# NTSB GAA17CA557: Bellet James J Vans RV 8, N184SJ, Orange, MA, September 26, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: September 26, 2017, 12:50 local (16:50 UTC) - Place: Orange, MA - Coordinates: 42.569999, -72.288612 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.5700&lon=-72.2886&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report December 15, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA/ FSDO - NTSB case key (mKey): 96094 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA557 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96094/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96094 - Page: https://openairdocs.org/ntsb/GAA17CA557 ## Probable cause The pilot's failure to remove the engine cowl plugs during preflight, which resulted in excessive engine cylinder head temperatures during climb and a total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=05615GO), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=05615GO), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Power plant: engine cowling system](https://openairdocs.org/ntsb-findings/01057110): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/01057110/cases.md?model=05615GO), [All aircraft, 11 cases](https://openairdocs.org/ntsb-findings/01057110/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible; cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=05615GO), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure; cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=05615GO), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/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 servicing event](https://openairdocs.org/ntsb-events/020); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/020/sequence.md?model=05615GO), [All aircraft, 70 cases](https://openairdocs.org/ntsb-events/020/sequence.md) - [Approach-VFR pattern downwind: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05615GO), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05615GO), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bellet James J VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05615GO), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The Federal Aviation Administration (FAA) aviation safety inspector reported that, during a telephone conversation, the pilot reported that, during the climb, he noticed the engine cylinder heat temperature gauge exceed 500°F. The pilot added that he immediately turned back to the departure airport, and while in the downwind for the landing runway, the engine lost power. The pilot further added that the airplane immediately lost altitude and cleared a tree line in the path to the runway but then impacted terrain hard in a base-to-final flightpath near the runway threshold. He added that, when he exited the airplane, he observed an engine cowl plug installed on the right side of the engine cowl and removed it. The right wing and fuselage sustained substantial damage. The FAA inspector reported that he traveled to the accident, and while on-site, he observed the left cowl plug melted onto the engine cylinders. He added that the right cowl plug was found on the ground near the airplane. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot did not submit the National Transportation Safety Board Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report. ## Factual narrative The Federal Aviation Administration (FAA) Aviation Safety Inspector reported that, during a telephone conversation, the pilot reported that during the climb he noticed the engine cylinder heat temperature gauge exceed 500° F. The pilot added that, he immediately turned back to the departure airport, and while in the downwind for the landing runway, the engine lost power. The pilot further added that, the airplane immediately lost altitude, cleared a tree line in the path to the runway, but impacted the terrain hard in a base to final flight path near the runway threshold. He added that when he exited the airplane, he observed an engine cowl plug installed on the right side of the engine cowl and removed it. The right wing and fuselage sustained substantial damage. The FAA inspector reported that he traveled to the accident, and while on-site, he observed the left cowl plug melted onto the engine cylinders. He added that the right cowl plug was found on the ground near the airplane. The pilot did not report that there were any preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot failed to submit the NTSB Form 6120.1 Pilot/ Operator Aircraft Accident/ Incident Report. ## Aircraft - Registration: [N184SJ](https://openairdocs.org/deregistered/N184SJ-2019-04-02), registration cancelled 2019-04-02, S/N 81645, built 2003 (OpenAirDocs) - Reported make and model: BELLET JAMES J VANS RV 8 (UNDESIGNAT) - Registry model: [Bellet James J VANS RV-8](https://openairdocs.org/model/bellet-james-j-vans-rv-8) (registry code 05615GO) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 81645 - Year built: 2003 - Engines: Lycoming IO-360 reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: ORE, Orange, MA - Flight plan: Unknown - Airport: ORE, Orange Muni, runway 32, 4,801 × 75 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: minor; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left ## Weather - Conditions: Visual (VMC), Dawn - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 66 °F - Altimeter: 30.03 inHg - Observed at: KORE ## 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 20170926019899A](https://openairdocs.org/incident/20170926019899A), Sep 26, 2017: Bellet James J VANS RV-8, Orange, MA, Substantial damage. On September 26, 2017, at approximately 12:10 pm, aircraft N184SJ was involved in an accident at the Orange Municipal Airport (ore) located in Orange, MA.… ## Docket (3 files) The files NTSB released with the investigation on November 13, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96094. 902 KB in all. - FAA Inspector Statement (item 1, .PDF, 333 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457895&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Record of Conversation (FAA Inspector) (item 2, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457896&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(FAA%20Inspector)-Master.PDF - Accident Photos (item 3, .PDF, 4 photos, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457897&FileExtension=.PDF&FileName=Accident%20Photos-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.