ERA24LA043

NTSB accident investigation · Lancair IV · Perry, FL · November 17, 2023

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
November 17, 2023, 17:08 local (22:08 UTC)
Place
Perry, FL · near 12460 Josh H Ezell Grde Perry, FL 32348
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N37MBLancair IV
Defining event
Enroute-descent: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Aerospace Technologies
FAA report
20231117017159A
Case key
193406

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A rapid throttle advancement after a period of idling, which resulted in a flooded engine and total loss of engine power.

Findings · 1

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.

Engine fuel and controlAircraft › Aircraft power plant · Not specifiedKillian John M LANCAIR IVP: 1 caseAll aircraft: 49 casesProbable cause

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

The pilot reported a loss of engine power after descending from 11,500 ft mean sea level (msl) and leveling off under a cloud layer at 2,000 ft msl. The pilot switched fuel tanks and enrichened the mixture; however, he was unable to restore engine power and elected to execute a forced landing during which he impacted trees. Postaccident examination of the airframe and fuel-injected engine revealed no anomalies that would have precluded normal operation. The engine subsequently started without hesitation during a test cell run at the manufacturer’s facility. After running at idle for 5 minutes, the engine was run for 5 minutes at various rpm settings. The engine test run revealed that the fuel system was mal-adjusted and set too lean, and the manifold pressure was about 2 inches of mercury lower than that required to produce rated power. This could have been due to an observed leak of the turbocharger exhaust or the sonic venturis which were open to the atmosphere for the engine test. Following these static engine runs, the engine was brought to idle and then the throttle was rapidly advanced. When the throttle was advanced quickly, the engine ran very rich with black exhaust smoke, and then would falter. If the throttle was not immediately retarded, the engine lost power completely. If the engine was immediately brought back to idle after it faltered upon rapid throttle advancement, the engine regained power. This was consistent with the engine flooding with rapid throttle advancement after a period of idling. Given that no anomalies were noted in the examination and that the engine repeatedly stopped producing power after rapid throttle advancement after a period of idling in the test cell, it is possible that the speed with which the pilot advanced the throttle after leveling from the descent was too quick. The engine likely then would have flooded with fuel and stopped producing power, similar to the behavior observed during the postaccident test run.

Factual narrative

On November 17, 2023, about 1708 eastern standard time, an experimental amateur-built Lancair IV-P, N37MB, was substantially damaged when it was involved in an accident near Perry, Florida. The pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was in cruise flight at 11,500 ft msl with about 40 minutes of daylight remaining when he noted that a ceiling had developed below him. Accordingly, he decided to descend through a hole in the cloud layer and divert to Perry-Foley Airport (FPY), Perry, Florida. When the airplane levelled off under the cloud layer at 2,000 ft msl, he pushed in the throttle but “nothing happened.” The propeller was windmilling, and he thought the fuel-injected engine was at idle power. After several seconds, he pulled the throttle fully out expecting the engine to slow, but the engine power remained unchanged at the low-power setting. Realizing he had lost engine power, the pilot switched fuel tanks and enrichened the mixture; however, he was unable to restore power to the engine. He chose to execute a forced landing and considered landing on a road but believed that he could not slow the airplane enough to make a safe landing, so he landed straight ahead into sapling pine trees. The airplane nosed over and sustained substantial damage to the wings and fuselage; the pilot exited the airplane unassisted. Postaccident examination of the airframe and engine revealed that the fuel strainer contained fuel with a color and odor consistent with 100LL Avgas. There were no signs of debris or water contamination in the retrieved fuel sample. The fuel strainer bowl was removed, and the fuel strainer screen was clear of any contamination. The throttle, mixture, and propeller controls were secured in the cockpit and at their respective control arms at the engine. The crankshaft was rotated by hand and continuity was established between the crankshaft, camshaft, connecting rods, and associated components. All six cylinders displayed good thumb compression and suction. Examination of the engine and airframe fuel system revealed no anomalies; therefore, a determination was made to ship the engine to the manufacturer for an engine test run. At the manufacturer’s facility, the engine was prepared to run in the test cell. The oil sump was impact damaged and was replaced for testing. A fracture was observed on the No. 2 turbocharger exhaust where it had been previously welded. No determination could be made as to whether this was impact-related damage. The magneto-to-engine timing was confirmed to be within specification. A replacement propeller was installed on the engine. The engine started without hesitation in the test cell and ran at idle for 5 minutes, followed by subsequent 5-minute runs at each of the following rpm settings: 1200,1600, 2100, 2450, and then again at idle. Although the engine ran normally at all rpm settings, the enginetest run revealed that the fuel system was set too lean, and the manifold pressure was about 2 inches of mercury lower than that required to produce rated power. Following these static engine runs, the engine was brought to idle and then the throttle was rapidly advanced. This sequence was repeated several times, and when the throttle was advanced quickly, the engine ran very rich with black exhaust smoke, and then would falter. If the throttle was not immediately retarded, the engine lost power completely. If the engine was immediately brought back to idle after it faltered upon rapid throttle advancement, the engine regained power.

Aircraft

Registration
N37MB
Reported as
Lancair IV (P)
Category
Airplane, amateur-built
Serial number
LIV-362
Built
1999
Airframe hours
1,016.4
Engine
Continental TSIO-550-E1B, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · October 1, 2023 · 25.1 hours before
Departed
CFD · Bryan, TX
Destination
X39 · Tampa, FL
Equipment
Auto-pilot, Angle of attack indicator, ADS-B, Satellite tracking device, Onboard weather, Electronic primary flight display, Electronic multifunction display

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
45
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
311 total · 64 in this make and model · 210 as pilot in command · 25 in the last 90 days · 16 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
359° at 6 knots
Lowest ceiling
2,300 ft overcast
Temperature
73 °F, dew point 64 °F
Altimeter
29.83 inHg
Turbulence
Unknown
Observed at
FPY, 8 nm away
METAR
METAR KFPY 172235Z AUTO 36006KT 10SM OVC023 23/18 A2983 RMK AO2 T02260183=

Docket · 10

The files NTSB released with the investigation on September 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 473 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.