# NTSB NYC06LA112: Bulmer Lancair IV-P, N5473, Somerset, PA, May 10, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: May 10, 2006, 15:25 local (19:25 UTC) - Place: Somerset, PA - Coordinates: 40.038887, -79.014442 - Nearby events: https://openairdocs.org/map.md?lat=40.0389&lon=-79.0144&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 29, 2007 - Report: Approved by Office Director - Parties: Teledyne Continental, FAA/FSDO - NTSB case key (mKey): 63666 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC06LA112 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/63666/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=63666 - Page: https://openairdocs.org/ntsb/NYC06LA112 ## Probable cause The pilot's failure to maintain sufficient airspeed after takeoff to preclude a stall, which resulted in a loss of control and an inadvertent stall. Factors associated with the accident are the inadvertent stall, the loss of engine power due to the pilot's inadvertent activation of the high pressure auxiliary fuel pump, and the pilot's failure to abort the takeoff after receiving abnormal engine and fuel flow warnings on the primary flight display. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - nonmechanical, takeoff - roll/run - aborted takeoff - not performed, pilot in command (contributing factor) - fuel system,electric boost pump - output high (contributing factor) - Loss of control - in flight, takeoff - initial climb - airspeed(vs) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - grass ## Analysis The experimental airplane had accrued 27 hours of total flight time, and had just completed its 25-hour Phase I flight testing period. Witnesses related that they saw the airplane engine start, and that the crew appeared to go through an extensive series of checks for approximately 10 minutes prior to takeoff. The engine idled smoothly, and was accelerated several times prior to taxi, once to full power. At takeoff, with a tailwind, the airplane accelerated smoothly, and rotated at a point along the runway that the witnesses thought was later than usual. The airplane pitched nose-up about 20 to 30 degrees in the climb, and the landing gear retracted. When the airplane reached treetop height, black smoke trailed from the engine exhaust system, and the engine "sputtered." The airplane entered a smooth roll to the left, yawed left, and then "plunged" to the ground, in a near vertical attitude. Witnesses said the turn after the loss of engine power was performed at a very high deck angle. Examination of data extracted from the airplane's electronic flight instrumentation system revealed that during the takeoff roll, the fuel flow was more than 20 percent above maximum, and the propeller was over-speeding. The engine rpm, fuel flow, and "Engine" warnings on the multi-function displays should have been visible to the crew. Examination of flight data revealed that the airplane continued to pitch-up as high as 22 degrees, as altitude decreased and airspeed decayed. Examination of the cockpit schematic revealed that the auxiliary fuel pump "high boost/low boost" switch was positioned next to the "Nav" lighting switch. In the airplane's "Before Takeoff" checklist, the "Lights-as required" task was to be performed four tasks prior to the "Takeoff" checklist. ## Factual narrative HISTORY OF FLIGHT On May 10, 2006, at 1525 eastern daylight time, an amateur-built Lancair IV-P, N5473, was destroyed following an uncontrolled descent after takeoff from runway 7 at Somerset County Airport (2G9), Somerset, Pennsylvania. Both certificated commercial pilots were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the ferry flight conducted under 14 CFR Part 91. The purpose of the flight was to deliver the airplane to its owner on the west coast; however, the planned stopover destinations could not be determined. Several witnesses observed the accident flight, and their versions of the event remained consistent. According to the witnesses, the airplane engine started, and the crew appeared to go through an extensive series of checks for approximately 10 minutes prior to takeoff. The engine idled smoothly, and was accelerated several times prior to taxi, once to full power. The engine ran smoothly and without interruption throughout the pre-takeoff checks. At takeoff, the airplane accelerated smoothly, and rotated at a point along the runway that was "later than usual." The airplane pitched nose-up about "20 to 30 degrees" in the climb, and the landing gear retracted. When the airplane reached treetop height, black smoke trailed from the engine exhaust system, the engine "sputtered," and then stopped producing power. The airplane entered a "smooth roll" to the left, yawed left, and then "plunged" to the ground, near vertically. The witnesses said the turn after the loss of engine power, was performed at a "very high deck angle." The accident occurred during the hours of daylight approximately 39 degrees, 14 minutes north latitude, and 76 degrees, 31 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single-engine land, and instrument airplane. The pilot had accrued 2,571 total hours of flight experience, with 500 hours in make and model. