# NTSB MIA08FA052: Kaylor J E/Strahlmann R L RV-4, N580RG, Elkin, NC, February 3, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 3, 2008, 16:17 local (21:17 UTC) - Place: Elkin, NC - Coordinates: 36.281112, -80.780281 - Nearby events: https://openairdocs.org/map.md?lat=36.2811&lon=-80.7803&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-aerobatics: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report February 25, 2009 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 67457 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA08FA052 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67457/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67457 - Page: https://openairdocs.org/ntsb/MIA08FA052 ## Probable cause The pilot's decision to attempt an aerobatic maneuver in close proximity to the ground. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Kaylor J E/Strahlmann R L RV-4, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05623SM), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Kaylor J E/Strahlmann R L RV-4, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05623SM), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-aerobatics: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Kaylor J E/Strahlmann R L RV-4, 1 case](https://openairdocs.org/ntsb-events/220/sequence.md?model=05623SM), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Maneuvering-aerobatics: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Kaylor J E/Strahlmann R L RV-4, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05623SM), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The accident pilot and the pilots of 2 other airplanes departed from runway 07. After takeoff, the accident pilot turned downwind, base, and final for runway 07, and performed a low pass, flying over the runway at an estimated altitude of 8 feet above ground level (agl). Witnesses reported that when the flight was near the departure end of runway 07, the airplane was observed to pitch up and roll to the left while continuing to climb. One pilot-rated witness reported that at the top of the climb at about 250 to 300 feet agl, the airplane appeared to perform a "split s" type maneuver, and the pilot appeared to have "...dished out of the roll...." The airplane began descending in a nose-low attitude, and the witness further reported that before losing sight of the airplane due to obstructions, the airplane was flying nearly perpendicular to the runway and began a rapid nose-up pitch change. The witness then observed a fireball. Prior to landing the airplane earlier that day, the pilot performed a "poorly executed aileron roll" at a low altitude. The pilot was not wearing a parachute as required for aerobatic flight, and was below the 1,500 feet agl requirement for executing aerobatic maneuvers. Postaccident examination of the flight control system revealed no preimpact failures or malfunctions, nor were any identified with the engine or any other system onboard the airplane. ## Factual narrative HISTORY OF FLIGHT On February 3, 2008, about 1617 eastern standard time, an experimental amateur built RV-4, N580RG, crashed while maneuvering at Elkin Municipal Airport (ZEF), Elkin, North Carolina. The flight was operated by the pilot as a personal flight under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The airplane was substantially damaged by impact and a postcrash fire, and the commercial pilot, the sole occupant, was killed. The flight originated about 1612, from Elkin Municipal Airport. The accident pilot and the pilots of 2 other airplanes departed from runway 07. After takeoff, the accident pilot turned downwind, base, and final for runway 07, and performed a low pass flying over the runway at an estimated altitude of 8 feet above ground level (agl). Witnesses reported that when the flight was near the departure end of runway 07, the airplane was observed to pitch up and roll to the left while continuing to climb. One pilot-rated witness reported that at the top of the climb at about 250 to 300 feet agl, the airplane appeared to perform a "split s" type maneuver, and the pilot appeared to have "...dished out of the roll...." The airplane began descending in a nose-low attitude, and the witness further reported that before losing sight of the airplane due to obstructions, the airplane was flying nearly perpendicular to the runway and began a rapid nose-up pitch change. The witness then observed a fireball. Friends of the pilot were at ZEF and witnessed the accident. PERSONNEL INFORMATION The pilot, age 64, held a commercial pilot certificate with an airplane single engine land rating issued September 12, 1969, and held a third class medical certificate issued March 1, 2006, with a limitation to have available glasses for near vision. The pilot's logbook was not located. He listed 2,050 hours total time on the application for his last medical certificate. AIRCRAFT INFORMATION The amateur-built airplane was manufactured in October 1993, as model RV-4, and was designated serial number 2148. It was powered by a Lycoming O-320-B3B 160 horsepower engine and equipped with an Edward Sterba 68-70 wood fixed-pitch propeller. The pilot purchased the airplane on September 20, 2005. The maintenance records were not located. No determination could be made as to when the airplane's last condition inspection occurred. METEOROLOGICAL INFORMATION A surface observation weather report taken at Wilkes County Airport (UKF), North Wilkesboro, North Carolina, at 1621, or approximately 4 minutes after the accident indicates the wind was from 070 degrees at 3 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dew point were 15 and minus 02 degrees Celsius respectively, and the altimeter setting was 30.17 inches of mercury. The accident airport was located 084 degrees and 15.5 nautical