# NTSB NYC08FA292: Steven A. Jones Lancair IV P, N731SJ, Stafford, VA, August 11, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Field investigation · Final report - Date: August 11, 2008, 08:39 local (12:39 UTC) - Place: Stafford, VA - Coordinates: 38.398056, -77.455558 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.3981&lon=-77.4556&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 11, 2010 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 68803 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08FA292 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68803/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68803 - Page: https://openairdocs.org/ntsb/NYC08FA292 ## Probable cause The pilot's decision to install voltage regulators in the engine compartment where they were susceptible to water intrusion, which resulted in a malfunction of the standby electrical system's voltage regulator and a subsequent in-flight fire. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Electrical power system: dC regulator](https://openairdocs.org/ntsb-findings/01022436): Aircraft › Aircraft systems · Malfunction; cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-findings/01022436/cases.md?model=05620O6), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01022436/cases.md) - [Electrical power system: battery/charger](https://openairdocs.org/ntsb-findings/01022432): Aircraft › Aircraft systems · Failure; cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-findings/01022432/cases.md?model=05620O6), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022432/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05620O6), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Pilot; cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05620O6), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Electrical system malf/failure](https://openairdocs.org/ntsb-events/332) (defining event); cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-events/332/sequence.md?model=05620O6), [All aircraft, 182 cases](https://openairdocs.org/ntsb-events/332/sequence.md) - [Maneuvering: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=05620O6), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Jones Steven LANCAIR-IV-P, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=05620O6), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The airplane was equipped with a dual battery system. After takeoff the pilot turned on the standby battery switch to charge the standby battery. He smelled smoke which became “very heavy and thick.” After landing, he opened the door and the smoke evacuated. He observed "billowing clouds of black and gray acrid smoke," toward the rear of the airplane. After opening the baggage compartment door, and removing the compartment floor, the pilot discharged a fire extinguisher into the area of the standby battery. He observed a flame, and discharged the fire extinguisher again. He then observed a red glow in the battery box. During construction of the airplane, the pilot had coated the inside of the battery box with room temperature vulcanizing (RTV) silicone. Examination revealed, remnants of a charred wood block (a combustible organic material), and the RTV silicone which had charred, melted, and adhered to the top of the standby battery and its partially melted vent caps. Holes with charring along the upper edge of one side of the battery case were evident where the battery outgassed since its vents caps were blocked. Lead acid batteries must be protected from overcharging and sources of ignition, as hydrogen gas can explode when ignited. Sulfuric acid in contact with combustible and/or organic materials can cause fire or explosion. The airplane’s voltage regulators were mounted in the engine compartment. Their cases were metal, they were rectangular in shape, and a plastic terminal strip protruded from a slot in the case on one side. The regulators were not potted, the internal circuit board was not conformally coated, and no weather seal existed between the plastic terminal strip and the case. Water staining and evidence of arcing were present on the inside of the standby regulator. The manufacturer recommended the regulators be installed in a location that would protect them from heat, vibration, and water on the pilot side of the firewall, or inside the cabin. The pilot was aware of the recommendation, but thought that the heat in the airplane would be worse in the cockpit than in the engine compartment. He also believed the regulators were "sealed in Bakelite," and it would provide "ease of access" to mount them on the firewall. ## Factual narrative HISTORY OF FLIGHT On August 11, 2008, at 0839 eastern daylight time, an experimental amateur built Jones Lancair IV-P, was substantially damaged by an in-flight fire shortly after takeoff from Stafford Regional Airport (RMN), Stafford, Virginia. The certificated airline transport pilot and his one passenger were uninjured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal local flight conducted under 14 Code of Federal Regulations (CFR) Part 91. The airplane was equipped with a dual battery system. According to the pilot, after departing runway 33 at RMN he turned on the "rear battery switch" to charge the battery. Upon reaching 3,000 feet above mean sea level he engaged the autopilot to run a flight test. After turning the airplane to the right and left utilizing the heading select knob he suddenly smelled smoke. At this point the airplane was about 12 nautical miles from the airport. The pilot checked all of the engine indications and they were "normal." He then checked all of the circuit breakers and they were also "normal." While turning towards the airport, the