# NTSB ERA15LA205: Jerome D Fischer RV-7, N364SJ, Bartow, GA, May 5, 2015 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: May 5, 2015, 10:24 local (14:24 UTC) - Place: Bartow, GA - Coordinates: 32.838611, -82.624725 - Nearby events: https://openairdocs.org/map.md?lat=32.8386&lon=-82.6247&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report October 19, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 91136 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA205 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91136/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91136 - Page: https://openairdocs.org/ntsb/ERA15LA205 ## Probable cause The pilot's use of the improper fuel grade for the engine, which resulted in detonation, engine damage, and loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid type (probable cause); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=05631BE), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=05631BE), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=05631BE), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/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: Wrong fuel](https://openairdocs.org/ntsb-events/194); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-events/194/sequence.md?model=05631BE), [All aircraft, 9 cases](https://openairdocs.org/ntsb-events/194/sequence.md) - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=05631BE), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05631BE), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05631BE), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Jerome D Fischer RV-7, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05631BE), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, during cruise flight, he observed that the engine would not advance past 2,100 rpm, which was 300 rpm below the airplane's normal cruise power setting. The pilot's attempts to troubleshoot the engine issue were unsuccessful, and he chose to conduct a precautionary landing. Shortly after, the oil temperature increased, and oil covered the windshield. During the precautionary landing on a dirt road, the left wingtip impacted the ground and the airplane cart-wheeled, which resulted in substantial damage to the wings and rudder. After the accident, about 10 gallons of 90-octane automotive gasoline (auto gas) were drained from the airplane. According to a service letter issued by the engine manufacturer, "Use of lower-than-specified octane fuel could cause detonation and mechanical damage to the engine." The service letter did not list 90-octane auto gas as an approved fuel for use in the accident engine. Examination of the engine also revealed significant thermal damage to the No. 1 cylinder, piston, and rings consistent with detonation, which likely resulted from the pilot's use of the improper fuel grade for the engine. ## Factual narrative On May 5, 2015, about 1024 eastern daylight time, an experimental, amateur built Fischer RV-7, N364SJ, was substantially damaged during an emergency landing near Bartow, Georgia. The commercial pilot received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the personal cross country flight, which departed from East Georgia Regional Airport (SBO), Swainsboro, Georgia about 1000 and was destined for Gwinnett County Airport-Briscoe Field (LZU), Lawrenceville, Georgia. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The accident flight was the beginning of a planned cross-country flight to Wyoming. On the morning of the accident, he noted that the oil level was 1.5 quarts above the minimum. The pilot conducted an engine run-up check prior to takeoff and observed no anomalies. After departing SBO, the pilot initiated a climb and established a direct course to LZU. About 5 minutes after takeoff, the pilot leveled the airplane at 2,500 feet mean sea level and configured the airplane for cruise flight, but the engine would not exceed 2,100 rpm; 300 rpm below desired cruise power. He attempted to manipulate the mixture and activated the electric fuel pump, but the engine power remained steady at about 2,100 rpm. The pilot elected to make a precautionary landing at a nearby airport, but moments after he diverted, the engine oil temperature increased "quickly" and oil began to cover the windshield. The pilot subsequently attempted a precautionary landing on a dirt road, but the left wingtip impacted the ground, the airplane cartwheeled, and came to rest inverted, resulting in substantial damage to the wings and rudder. The 1015 recorded weather observation at Kaolin Field (OKZ), Sandersville, Georgia, located about 13 nautical miles northwest of the accident site, included winds from 060 degrees at 5 knots, clear skies, 10 miles visibility, temperature 22 degrees C, dewpoint 15 degrees C, and an altimeter setting of 30.33 inches of mercury. The pilot held a commercial pilot certificate with ratings for airplane single-engine land, instrument airplane, and instrument helicopter. He reported 3,000 hours of flight experience, of which 300 were in the accident airplane make and model. His most recent FAA second class medical certificate was issued May 4, 2014. The airplane was a single-engine, low-wing, fixed tricycle-gear airplane. It was powered by an experimental engine rated at 180 horsepower that resembled a Lycoming O-360A1A reciprocating engine. A review of aircraft maintenance records revealed that the airplane had accumulated about 38.1 hours since its most recent condition inspection, which was completed on April 20, 2015. At the time of the inspection, the airframe and engine had accumulated about 364.4 total hours of operation. Postaccident examination of the airplane by a