tachometer indicated 1,633 total aircraft hours at the accident site. The airplane was configured with one main fuselage tank (40 gallons useable), two wing tanks (17 gallons each useable), and two wing-mounted auxiliary tanks (7 gallons each useable). Fuel was supplied to the engine from the main tank only. Fuel from the auxiliary tanks was supplied to the main tank by auxiliary fuelpumps. Fuel from the wing tanks to the main tank was gravity-fed through one-way valves. The normal procedures checklist for the Supplemental Type Certificate (Installation of Wing Fuel Tanks) directs the pilot to check each tank for quantity and contamination: 2a. CHECK VISUALLY (DIPSTICK) FOR FUEL LEVEL. ANGLE DIPSTICK THROUGH AFT LIGHTNING HOLES INSIDE TANK. 2c. Fuel tank sump drain – DRAIN AND CHECK FOR CONTAMINATION A fuel boost pump was actuated for takeoff and landing only. The engine-driven fuel pump provided fuel pressure to the engine in all other modes of flight. According to airport and maintenance personnel, the pilot did not service the auxiliary tanks with fuel whenever he serviced the airplane. The field elevation at SMQ was 106 ft mean sea level (msl) and the pattern altitude was 1,101 ft msl. The airport was equipped with one asphalt runway oriented 12/30, which was 2,739 ft long and 65 ft wide, and an intersecting turf runway oriented 08/26, which was 1,923 ft long and 100 ft wide. The area off the departure end of runway 30 and surrounding the airport was rural farmland, with very little man-made ambient light. On September 8, 2015, about 2048 eastern daylight time (EDT), an Aerofab Inc. Lake LA-4-250 amphibious airplane, N1401P, was destroyed when it impacted trees and terrain during a forced landing after takeoff from Somerset Airport (SMQ), Bedminster, New Jersey. The private pilot was fatally injured. Night visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The pilot was reported missing September 10, 2015, by coworkers, and a search by air and ground discovered the wreckage on the SMQ property about 1300. According to the pilot's wife and his coworkers, he departed his office at 1700 on the day of the accident to recover his boat from a repair shop and return it to SMQ, where it shared hangar space with the accident airplane. A coworker estimated that, based on the time he departed the office, he would not reach SMQ until after 2000. Multiple surveillance cameras around the terminal building and mounted on the pilot's hangar captured video on the night of the accident. Review of the video revealed that the pilot arrived at SMQ at 2022 (after sunset). He towed his airplane from its hangar, parked the boat inside, disconnected his vehicle from the boat trailer, and parked the vehicle outside the hangar at 2032. The pilot then boarded his airplane, taxied away from the hangar at 2039, and departed runway 30 at 2048. Video from a camera located on the airport terminal captured a bright light travelling the opposite direction about 30 seconds after the takeoff. The light was seen descending approximately parallel to the runway in the wooded area that surrounded the accident site. The video faced toward the departure end of the runway and the wood line where the airplane came to rest. There werebright lights in the foreground, and the view beyond displayed very dark night conditions with little to no ambient lighting. The NTSB Recorders Laboratory completed a day/night video overlay of the airport and the accident flight. The composite video product allowed for a comparison of the path of the airplane's light and the runway orientation. The Office of the State Medical Examiner, Newark, New Jersey, performed the autopsy on the pilot and noted the cause of death as blunt traumatic injuries. Toxicological testing was performed on the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results were negative for any tested-for substances. The 2053 weather observation at SMQ included clear skies, calm winds, and 10 statute miles visibility. The temperature was 23° C, the dew point was 18° C, and the altimeter setting was 29.96 inches of mercury. At the time of the accident, the moon was below the horizon with 19 percent of the visible disk illuminated. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single engine land and sea. He did not possess an instrument rating. The pilot's most recent FAA third-class medical certificate was issued on September 8, 2015, and he reported 900 total hours of flight experience on that date. A pilot logbook was recovered, and entries began with 625 total hours of flight experience carried forward from a previous logbook. The pilot's total flight experience could not be reconciled due to incomplete entries; however, all entries appeared to reflect flight experience in the accident airplane. The wreckage was examined at the accident site on September 11, 2015, and all major components were accounted for at the scene. There was no odor of fuel and no evidence of fuel spillage. The wreckage came to rest upright on flat wooded terrain. The wreckage path was 93 ft long, and oriented about 090 degrees magnetic. The initial impact was in trees about 50 ft above the ground, and the left wing and right wing auxiliary tanks were found between the first tree strike and the main wreckage. Several pieces of angularly-cut wood were found along the wreckage path. The nose of the airplane faced approximately opposite the direction of travel. The cabin roof was separated to the aft cabin. The aft cabin, wing box structure, empennage, and tail section were collapsed and wrapped in a "U" shape such that the tail section rested immediately adjacent to the nose section. The empennage