# NTSB IAD99FA025: Lake LA-4-250, N14001, Laconia, NH, January 4, 1999 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 4, 1999, 12:17 local (17:17 UTC) - Place: Laconia, NH - Location: 43.5418° N, 71.4595° W: Placed by OpenAirDocs from NTSB’s distance and direction from LACONIA MUNI (LCI), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.5418&lon=-71.4595&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report December 5, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 45594 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD99FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/45594/pdf - Page: https://openairdocs.org/ntsb/IAD99FA025 ## Probable cause A loss of engine power during initial climb due to oil starvation. Contributing to the accident was the failure to perform an engine overhaul. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - fluid,oil - inadequate (cause) - powerplant - failure - maintenance,overhaul - not performed, other maintenance personnel (cause) - Forced landing, descent - emergency - On ground/water encounter with terrain/water, emergency landing ## Analysis The pilot/owner, sitting in the left seat, and flight instructor were on an instructional instrument flight. Shortly after takeoff, the airplane was seen trailing smoke. The smoke and engine noise stopped, then started again as the airplane leveled off, and began a left, 180-degree turn. The smoke and engine noise again stopped. Then the airplane descended, impacted a parking lot in a left-wing-down attitude, and bounced through a snow bank and down a 15-foot embankment, onto a field. It then rolled upside down, and caught on fire. A large hole was in the top of the engine crankcase, in line with a dislodged number 4 connecting rod. A hole in the bottom of the case was in line with a dislodged number 5 connecting rod. The number 1 connecting rod bearing and journal had light distress scoring in line with the oil supply hole. The number 2 connecting rod bearing and journal were normal, except for fire and heat damage to the bearing. The number 3, 4, 5, and 6 connecting rod journals had heavy distress scoring with extruded bearings. The injuries sustained by the pilot/owner precluded any recollection of the flight. He was not known to preheat the engine, and there were no witnesses to the airplane's preflight, start, runup or takeoff. Outside air temperature was 23 degrees Fahrenheit, and the airplane was stored in an unheated hangar. Recommended time between engine overhaul was 2,000 hours, or 12 years, which ever came first. The engine had in excess of 919 hours of operation, was built over 15 years earlier, and had not had an overhaul. ## Factual narrative HISTORY OF FLIGHT On January 4, 1999, at 1217 Eastern Standard Time, a Lake LA-4-250, N14001, was destroyed when it impacted terrain during a forced landing, shortly after takeoff from Laconia Municipal Airport (LCI), Laconia, New Hampshire. The certificated private pilot/owner received serious injuries and the certificated flight instructor was fatally injured. Visual meteorological conditions prevailed, and a instrument flight rules flight plan had been filed between Laconia and Manchester Airport (MHT), Manchester, New Hampshire. The instructional instrument flight was conducted under 14 CFR Part 91. A witness near the airport stated that the airplane was trailing smoke shortly after takeoff from Runway 26. Another witness, about 3 miles further along the departure path, stated that he saw gray smoke trailing the engine as the airplane was climbing. He recalled that the smoke and engine noise stopped, then started again, as the airplane leveled off and began a left, 180-degree turn. The witness thought the airplane was returning to the airport, and watched as it started another left turn towards the north/northwest, but no longer smoking or emitting engine noise. The witness was momentarily distracted, but then regained sight of the airplane as it descended below a treeline, on a southerly heading. Other witnesses saw the airplane impact an asphalt parking lot, in a left-wing-down attitude, then bounce through a snow bank and down a 15-foot embankment, onto a field. The airplane rolled, and came to rest upside down on a west/southwesterly heading. Witnesses stated that the wreckage was burning when they arrived, and that they were able to extract the pilot/owner from the left seat before the airplane became completely engulfed in flames. The accident occurred during the daylight hours, with the first impact point at 43 degrees, 32.55 minutes north latitude, 71 degrees, 29.27 degrees west longitude. PERSONNEL INFORMATION The certificated private pilot/owner held ratings for single engine and multi-engine land and sea airplanes. On his most recent Federal Aviation Administration (FAA) third class medical certificate application, dated October 2, 1998, the pilot stated he had 700 hours of flight time. In a replacement logbook, dated January 2, 1999, the pilot listed 502 hours of flight time. The flight instructor was a certificated commercial pilot, with ratings for single engine land airplanes and instrument-airplane, and was a single engine airplane certificated flight instructor, and an instrument airplane flight instructor. On his most recent FAA second class medical certificate application, dated July 7, 1998, the pilot stated he had 5,700 hours of flight time. WRECKAGE AND IMPACT INFORMATION All major components of the airplane were found at the accident scene. The initial impact point in the parking lot was marked by metal scrapings, and paint chips which matched the color of the airplane. The main wreckage was located in a field, about 130 feet, 180 degrees magnetic, from the initial impact point. The left door, the outboard portion of the left wing, and the left pontoon were lying in the field, away from the main wreckage. The