LAX98FA008

The pilot had recently purchased the experimental, amateur-built Long-EZ airplane, which had a fuel system that differed from the designer's plans. The original builder had modified the fuel system by relocating the fuel selector handle from a position between the front pilot's legs to a position behind & above his (or her) left shoulder. There were no markings for the operating positions of the fuel selector handle, which were up (for off), down (for the right tank), and to the right (for the left tank). This deviation from the original design plans did not require FAA approval, nor did it require a placard to indicate such change from the original design. On 10/11/97 at Santa Maria, CA, the pilot received a 1/2-hour flight and ground checkout in the airplane by another Long-EZ pilot. The checkout pilot reported that the pilot needed a seatback cushion to be in position to reach the rudder pedals, and that he had difficulty reaching the fuel selector handle while seated with the cushion added. The pilot then departed on a 1-hour flight to his home base at Monterey with an estimated 12.5 gallons of fuel in the right tank & 6.5 gallons in the left tank. The checkout pilot estimated about 9 gallons of fuel were needed for the flight, and he noted the fuel selector was positioned to the right tank before departure. On 10/12/97 (the next day), a maintenance technician assisted the pilot in preparing for another flight. During preflight, the pilot was not observed to visually check the fuel. The technician noted that when the pilot was seated in the airplane, he had difficulty reaching the fuel selector handle. Also, he gave the pilot a mirror to look over his shoulder to see the unmarked, non-linear, fuel sight gauges, which were located in the rear cockpit. The technician estimated the available fuel and advised the pilot that the left tank indicated less than 1/4 full and that the right tank indicated less than 1/2 full. He said his estimate was based on the assumption that the gauges were accurate and linear. The pilot declined an offer for additional fuel, saying he would only be airborne about 1 hour and did not need fuel. The technician observed that before the engine was started, the fuel selector handle was in a vertical position; however, he did not note whether it was up (off) or down (right tank). As the technician went to the hangar, he heard the engine start & run for a short time, then quit. He saw the pilot turn in the seat toward the fuel selector handle, then the pilot motioned with his hand that things were all right. The technician did not observe whether the pilot had repositioned the fuel selector. The pilot restarted the engine, taxied, took off, and performed three touch-and-go landings in a span of about 26 minutes, followed by a straight-out departure to the west. Ground witnesses saw the airplane in straight and level flight about 350 to 500 feet over a residential area, then they heard a reduction of engine noise. The airplane was seen to pitch slightly nose up; then it banked sharply to the right & descended nose first into the ocean. The major structural components of the airframe were found fragmented on the ocean floor near the engine, but no preimpact part failure was found. The fuel selector valve was found in an intermediate position, about 1/3 open between the engine feed line and the right tank, and about 2-4% open to the left tank. Tests using another engine showed that the engine could be operated at full power with the selector in the as-found position; however, when the cap was removed from the left port (simulating the effect of an empty left tank), fuel pressure dropped to less than 1/2; & within a few seconds, the engine lost power. Conditions were simulated using another Long-EZ to evaluate the maneuver required to switch tanks from the front seat. The simulation revealed that 4 actions were required to change the fuel selector in flight: 1) Remove pilot's hand from the control stick; 2) Loosen shoulder harness; 3) Rotate upper body to the extreme left to reach the fuel selector handle; & 4) Rotate the handle to a non-marked (not logically oriented) position. During the evaluation, investigators noted a natural reaction for the pilot's right foot to depress the right rudder pedal when turning in the seat to reach the fuel selector handle. With the right rudder depressed in flight, the airplane would pitch up slightly & bank to the right.

History of flight

On October 12, 1997, shortly after 1728 Pacific daylight time, an experimental Adrian Davis Long EZ, N555JD, crashed into the Pacific Ocean near Pacific Grove, California. The airplane was destroyed and the pilot, the sole occupant, received fatal injuries. The accident occurred during a local, personal flight, visual meteorological conditions and no flight plan was filed.

An aircraft maintenance technician who assisted the pilot in removing the airplane from a hangar before the accident flight stated that he observed the pilot perform a preflight check that took about 20 minutes. He stated that the pilot borrowed a fuel sump cup and drained a fuel sample to check for contaminants. He did not observe whether the pilot visually verified the quantity of fuel aboard the airplane. He did not see the pilot check the engine oil level.

The technician stated that he and the pilot talked about the inaccessibility of the cockpit fuel selector valve handle and its resistance to being turned. The handle was located behind the pilot's left shoulder. They attempted to extend the reach of the handle, using a pair of vice grip pliers. But this did not solve the problem as the pilot could not reach the handle. The pilot said he would use the autopilot inflight, if necessary, to hold the airplane level while he turned the fuel selector valve.

