# NTSB ERA18LA163: Vans RV4, N7765X, Butler, PA, June 7, 2018 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: June 7, 2018, 11:00 local (15:00 UTC) - Place: Butler, PA - Coordinates: 40.756111, -79.950553 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.7561&lon=-79.9506&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report February 5, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/ FSDO - NTSB case key (mKey): 97431 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA163 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97431/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97431 - Page: https://openairdocs.org/ntsb/ERA18LA163 ## Probable cause The pilot's improper decision to fly the airplane with a known engine problem and his improper modification of the engine control unit fuel delivery software, which led to the engine running too lean and resulted in a total loss of engine power during climb. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=056339Z), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Maintenance: modification/alteration](https://openairdocs.org/ntsb-findings/02062030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/02062030/cases.md?model=056339Z), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02062030/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=056339Z), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=056339Z), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Failure; cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=056339Z), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=056339Z), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=056339Z), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=056339Z), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-climb to cruise: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=056339Z), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Enroute-climb to cruise: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Axelrad Michael R VANS AIRCRAFT RV-4, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056339Z), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Shortly after takeoff on an extended crosswind leg about 800 ft mean sea level, the engine lost total power. The private pilot continued ahead and landed the airplane in a field. During the landing, the airplane impacted a wire fence and brush, which resulted in substantial damage to the fuselage and wings. During postaccident interviews, the pilot reported that this was the first flight after he had made maintenance repairs to the automobile-converted engine due to an engine failure 1 month before the accident. He stated that he installed an aftermarket engine control unit and modified the fuel delivery software, which resulted in the engine running too lean for flight and likely caused detonation and piston damage to occur. During the run-up before the accident flight, the pilot was aware that the engine was not producing power as it should. However, he decided to depart with a known engine problem, and his decision to do so led to the accident. ## Factual narrative On June 7, 2018 about 1100 eastern standard time, an experimental amateur-built Vans Aircraft RV-4, N7765X, was substantially damaged during a forced landing shortly after takeoff from Pittsburgh/Butler Regional Airport (BTP), Butler, Pennsylvania. The private pilot sustained minor injuries. The personal flight was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight. According to the pilot, after takeoff from runway 26 at BTP, while flying on an extended crosswind traffic pattern leg about 800 ft mean sea level, the engine lost total power. He subsequently continued ahead, maintained best glide speed, and landed in a field. During the landing, the airplane impacted a wire fence and brush. The fuselage and wings sustained substantial damage. The pilot further reported that that this was the first flight after maintenance repairs he had performed to the airplane's automobile-converted engine, due to a prior engine failure that occurred about one month earlier. During the repair, he replaced all four pistons on the engine. He also stated that he had installed an "aftermarket ECU [engine control unit]," and modified the fuel delivery software to lean the fuel to air mixture for improved engine starts. In discussing the engine failure that occurred during the accident flight, the pilot stated that the "cause of the engine failure was my entering a bad tune which caused the engine to run lean under high load. Detonation occurred and caused a piston to melt halting the engine." According to a Federal Aviation Administration inspector, the pilot reported that he had previously "burnt through a piston" with this engine during flight. The pilot also reported that during the run-up on the day of the accident, the engine was "not as strong" as it should had been, but he decided to fly anyway. The pilot held a private pilot certificate with a rating for airplane single-engine land. He also held a repairman experimental aircraft builder certificate, limited to inspection of the accident airplane. He reported total flight experience of 420 hours and 90 hours in the accident make and model airplane. His most recent Basic Medical requirements were completed in June 2017. His most recent flight review was in July 2017. The two-seat, low-wing, fixed landing gear, single-engine airplane was manufactured in 2015. It was equipped with an automobile converted, fuel-injected, General Motors Ecotec L61, 142-horsepower engine. The weather conditions reported at 1056 at BTP, included variable wind at 3 knots, visibility 10 statute miles, clear skies, temperature 17°C, and dew point 10°C. ## Aircraft - Registration: [N7765X](https://openairdocs.org/deregistered/N7765X-2021-07-31), registration cancelled 2021-07-31, S/N 3890, built 2015 (OpenAirDocs) - Reported make and model: VANS RV4 (UNDESIGNAT) - Registry model: [Axelrad Michael R VANS AIRCRAFT RV-4](https://openairdocs.org/model/axelrad-michael-r-vans-aircraft-rv-4) (registry code 056339Z) (OpenAirDocs) - Registry engine: [GM ECO TEC 2.4L](https://openairdocs.org/engine/gm-eco-tec-2-4l) (registry code 30900, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 3890 - Year built: 2015 - Airframe hours: 90 - Engines: General Motors ECOTEC L61 142 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, October 25, 2017 - Departed: BTP, Butler, PA - Destination: BTP, Butler, PA - Airport: BTP, Pittsburgh/Butler Rgnl, runway 26, 4,801 × 100 ft, asphalt - Equipment: Electronic flight bag or handheld device, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed; last flight review July 15, 2017; seat: front; restraint: 4-point; flight hours: 420 total, 90 in this make and model, 420 as pilot in command, 1 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Lowest ceiling: none - Temperature: 63 °F - Altimeter: 30.12 inHg - Observed at: BTP, 2 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 20180607007249A](https://openairdocs.org/incident/20180607007249A), Jun 7, 2018: Van'S RV-4, Butler, PA, Substantial damage. During climbout from kbtp, engine lost power. Pilot located a field and landed striking a fence and brush. Engine was automotive and had previous history of… ## Docket (4 files) The files NTSB released with the investigation on October 16, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97431. 5.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467427&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (FAA Inspector) (item 2, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467428&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(FAA%20Inspector)-Master.PDF - Record of Conversation (Pilot in Command) (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467429&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot%20in%20Command)-Master.PDF - Photo Array (item 4, .PDF, 2 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40467430&FileExtension=.PDF&FileName=Photo%20Array-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.