majority of the remaining wreckage was consumed in the post-crash fire. The flap actuator and selector were found in the down position. The nose wheel was in the up position, both main landing gear drag struts were not extended, and the gear selector valve was in the up position. Flight control continuity could not be verified because 80 percent of the push rods were consumed in the post-crash fire. All but one flight control bell crank and associated attach fittings were found in the wreckage. The engine, with the propeller still attached, was lying inverted in the middle of the main debris field. There was a 5-inch hole on the top of the casing, directly above the number 3 and number 4 connecting rods. After removal of the oil sump and melted ash, an additional hole was found on the bottom of the casing. The bottom hole was aligned with the number 4 and number 5 connecting rods. The majority of the number 4 connecting rod was absent, and the number 5 connecting rod was protruding through the casing. Both rods displayed elongation and discoloration similar to heat distress. TESTS AND RESEARCH The engine, a Textron Lycoming IO-540-C4B5, was further examined at the manufacturing facility under the supervision of a Safety Board investigator. The manufacturer produced a disassembly report, and the factual observations of that report were verified by the investigator. Excerpts included: "A large hole was observed in the top of the crankcase in line with the dislodged number 4 connecting rod. A hole in the bottom of the case was in line with the dislodged number 5 connecting rod.... The engine could not be rotated. Compression could not be checked. Engine continuity was verified during engine disassembly and was normal except for broken connecting rods.... The fire damaged oil suction screen was found clean. The partial pressure filter appeared to be contaminated with bearing material, but was fire damaged.... All of the push rods had fire damage with the number 3 intake found bent along with the fire damage.... The oil sump and induction housing were destroyed in the fire.... The oil filter was fire damaged, with ferrous and non-ferrous metal contamination found in the partial filter element returned with the engine.... The crankcase cylinder pads, parting surfaces, and bearing saddles were all found in normal condition. The oil holes were open.... All of the main bearings and journals were normal, with the exception of fire damage. The number 1 connecting rod bearing and journal had light distress scores in line with the oil supply hole. The number 2 connecting rod bearing and journal was normal, except for fire and heat damage to the bearing. The number 3, 4, 5, and 6 connecting rod journals had heavy distress scoring with extruded bearings." MEDICAL AND PATHOLOGICAL INFORMATION According to the pilot-owner's wife, the injuries he sustained precluded any recollection of the flight. An autopsy was conducted on the flight instructor's remains by the State of New Hampshire, Department of Health and Human Services, Concord, New Hampshire. Toxicological testing was performed by the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma. ADDITIONAL INFORMATION No witnesses were found, who might have seen the airplane start up, taxi, run up, or take off. According to the FAA inspector on scene, the pilot's hangar was checked. It was an unheated hangar, there was no electricity installed, and there was no engine preheat equipment. Additionally, in discussions with people who knew the pilot, none had ever known him to preheat the engine. A reference book about aircraft piston engines, the "Sky Ranch Engineering Manual," included the following: Under "Engine Starting and Idle," "Preheat is required when the outside temperatures are +10 degrees Fahrenheit and below. Consult your POH for specific preheat recommendations for your engine.... Preheat recommendations assume you are using the correct grade of oil for the season.... This does not mean the engine will not start at cold temperatures, but starting without preheat has caused engine damage. Even though your starter is sufficiently strong to turn the engine, the oil pump may not be able to pump the oil.... Scuffed piston skirts, spalled cam followers and seized thrust bearings are indicative of cold weather starts.... Under "Oil Starvation," "The first area of damage is usually the rod bearing. Upon loss of oil pressure, the rod journal comes in contact with the rod bearing. Heating and scuffing causes the bearing babbitt to melt and flow off the bearing shell. The bearing shell then scores the crankshaft rod journal ## Aircraft - Registration: [N14001](https://openairdocs.org/deregistered/N14001-2003-03-19), registration cancelled 2003-03-19, S/N 6, built 1984 (OpenAirDocs) - Reported make and model: 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: 6 - Engines: Lycoming IO-540 250 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: David L. Penney - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 3, 1998 - Departed: LCI, LACONIA, NH - Destination: MHT, MANCHESTER, NH - Flight plan: IFR - Airport: LCI, Laconia Municipal, runway 26, 5,286 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; private; airplane ratings: single-engine sea, multi-engine sea, single-engine land, multi-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 700 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 23 °F, dew point 12 °F - Altimeter: 29.00 inHg - Observed at: LCI, 3 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 19990104046029A](https://openairdocs.org/incident/19990104046029A), Jan 4, 1999: Conaer LA4250, Laconia, NH, No damage. (-23) 33. On January 4, 1999, at approximately 1215LCL, a lake LA-4-250, N14001, pilot[privacy data omitted] lost power during climb after take off. According… 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.