lay atop the right wing, while the engine pylon was fractured at its base, and lay adjacent to the left wing. The left and right wing tanks were both breached on impact, contained no residual fuel, and there was no evidence of fuel blighting of the vegetation surrounding the wreckage. Both auxiliary tanks were intact and contained no fuel. The engine remained inside the nacelle, and the nacelle appeared intact and undamaged. The3-bladed propeller displayed similar twisting, bending, leading-edge gouging, and chordwise scratching. Two blades displayed similar curling at the tips, and one blade tip was separated. The fracture surface displayed features consistent with overload. During recovery of the airplane, flight control continuity was confirmed from the flight controls in the cockpit to all flight control surfaces. The aft fuselage, which contained the main fuel tank, was inverted for transport, and trace amounts of fuel drained from the vent lines. The main fuel tank was intact and contained no fuel. Engine Examination The engine was examined and placed in a test cell at the manufacturer's facility in Williamsport, Pennsylvania. The top spark plugs were removed to visually inspect the cylinder condition and provide a thumb compression check. All cylinders were unremarkable, and all produced thumb compression. Mechanical continuity of the valve train was confirmed with hand rotation of the crankshaft via the crankshaft propeller flange. Magneto-to-engine timing was confirmed to be 25 degrees before top dead center in accordance with the data plate specification. All accessories not needed in the production test cell were removed, including the starter, alternator, vacuum pump, and oil cooler. The original fuel servo was installed and used for the test run. The engine started immediately, accelerated smoothly, and ran continuously without interruption at all power settings. ## Aircraft - Registration: [N1401P](https://openairdocs.org/deregistered/N1401P-2018-04-19), registration cancelled 2018-04-19, S/N 12, built 1984 (OpenAirDocs) - Reported make and model: AEROFAB INC. Lake LA-4-250 - Registry model: [Aerofab LAKE LA-4-250](https://openairdocs.org/model/aerofab-lake-la-4-250) (registry code 5110320) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 12 - Year built: 1984 - Airframe hours: 1633 - Engines: LYCOMING IO-540-C4B5 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 27, 2015, 21 hours before - Departed: SMQ, Somerset, NJ - Destination: SMQ, Somerset, NJ - Airport: SMQ, Somerset Airport, runway 30, 2,739 × 65 ft, asphalt - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land; medical: class 3, waiver time limited special; last flight review November 7, 2014; seat: left; restraint: lap only; toxicology performed; flight hours: 900 total, 625 in this make and model ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 64 °F - Altimeter: 29.95 inHg - Observed at: SMQ ## 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 20150908014649A](https://openairdocs.org/incident/20150908014649A), Sep 8, 2015: Aerofab Inc LAKE LA-4-250, Somerset, NJ, Destroyed, 1 fatal. On 9/8/2015 at approximately 2045 local time, Mr. Philip clements was the pilot in command of N1401P (lake LA-4-250) and had departed runway 30 at the… ## Other investigations on N1401P (1) 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. - [NTSB ATL98LA100](https://openairdocs.org/ntsb/ATL98LA100), Jul 4, 1998: Aerofab Lake LA-4-250 (N1401P), Wise, NC, substantial damage. Probable cause: The pilot's improper turn during the takeoff that resulted in dragging the sponson. A factor was the rough water caused by the boat wake. ## Docket (11 files) The files NTSB released with the investigation on March 28, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91953. 3.5 MB in all. - Police Report (item 1, .PDF, 616 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450308&FileExtension=.PDF&FileName=Police%20Report-Master.PDF - Fuel Receipts (item 2, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450309&FileExtension=.PDF&FileName=Fuel%20Receipts-Master.PDF - Pilot Logbook Excerpts (item 3, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450310&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Master.PDF - Global Positioning System (GPS) Device - Specialist's Factual Report (item 4, .PDF, 4 photos, 394 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450311&FileExtension=.PDF&FileName=Global%20Positioning%20System%20(GPS)%20%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Engine Data Monitor (EDM) - Specialist's Factual Report (item 5, .PDF, 4 photos, 325 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450312&FileExtension=.PDF&FileName=Engine%20Data%20Monitor%20(EDM)%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 476 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450313&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Video File Accident Flight (item 7, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450314&FileExtension=.PDF&FileName=Video%20File%20Accident%20Flight-Master.PDF - Video File Surveillance Video - Shelf Item (item 8, .PDF, 190 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450315&FileExtension=.PDF&FileName=Video%20File%20Surveillance%20Video%20-%20Shelf%20Item-Master.PDF - Photo Array (item 9, .PDF, 6 photos, 930 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450316&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450317&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 11, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450318&FileExtension=.PDF&FileName=Toxicological%20Report-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.