miles from UKF. COMMUNICATIONS The ZEF airport is equipped with a common traffic advisory frequency (CTAF) of 123.05 MHz, which is not recorded. There is no information that would suggest the pilot announced on the CTAF his intention of performing low level aerobatics. AIRPORT INFORMATION The ZEF airport is equipped with one runway designated 07/25. WRECKAGE AND IMPACT INFORMATION Examination of the departure end of runway 07 revealed ground scars on grass south of the south edge of runway 07/25. The ground scars were oriented on a magnetic heading of 164 degrees. The first ground scar was located approximately 16 feet south of the south edge of the runway. Several marks on the grass continue to a berm located approximately 47 feet from the south edge of the runway. Pieces of wooden propeller blade were located at the berm. Additionally, gray colored paint was noted at the ground scars south of the runway. The airplane came to rest inverted in an area of lower elevation south of the runway. Fire damage to the ground was noted between the berm and final resting point of the wreckage. Examination of the airplane revealed the cockpit, fuselage, and inboard portion of both wings were consumed in the postcrash fire. All components necessary to sustain flight remained attached to the airplane. Examination of the rudder and elevator flight control system revealed no evidence of preimpact failure or malfunction. Examination of the aileron flight control system revealed the left and right aluminum pushrod assemblies (Control Stick to Bellcrank, P/N W-416) were consumed by fire in each wing root area; however, each respective rod end that connects to the rear control stick remained connected at the control stick. The remaining sections of the left and right pushrod assemblies were connected at each aileron bellcrank. Further examination of the aileron flight control system revealed the right pushrod assembly (P/N W-418) was connected at the bellcrank and at the control surface. The left pushrod assembly (P/N W-418) was connected at the bellcrank but was separated from the rod end that remained connected to the control surface. Comparison of the left and right pushrod assemblies (P/N W-418) revealed the threaded rod ends at each end of the right tube were secured to it by two rivets 90 degrees apart, while only the threaded rod end at the left bellcrank was secured by rivets. The threaded rod end for the left pushrod assembly near the control surface was not secured by rivets. The left pushrod assembly and rod end were retained for further examination. Examination of the engine with Federal Aviation Administration (FAA) oversight revealed crankshaft, camshaft, and valve train continuity during hand rotation of the crankshaft. Fire damage to the engine and engine accessories precluded an engine run. The magnetos and carburetor were heat damaged which precluded bench testing. The spark plug electrodes were light gray in color consistent with normal fuel/air metering. No evidence of preimpact failure or malfunction of the engine or engine accessories was noted. Examination of the two-bladed wood propeller which remained attached to the engine revealed both blades were shattered and heat damaged to the root end of each blade. As previously reported, sections of propeller blade were noted at the initial ground impact location. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was performed by Wake Forest University School of Medicine Department of Pathology. The cause of death was listed as "blunt force injuries to head and torso." The autopsy report did not indicate the pilot was wearing a parachute. Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, cyanide, volatiles, and tested drugs. TESTS AND RESEARCH The pilot landed at ZEF approximately 1.5 hours earlier, and prior to landing, the accident pilot performed a low pass over runway 25. When the flight was past the departure end of runway 25, the accident pilot was noted to perform a "poorly executed aileron roll." After completing the roll, the accident pilot remained in the traffic pattern, landed uneventfully on runway 25, and then secured the airplane. There was no evidence indicating the pilot reported on the CTAF that he intended to perform low level aerobatics. The airport manager who is also a pilot and was at the airport at the time did not discuss the low level aerobatics issue with the accident pilot. Examination of the left pushrod assembly (P/N W-418) was performed by the National Transportation Safety Board's Materials Laboratory. The rod end and threaded rod end assembly that connect to the aileron flight control surface exhibited a bend of approximately 3 degrees centered where the thread portion of the threaded rod end joined the plain diameter portion. The ## Aircraft - Registration: [N580RG](https://openairdocs.org/deregistered/N580RG-2009-04-23), registration cancelled 2009-04-23, S/N 2148, built 1993 (OpenAirDocs) - Reported make and model: KAYLOR J E/STRAHLMANN R L RV-4 - Registry model: [Kaylor J E/Strahlmann R L RV-4](https://openairdocs.org/model/kaylor-j-e-strahlmann-r-l-rv-4) (registry code 05623SM) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 2148 - Engines: LYCOMING O-320 160 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Proctor Lawrence D - Registered owner: Proctor Lawrence D - Airworthiness certificate: Special, Experimental (Special) - Departed: ZEF, Elkin, NC - Destination: Unknown - Airport: ZEF, Elkin Municipal Airport, runway 07, 4,003 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; commercial; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: front; toxicology performed; flight hours: 2,050 total ## Weather - Conditions: Visual (VMC), Day - Wind: 70° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 28 °F - Altimeter: 30.17 inHg - Observed at: UKF, 16 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 20080203011059A](https://openairdocs.org/incident/20080203011059A), Feb 3, 2008: Amtr RV4, Elkin, NC, Destroyed, 1 fatal. (-23) After takeoff, pilot attempted an aileron roll, lost control of aircraft and struck embankment. Aircraft became inverted and caught fire continuing down… ## Docket (22 files) The files NTSB released with the investigation on January 17, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67457. 