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued in October 2005. The copilot held a commercial pilot certificate with ratings for airplane single engine land, multi-engine land, and instrument airplane. He also held a flight engineer certificate with a rating for turbojet airplanes. The copilot had accrued 5,585 total hours of flight experience. His most recent FAA third-class medical certificate was issued in December 2005. AIRCRAFT INFORMATION Examination of the aircraft logbooks revealed that the airplane had accrued 27 total hours of flight time, and the most recent airworthiness inspection was completed on July 31, 2005. The 25-hour Phase I flight testing period, as prescribed by the Operating Limitations outlined by the FAA Manufacturing and Inspection District Office, New Cumberland, Pennsylvania, had just been completed. METEOROLOGICAL INFORMATION At 1454, the weather reported at the Johnstown-Cambria Airport, Johnstown, Pennsylvania, 19 miles northeast, included visibility 10 miles, clear skies, and winds from 200 degrees at 8 knots. The temperature was 71 degrees Fahrenheit, and the dew point was 35 degrees Fahrenheit. WRECKAGE AND IMPACT INFORMATION The airplane was examined and photographed at the site by FAA aviation safety inspectors, and all major components were accounted for at the scene. The initial ground scar was 50 feet beyond the departure end of the runway, and 200 feet left of centerline. The airplane came to rest on its right side facing opposite the direction of travel. The nose, engine, cockpit, and cabin areas were destroyed by impact, and fragments of composite materials were scattered in a wide arc beyond the wreckage. The engine came to rest inverted and displayed impact damage to the intake and exhaust tubes. The oil pan was crushed. The number 3 and number 5 cylinders displayed impact damage and appeared displaced. The spark plugs were removed, and the electrodes were dark and soot covered. The engine crankshaft was rotated by hand at the propeller, and continuity was confirmed through the powertrain, valvetrain, and accessory sections. Compression was confirmed on all but the number 5 cylinder, using the thumb method. The fuel pump ejected fuel when actuated. Field tests could not be completed on either magneto due to impact damage. The engine examination was suspended, and the engine and its accessories were moved to an engine overhaul facility in Mattituck, New York, for further examination. TESTS AND RESEARCH The engine was examined in Mattituck, New York, on August 22, 2006. A complete disassembly of the engine revealed no abnormal wear or mechanical deficiency. Electrical power was applied to the auxiliary fuel pump and the motor ran at high rpm and pumped liquid at a constant rate. The pump was forwarded to the manufacturer and bench tested. Test results revealed that the pump operated at the proper flow rates in both the high and low settings. The airplane was equipped with a Chelton Flight Systems Electronic Flight Instrumentation System (EFIS). FAA inspectors recovered the non-volatile memory from the EFIS, and forwarded it to Chelton Flight Systems for data recovery. The last flight, and four previous "power-ups" of the system, was recovered. No previous flights were recovered. The data was then downloaded into a software program that re-created the accident flight on simulated primary flight and engine instrument displays, as viewed by the pilot. Examination of the data revealed that the engine rpm and fuel flow limits were exceeded during the ground roll prior to takeoff. Once these limits were exceeded, the fuel flow peaked between 52 and 53 gallons per hour and remained there for the duration of the takeoff, the manifold pressure peaked and remained between 38.7 and 38.9 inches of Hg., while the propeller rpm fluctuated between 2,730 and 3,190 rpm. The maximum rated propeller speed for the Continental TSIO-550-E was 2,700 rpm. The maximum fuel flow was 41.7 to 43.4 gallons per hour. Examination of the flight data revealed that, early in the climb the airplane achieved positive climb rates of between 1,400 and 1,700 feet per minute, at speeds between 73 and 83 knots. Once the pitch-up attitude continued beyond 13.7 degrees, the positive climb rate diminished, and beyond 17.7 degrees, the