Federal Aviation Administration inspector, with assistance from an airframeand powerplant mechanic, revealed that the forward crankcase seal on the engine was intact, but had separated forward of the crankcase. Approximately 10 gallons of non-ethanol 90 octane automotive gasoline was drained from the wing tanks at the accident site. The spark plugs were removed and examined. All plugs, with the exception of the number 1 top plug, were secured properly and appeared normal in wear. The number 1 spark top spark plug was removed by hand and exhibited normal operating signatures. The magnetos were not examined, and magneto timing could not be verified due to impact damage. Further disassembly of the engine revealed that portions of the number 1 cylinder wall, compression rings and oil control ring had been burned through, and the number 1 piston head also exhibited thermal deterioration and pitting on the piston face. The numbers 2, 3, and 4 cylinder combustion chambers and their associated pistons displayed normal operating signatures. According to the last engine logbook entry, the engine was inspected in accordance with the condition inspection checklist provided by the manufacturer. According to Sky Ranch Engineering Manual, detonation is a process of self-ignition or explosive combustion that occurs when the unburned charge of compressed fuel reaches a critical temperature in the cylinder. According to a service letter issued by the engine manufacturer, "Use of lower-than-specified octane fuel could cause detonation and mechanical damage to the engine." The service letter did not list 90 octane rated fuel as an approved automotive fuel for use in this engine. ## Aircraft - Registration: [N364SJ](https://openairdocs.org/deregistered/N364SJ-2018-10-23), registration cancelled 2018-10-23, S/N 73046, built 2011 (OpenAirDocs) - Reported make and model: JEROME D FISCHER RV-7 - Registry model: [Jerome D Fischer RV-7](https://openairdocs.org/model/jerome-d-fischer-rv-7) (registry code 05631BE) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 73046 - Year built: 2011 - Airframe hours: 401.5 - Engines: Experimental O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: David Malmin - Registered owner: David Malmin - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, April 20, 2015, 38 hours before - Departed: SBO, SWAINSBORO, GA - Destination: LZU, LAWRENCEVILLE, GA - Equipment: Handheld GPS, Auto-pilot, Electronic primary flight display, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: minor; commercial; airplane ratings: single-engine land; instrument ratings: airplane, helicopter; medical: class 2, with waivers/limitations; last flight review November 24, 2012; seat: left; restraint: lap only; flight hours: 3,000 total, 300 in this make and model, 3,000 as pilot in command, 8 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 59 °F - Altimeter: 30.32 inHg - Observed at: OKZ, 13 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 20150505008209A](https://openairdocs.org/incident/20150505008209A), May 5, 2015: Jerome D Fischer RV-7, Bartow, GA, Substantial damage. Aircraft took off from Swainsboro Airport (sbo), and at 2500' pilot could not achieve more than 2100 RPM. Shortly after pilot noticed oil temp rising quickly… ## Docket (12 files) The files NTSB released with the investigation on September 23, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91136. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 928 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432040&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Correspondence (item 2, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432041&FileExtension=.PDF&FileName=Pilot%20Correspondence-Redacted.PDF - Record of Conversations (item 3, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432042&FileExtension=.PDF&FileName=Record%20of%20Conversations-Master.PDF - Excerpts from Engine Logbook (item 4, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432043&FileExtension=.PDF&FileName=Excerpts%20from%20Engine%20Logbook-Redacted.PDF - Engine Teardown/Examination Notes from Mechanic (item 5, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432044&FileExtension=.PDF&FileName=Engine%20Teardown%2FExamination%20Notes%20from%20Mechanic-Redacted.PDF - Manufacturer Service Letters (item 6, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432045&FileExtension=.PDF&FileName=Manufacturer%20Service%20Letters-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432046&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Weather Report and Record (item 8, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432047&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Photograph 1: Airplane at Accident Site (Courtesy of FAA) (item 9, .PDF, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432048&FileExtension=.PDF&FileName=Photograph%201%3A%20Airplane%20at%20Accident%20Site%20(Courtesy%20of%20FAA)-Master.PDF - Photograph 2: Forward Section of Crankcase and Propeller Flange (Courtesy of FAA) (item 10, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432049&FileExtension=.PDF&FileName=Photograph%202%3A%20Forward%20Section%20of%20Crankcase%20and%20Propeller%20Flange%20(Courtesy%20of%20FAA)-Master.PDF - Photograph 3: Number 1 Piston (Courtesy of FAA) (item 11, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432050&FileExtension=.PDF&FileName=Photograph%203%3A%20Number%201%20Piston%20(Courtesy%20of%20FAA)-Master.PDF - Photograph 4: Number 1 Piston (Courtesy of FAA) (item 12, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40432051&FileExtension=.PDF&FileName=Photograph%204%3A%20Number%201%20Piston%20(Courtesy%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.