8.0 MB in all. - Materials Laboratory Factual Report of 08-018 (item 1, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293610&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%20of%2008-018-Master.PDF - Witness Statements (item 2, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306224&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Weather Reports and Records (item 3, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306225&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - FAA Inspector Statement (item 4, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306226&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Drawing Excerpt (item 5, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306237&FileExtension=.PDF&FileName=Drawing%20Excerpt-Master.PDF - 14 Code of Federal Regulation (CFR) Part 91.303 (item 6, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306247&FileExtension=.PDF&FileName=14%20Code%20of%20Federal%20Regulation%20(CFR)%20Part%2091.303-Master.PDF - 14 Code of Federal Regulation (CFR) Part 91.307 (item 7, .PDF, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306263&FileExtension=.PDF&FileName=14%20Code%20of%20Federal%20Regulation%20(CFR)%20Part%2091.307-Master.PDF - Record of NTSB Conversation (item 8, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306252&FileExtension=.PDF&FileName=Record%20of%20NTSB%20Conversation-Master.PDF - Record of Conference Call (item 9, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306253&FileExtension=.PDF&FileName=Record%20of%20Conference%20Call-Master.PDF - Toxicological Report (item 10, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306227&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - RVator (Newsletter) (item 11, .PDF, 801 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306220&FileExtension=.PDF&FileName=RVator%20(Newsletter)-Master.PDF - Document from North Carolina Highway Patrol (item 12, .PDF, 570 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306272&FileExtension=.PDF&FileName=Document%20from%20North%20Carolina%20Highway%20Patrol-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306228&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: NTSB Digital Photograph. View of the First Ground Contact Marks. (item 14, .PDF, 646 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306254&FileExtension=.PDF&FileName=Photo%201%3A%20NTSB%20Digital%20Photograph.%20View%20of%20the%20First%20Ground%20Contact%20Marks.-Master.PDF - Photo 2: NTSB Digital Photograph. View Showing the Berm Contact. The Main Wreckage is in the Background. (item 15, .PDF, 621 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306255&FileExtension=.PDF&FileName=Photo%202%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Berm%20Contact.%20The%20Main%20Wreckage%20is%20in%20the%20Background.-Master.PDF - Photo 3: NTSB Digital Photograph. View From the Edge of the Berm With the Wreckage Visible in the Background. (item 16, .PDF, 589 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306256&FileExtension=.PDF&FileName=Photo%203%3A%20NTSB%20Digital%20Photograph.%20View%20From%20the%20Edge%20of%20the%20Berm%20With%20the%20Wreckage%20Visible%20in%20the%20Background.-Master.PDF - Photo 4: NTSB Digital Photograph. View Showing the Wreckage (item 17, .PDF, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306257&FileExtension=.PDF&FileName=Photo%204%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Wreckage-Master.PDF - Photo 5: NTSB Digital Photograph. View Showing the Engine and Propeller (item 18, .PDF, 697 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306258&FileExtension=.PDF&FileName=Photo%205%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Engine%20and%20Propeller-Master.PDF - Photo 6: NTSB Digital Photograph. View of the Left Wing. (item 19, .PDF, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306259&FileExtension=.PDF&FileName=Photo%206%3A%20NTSB%20Digital%20Photograph.%20View%20of%20the%20Left%20Wing.-Master.PDF - Photo 7: NTSB Digital Photograph. View Showing the Disconnected Left Aileron Pushrod From the Rod End. (item 20, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306260&FileExtension=.PDF&FileName=Photo%207%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Disconnected%20Left%20Aileron%20Pushrod%20From%20the%20Rod%20End.-Master.PDF - Photo 8: NTSB Digital Photograph. View Showing the Left Pushrod Assembly (Bellcrank to Aileron), Connected at the Bellcrank. Note the two Rivets Securing the Rod End to the Pushrod Tube. (item 21, .PDF, 699 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306261&FileExtension=.PDF&FileName=Photo%208%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Left%20Pushrod%20Assembly%20(Bellcrank%20to%20Aileron),%20Connected%20at%20the%20Bellcrank.%20Note%20the%20two%20Rivets%20Securing%20the%20Rod%20End%20to%20the%20Pushrod%20Tube.-Master.PDF - Photo 9: NTSB Digital Photograph. View Showing the Left Aileron Pushrod Assembly (Bellcrank to Aileron) with Disconnected Rod End. (item 22, .PDF, 616 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40306262&FileExtension=.PDF&FileName=Photo%209%3A%20NTSB%20Digital%20Photograph.%20View%20Showing%20the%20Left%20Aileron%20Pushrod%20Assembly%20(Bellcrank%20to%20Aileron)%20with%20Disconnected%20Rod%20End.-Master.PDF From the NTSB's public API. 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