According to the maintenance technician, the pilot declined an offer of fuel service. The pilot told him that he would only be flying for about 1 hour. The pilot then got in the airplane and proceeded with his preflight duties, including checking the operation of the control surfaces According to the technician, he observed the fuel selector handle in a vertical position. (see Aircraft Information section for a discussion of fuel selector handle ). The technician said that he went into the hangar to put away his tools, and he heard the engine start; however, it soon quit. He walked out of the hangar and observed the pilot turned in his seat to the left, toward the fuel selector location. The technician said he believes that the pilot changed the fuel selector and restarted the engine.

A review of the Monterey Peninsula Airport Air Traffic Control Tower (ATCT) tapes revealed that the pilot contacted ground control at 1702 and obtained a taxi-for-takeoff clearance from the hangar. At 1709, the pilot contacted the local controller, reported ready for takeoff on runway 28, and requested to stay in the traffic pattern for some touch-and-go landings. He was subsequently cleared for takeoff at 1712, and performed three touch-and-go landings before departing the traffic pattern about 1727. At this time the controller asked the pilot to recycle his transponder code, and the pilot did so. The ATC tapes revealed no recorded distress calls from the pilot, and the pilot did not indicate any aircraft or engine malfunctions.

A certified audio cassette re-recording of the transmissions between the accident airplane and the Monterey ATCT local control position was sent to the Safety Board's audio laboratory for analysis. The radio transmissions were examined on an audio spectrum analyzer in an attempt to identify any background sound signatures that could be associated with either the engine or the propeller. Analysis of nine transmissions between 1714 and 1728:06 showed engine speed harmonics between 2,100 and 2,200 revolutions per minute (rpm). At the last radio transmission attributed by the Federal Aviation Administration (FAA) to the accident aircraft (at 1728:06), the measured frequency was to 2,200 rpm. A copy of the laboratory report is attached.

Twenty witnesses to the accident were interviewed. Some of the witnesses observed the airplane descend into the ocean near Point Pinos approximately 150 yards off shore, where the water is 30 feet deep. Depending on where they were when the crash occurred; four of the witnesses indicated that the airplane was originally heading west; five of them observed the airplane in a steep bank, with four of those five reporting the bank was to the right (north). Twelve witnesses saw the airplane in a steep nose-down descent, and 6 of them saw the airplane hit the water. Witnesses estimated the airplane at 350 to 500 feet over the residential area while heading toward the shoreline. Eight of the witnesses said that they heard a "pop" or "backfire," along with a reduction in the engine noise level just before the airplane descended into the water.

Personnel information

The pilot's logbook was not recovered. During the investigation, the pilot's FAA airman and medical records were obtained from the Airman and Medical Records Certification Branch, FAA, in Oklahoma City, Oklahoma. On his most recent medical application of record, dated June 13, 1996, he reported a total flight time of 2,750 hours. He held a private pilot certificate, with airplane ratings for single and multiengine land, single-engine sea and gliders. He also held an instrument airplane rating and a Lear Jet type rating.

Another Long EZ pilot (hereinafter referred to as the "checkout" pilot), gave the pilot about 1/2 hour of ground and flight checkout in the accident airplane in Santa Maria, California on the day before the accident, before the pilot's departure for Monterey. He said that they performed two touch-and-go landings and some slow flight maneuvers, and that they discussed the aircraft systems, including the fuel selector location. He said that he had made arrangements with the pilot to relocate the fuel selector handle while the pilot, a musical performer, was away on tour. He also said that a pillow was placed on the back of the pilot's seat to assist him in reaching the rudder pedals.

The checkout pilot stated that about a month before the accident, he had flown in the front seat with the pilot on a demonstration flight in the accident airplane. He said the pilot had also flown in the backseat on two other Long EZ demonstration flights.

A certified true copy of the pilot's FAA medical record files were obtained and reviewed by Safety Board investigators. According to the pilot's FAA medical records, the physician who examined the pilot on June 13, 1996, issued a third-class medical certificate to the pilot at the conclusion of the examination. His FAA medical records further showed that on November 6, 1996, the FAA Civil Aeromedical Certification Division sent the pilot a letter by certified mail, return receipt requested, acknowledging receipt of his June 13, 1996, medical application and stating, in part:

We had previously received an interim report from H. C. Whitcomb, Jr., M.D., pertinent to your alcohol problem. Dr. Whitcomb reported that "in general averages two to four drinks of either wine or beer/week when he's traveling." He further stated that there has been no abuse, (see footnote 1) ...in our letter of October 18, 1995, we specified that your "continued airman medical certification remains contingent upon your total abstinence for use of alcohol."

The letter informs the pilot that based on the above information, he did not meet the medical standards prescribed in Part 67 of the Federal Aviation Regulations, and a determination was made that he was not qualified for any class of medical certificate at that time. The letter further states: "If you do not wish to voluntarily return your certificate, your file may be sent to our regional office for appropriate action." According to U. S. Postal Service markings on the envelope, the letter was returned unclaimed to the FAA on December 2, 1996.

Examination of the FAA medical file disclosed that following the return of the unclaimed November 6, 1996, letter there was no followup action by the FAA until March 25, 1997, when the agency sent the pilot a second letter by certified mail, return request requested, again notifying him that he was medically disquali