airplane entered a descent, yet continued to increase nose-up pitch. The data showed that the airplane reached a maximum pitch-up attitude of 22.3 degrees, as it descended straight ahead for several seconds, while the propeller speed and fuel flow rate remained well above the maximum. A review of the computer simulation revealed that during the takeoff roll, when the fuel flow exceeded the maximum, the fuel-flow needle and gauge, as well as the tachometer needle and gauge, flashed on the multi-function display. These events were followed immediately by an "Engine" warning illumination on the primary flight display. According to the airplane's checklist, a normal takeoff was performed by a nosewheel "lift at 65 knots." Best angle of climb (Vx) was 110 knots with 10 degrees of flaps, and best rate of climb (Vy), was 135 knots with flaps retracted. Examination of the data revealed that the airplane reached a top speed of 86 knots, at which point the rate of climb became a negative number. From that point, the airplane decelerated and descended until ground contact. MEDICAL AND PATHOLOGICAL INFORMATION The Somerset County Coroner, Johnstown, Pennsylvania, performed autopsies on both pilots on May 11, 2006. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on both pilots. ADDITIONAL INFORMATION Examination of the cockpit schematic revealed that the auxiliary fuel pump "high boost/low boost" switch was positioned ## Aircraft - Registration: [N5473](https://openairdocs.org/deregistered/N5473-2013-11-04), registration cancelled 2013-11-04, S/N LIV-473, built 2000 (OpenAirDocs) - Reported make and model: Bulmer Lancair IV-P - Registry model: [Bulmer Jeffrey S LANCAIR IV-P](https://openairdocs.org/model/bulmer-jeffrey-s-lancair-iv-p) (registry code 05617YW) (OpenAirDocs) - Registry engine: [Continental TSIO-550-E](https://openairdocs.org/engine/continental-tsio-550-e) (registry code 17247, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: LIV-473 - Airframe hours: 27 - Engines: Continental TSIO-550-E 350 horsepower reciprocating - Damage: Destroyed - Flight: Positioning, Part 91 - Registered owner: N5473 LLC - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Continuous airworthiness, July 1, 2005, 27 hours before - Departed: 2G9, SOMERSET, PA - Airport: 2G9, Somerset County Airport, runway 06, 4,697 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; toxicology performed; flight hours: 2,571 total, 500 in this make and model - Co-pilot; age 59; injuries: fatal; flight engineer, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; seat: right; toxicology performed; flight hours: 5,585 total ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 34 °F - Altimeter: 29.84 inHg - Observed at: JST, 19 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 20060510025439A](https://openairdocs.org/incident/20060510025439A), May 10, 2006: Amtr LANCAIRIVP, Somerset, PA, Destroyed, 2 fatal. (-23) Shortly after takeoff from runway 7 at Somerset County Airport (2G9), eyewitnesses state there was a trail of black smoke coming from the aircraft, and… ## Docket (10 files) The files NTSB released with the investigation on April 15, 2007, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=63666. 1.7 MB in all. - PFD/MFD/Engine Data Animation (item 1, .PDF, 7 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274479&FileExtension=.PDF&FileName=PFD%2FMFD%2FEngine%20Data%20Animation-Master.PDF - Witness Statements (item 2, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274620&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Airport Manager's Follow Up Statement (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40280192&FileExtension=.PDF&FileName=Airport%20Manager%27s%20Follow%20Up%20Statement-Redacted.PDF - Continental Engine Field Report (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385042&FileExtension=.PDF&FileName=Continental%20Engine%20Field%20Report-Redacted.PDF - Owner's Email (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274624&FileExtension=.PDF&FileName=Owner%27s%20Email-Redacted.PDF - Normal Checklist (item 6, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274625&FileExtension=.PDF&FileName=Normal%20Checklist-Master.PDF - Emergency Checklist (item 7, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274626&FileExtension=.PDF&FileName=Emergency%20Checklist-Master.PDF - Pilot Tox Report (item 8, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274628&FileExtension=.PDF&FileName=Pilot%20Tox%20Report-Master.PDF - Co-pilot Tox Report (item 9, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274627&FileExtension=.PDF&FileName=Co-pilot%20Tox%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40274882&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.