pilot then turned off both battery, and both alternator switches. The pilot noticed that the smoke seemed to be getting "heavy" in the cockpit and breathing was "uncomfortable." He joined the downwind leg of the airport traffic pattern. He then turned on the "front battery" and transmitted that he was on the downwind leg of the traffic pattern and that he was going to land on runway 33. At this point he lowered the wing flaps and slowed to approach speed. The pilot heard another pilot transmit over the radio that he was on the right base leg for runway 33 and after acquiring the airplane visually, planned to land after the other aircraft, and shut off the battery once again. He then noticed when he was a 1/2 mile from touchdown that his landing gear was not down as the landing gear was actuated by an electrically powered hydraulic pump, and he had the battery off. He then executed a "go-around," and rejoined the traffic pattern for landing. As the pilot once again joined the downwind leg of the traffic pattern, he manually extended the landing gear using the hand operated pump as he was not sure what the source of the smoke was and thought that it might be the hydraulic pump motor. He then "pulled" the landing gear circuit breaker and when he "got pump resistance," he turned on the front battery and confirmed that the landing gear was down by observing that all three landing gear down indicator lights were illuminated. As the pilot flew the airplane on to the final for runway 33 the smoke was "very heavy and thick." The electric pitch trim was unavailable, but the landing and rollout were "normal." When the airplane was slowed to a safe taxi speed, the pilot opened the door and the smoke was "immediately" evacuated. The pilot observed that everything was "normal up front" and taxied the airplane to its hangar and shut down the engine. Upon exiting the airplane and looking toward the rear of the airplane, he was shocked to see "billowing clouds of black and gray acrid smoke." He then shouted to his passenger "the planes on fire get out." The pilot then retrieved a key to the baggage compartment door, opened the door, and smoke and heat "hit him full in the face." He then ran into the hangar and retrieved a cordless electric drill and Phillips head screwdriver bit. Five of the six screws were already loose from the fire and he removed the remaining screw, which held the floor in place with the cordless drill. He then reached in and removed the baggage compartment floor and false bulkhead from the rear of the baggage compartment. It was still very hot though, and the pilot could not see the battery or hydraulic pump due to the smoke. The passenger at this time retrieved a fire extinguisher and the pilot took it and discharged the fire extinguisher into the battery area. He then could see the battery. The battery had a visible flame for a "few seconds" and he discharged the fire extinguisher once again. When the "dust" from the fire extinguisher had settled, he observed a red glow in the center of the battery box. PERSONNEL INFORMATION According to FAA records, the pilot held an airline transport certificate with multiple ratings including airplane single-engine-land. He reported 11,360 total hours of flight experience on his most recent application for a Federal Aviation Administration (FAA) second-class medical certificate, dated August 12, 2008. AIRCRAFT INFORMATION The accident airplane was a single engine, pressurized, low wing monoplane with retractable landing gear, and a three bladed constant speed propeller. It was powered by a turbocharged 350 horsepower Continental TSIO-550-E that drove a primary and standby alternator which powered the airplanes main and standby electrical systems. It was equipped with an electronic flight instrumentation system (EFIS) and was classified by the FAA as a technically advanced aircraft. According to FAA and maintenance records, the airplane's special airworthiness certificate was issued on September 2, 2006.The airplane's most recent conditional inspection was completed on October 28, 2007 and at the time of the accident, the airplane had accrued 96 total hours of operation. METEOROLOGICAL INFORMATION A weather observation taken about 1 minute after the accident, at RMN included; wind at 310 degrees at 3 knots, visibility 10 miles, temperature 20 degrees Celsius (C), dew point 16 degrees C, and an altimeter setting of 29.89 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the airplane by National Transportation Safety Board Investigators revealed the fire had damaged approximately three feet of the aft fuselage in the area of the standby (rear) battery box and baggage compartment. The damaged section of the aft fuselage exhibited areas of peeling and blistered paint, softness, delamination, and sooting. Internal examination of the aft fuselage also revealed evidence of fire damage to the wiring harness, standby battery contactor, standby battery box, and standby battery. Further examination revealed that a charred rubber like substance had adhered to the top of the standby battery and its vent caps, along with the charred remnants of a rectangular shaped wood block. The standby battery’s vent caps were partially melted, and holes with charring along their circumference were present along the upper edges on one side of the battery. Examination of the wiring forward of the baggage compartment area revealed no evidence of any damage. The primary and standby voltage regulators, the remains of the standby battery, and the standby battery contactor, were removed by the Safety Board for further examination. TESTS AND RESEARCH Download of the EFIS revealed no anomalies with the main electrical system of