# NTSB LAX92FA064: Glasair SH-2R, N614LS, Nuevo, CA, December 6, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: December 6, 1991, 15:30 local (23:30 UTC)
- Place: Nuevo, CA
- Location: 33.8011° N, 117.1414° W: Placed by OpenAirDocs: center of Nuevo, CA, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=33.8011&lon=-117.1414&mi=10
- Phase of flight: [Unknown](https://openairdocs.org/ntsb-phases/990) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report April 23, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27394
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX92FA064
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27394/pdf
- Page: https://openairdocs.org/ntsb/LAX92FA064

## Probable cause

THE FAILURE OF THE PILOT TO PERFORM PREVENTATIVE MAINTENANCE ON THE AIRPLANE'S POWERPLANT WHICH RESULTED IN A LOSS OF PERFORMANCE DURING AN UNKNOWN PHASE OF OPERATION.  CONTRIBUTING TO THE ACCIDENT WAS FOULED SPARK PLUGS AND THE PARTIAL LOSS OF AIRCRAFT PERFORMANCE.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power, unknown
  - single engine aircraft
  - aircraft performance - loss,partial (contributing factor)
  - ignition system,spark plug - fouled (contributing factor)
  - maintenance - not performed, pilot in command (cause)
- In flight collision with terrain/water, unknown
  - terrain condition - rough/uneven

## Analysis

THE AIRPLANE COLLIDED WITH RUGGED TERRAIN AFTER A LOSS OF ENGINE POWER. IT STRUCK THE NORTH FACE OF 20 DEG SLOPE OF AN EAST-WEST RIDGE, JUST BELOW THE CREST. THE AIRPLANE THEN SLID ABOUT 20 FT DOWN THE SLOPE WHERE A POST-IMPACT FIRE DESTROYED THE PLANE. AN EXAM OF THE ENGINE SPARK PLUGS REVEALED THE #1 & #3 CYLINDER SPARK PLUG GAPS WERE BRIDGED WITH CINDER-LIKE DEPOSITS WITH METALLIC GLOBULES STARTING TO FILL THE FIRING END CAVITY & WORN CENTER ELECTRODES. ACCORDING TO THE SPARK PLUG MANUFACTURER, SEVERELY FOULED PLUGS WILL OPERATE COLDER CAUSING MISFIRES, AND WILL ALSO MISFIRE AT HIGHER POWER BECAUSE OF THE CONDUCTIVE NATURE OF THE DEPOSITS AT ELEVATED TEMPS. BRIDGED GAPS WILL SHORT OUT THE SPARK PLUG. SUCH A MALFUNCTIONED PLUG WILL MISFIRE AT ALL POWER SETTINGS IN A MANNER SIMILAR TO A OIL FOULED PLUG. BRIDGED GAPS BRIDGED BY BEADED LEAD GLOBULE WILL NOT CLEAR UP BY ENGINE OPERATION & CAN BE CORRECTED ONLY BY REPLACING THE MALFUNCTIONING SPARK PLUG WITH A SERVICEABLE UNIT. THE ACDNT TIME WAS ESTD BE AT 1530 PST.

## Aircraft

- Registration: [N614LS](https://openairdocs.org/deregistered/N614LS-1992-04-10), registration cancelled 1992-04-10, S/N 763 (OpenAirDocs)
- Reported make and model: GLASAIR SH-2R
- Registry model: [Sager Lloyd E SH-2R](https://openairdocs.org/model/sager-lloyd-e-sh-2r) (registry code 05691DU) (OpenAirDocs)
- Category: Airplane, amateur-built
- Serial number: 763
- Engines: LYCOMING O-360-B1E 180 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Other work use, Part 91
- Operator: Saber, Lloyd E.
- Registered owner: Saber, Lloyd E.
- Airworthiness certificate: Special, Experimental (Special)
- Last inspection: Annual, April 12, 1991
- Departed: L12, REDLANDS, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 62; commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; toxicology performed; flight hours: 2,030 total

## Weather

- Conditions: Visual (VMC), Day
- Visibility: 5 statute miles

## 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 19911206063009A](https://openairdocs.org/incident/19911206063009A), Dec 6, 1991: Amtr GLASAIR, Nuevo, CA, Destroyed, 1 fatal. Impact flat on hillside. Searching for lost aircraft. Low power at impact.

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.

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