the airplane. The standby system was not recorded. According to the pilot, the last time that any work had been performed had been in “mid- July,” is when he had installed an auxiliary power plug in the backseat of the airplane. The airplane had flown since the installation however, with no problems. Review of the regulator manufacturer's schematics which were provided by the pilot to the NTSB revealed that they did not include a provision for a standby battery. Three pages of hand drawn schematics of the airplane's wiring system provided by the pilot revealed that he had modified the basic design shown on the regulator manufacturer's schematics to include a standby battery, however it was discovered, that the drawings contained discrepancies which prevented determination of the airplane electrical system's actual configuration. Standby Battery Box According to the pilot, when he had built the standby battery box, he had glassed in “nuts” to vent the top of the battery box, and at the lowest ## Aircraft - Registration: [N731SJ](https://openairdocs.org/deregistered/N731SJ-2011-04-11), registration cancelled 2011-04-11, S/N LIV-575, built 2006 (OpenAirDocs) - Reported make and model: Steven A. Jones Lancair IV P - Registry model: [Jones Steven LANCAIR-IV-P](https://openairdocs.org/model/jones-steven-lancair-iv-p) (registry code 05620O6) (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-575 - Airframe hours: 96 - Engines: Continental TSIO-550-E 350 horsepower reciprocating - Damage: Substantial damage - Fire: Both - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, October 28, 2007 - Departed: RMN, Stafford, VA - Destination: RMN, Stafford, VA - Airport: RMN, Stafford Regional, runway 33, 5,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: none; flight instructor, airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 1, 2007; seat: left; flight hours: 8,100 total, 80 in this make and model, 6,700 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 3 knots - Visibility: 10 statute miles - Temperature: 68 °F, dew point 61 °F - Altimeter: 29.88 inHg - Observed at: RMN ## 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 20080811849849A](https://openairdocs.org/incident/20080811849849A), Aug 11, 2008: Joness LANCAIRIVP, Stafford, VA, Substantial damage. (-23) The aircraft, N731SJ a Lancair iv-p departed from krmn for a local flight at approx 0915. Upon reaching a cruise altitude of 3000 feet the PIC turned on… ## Docket (16 files) The files NTSB released with the investigation on February 18, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68803. 13.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 594 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326938&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326945&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Redacted.PDF - Weather Reports And Records (KRMN METARs) (item 3, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326955&FileExtension=.PDF&FileName=Weather%20Reports%20And%20Records%20(KRMN%20METARs)-Master.PDF - Wiring Diagrams (item 4, .PDF, 605 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326939&FileExtension=.PDF&FileName=Wiring%20Diagrams-Master.PDF - N731SJ Hand Drawn Schematics of Electrical System (item 5, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327321&FileExtension=.PDF&FileName=N731SJ%20Hand%20Drawn%20Schematics%20of%20Electrical%20System-Master.PDF - Manufacturer's Installation Instructions For Main and Standby Regulators (item 6, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326957&FileExtension=.PDF&FileName=Manufacturer%27s%20Installation%20Instructions%20For%20Main%20and%20Standby%20Regulators-Master.PDF - Chelton Log Files (Main Electrical System) (item 7, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326941&FileExtension=.PDF&FileName=Chelton%20Log%20Files%20(Main%20Electrical%20System)-Master.PDF - Fastbuild Options List (item 8, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326943&FileExtension=.PDF&FileName=Fastbuild%20Options%20List-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327407&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - N731SJ Photograph of Terminal Strip (item 10, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326965&FileExtension=.PDF&FileName=N731SJ%20Photograph%20of%20Terminal%20Strip-Master.PDF - N731SJ Photograph of Terminal Strip (Closeup) (item 11, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326970&FileExtension=.PDF&FileName=N731SJ%20Photograph%20of%20Terminal%20Strip%20(Closeup)-Master.PDF - N731SJ Photographs of Standby Regulator (Interior) (item 12, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326967&FileExtension=.PDF&FileName=N731SJ%20Photographs%20of%20Standby%20Regulator%20(Interior)-Master.PDF - N731SJ Photograph of Battery and Battery Box (item 13, .PDF, 551 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327112&FileExtension=.PDF&FileName=N731SJ%20Photograph%20of%20Battery%20and%20Battery%20Box-Master.PDF - N731SJ Photograph of Internal Fuselage Damage (item 14, .PDF, 632 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40327113&FileExtension=.PDF&FileName=N731SJ%20Photograph%20of%20Internal%20Fuselage%20Damage-Master.PDF - N437RP Original Regulator Installation (Photo) (item 15, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326954&FileExtension=.PDF&FileName=N437RP%20Original%20Regulator%20Installation%20(Photo)-Master.PDF - N437RP Modified Regulator Installation (Photo) (item 16, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326949&FileExtension=.PDF&FileName=N437RP%20Modified%20Regulator%20Installation%20(Photo)-Master.PDF From the NTSB's public API. 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