# NTSB SEA02LA072: Gallagher Taylor "Coot", N41RG, Creswell, OR, April 21, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 21, 2002, 13:05 local (20:05 UTC) - Place: Creswell, OR - Coordinates: 43.916667, -123.011108 - Nearby events: https://openairdocs.org/map.md?lat=43.9167&lon=-123.0111&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 25, 2003 - Report: Approved by Office Director - Parties: FAA-FSDO - NTSB case key (mKey): 54568 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA02LA072 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54568/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54568 - Page: https://openairdocs.org/ntsb/SEA02LA072 ## Probable cause A loss of engine power due to oil starvation followed by the pilot's failure to maintain aircraft control during the initial climb shortly after takeoff. An improper engine modification was a factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - maintenance,modification - improper, pilot in command (contributing factor) - fluid,oil - starvation (cause) - Forced landing, descent - emergency - Loss of control - in flight, takeoff - initial climb - aircraft control - not maintained, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - open field ## Analysis During the maiden flight of the experimental aircraft, shortly after takeoff, the engine began to run rough and subsequently quit. Witnesses observed the nose of the airplane drop and shortly thereafter, the airplane collided with the terrain in an open flat field located about one mile from the airport. Post-crash inspection of the airframe revealed no malfunctions in the aircraft's airframe or flight controls. In discussions with people at the airport, the pilot reported that he was having trouble getting the right fuel/oil mixture for the Mazda rotary engine. Each time the engine was run, the spark plugs would foul. Examination of the engine revealed that the engine was seized, with both rotors, an oil pump, and the rotor bearing surfaces exhibiting galling and burn damage consistent with oil starvation. The metering oil pump, which supplies oil to the combustion chambers, was missing from the engine installation, with its drive absent. Further examination disclosed that the oil injection nozzles associated with the missing metering oil pump were also missing from the combustion chambers, and that the nozzle holes were plugged with a non-metallic substance. ## Factual narrative HISTORY OF FLIGHT On April 21, 2002, approximately 1305 Pacific daylight time, a Gallagher Taylor "Coot" experimental amateur-built airplane, N41RG, was destroyed by impact forces and a post-crash fire in a collision with terrain following a loss of engine power and subsequent loss of control near Creswell, Oregon. The private pilot-in-command, who was the airplane's sole occupant, was fatally injured in the crash. Visual meteorological conditions were reported at Mahlon Sweet Field, Eugene, Oregon, at 1254, and no flight plan had been filed for the 14 CFR 91 flight. Witnesses at the airport who were observing the pilot's first flight in the accident aircraft reported that shortly after takeoff, the engine began to run rough and subsequently quit. The aircraft then nosed down and collided with the terrain in an open field about one mile west of the airport and caught fire. The flight duration prior to the accident was approximately 1 minute and 15 seconds. PERSONNEL INFORMATION At the time of the accident, the pilot held a private pilot certificate for single-engine land aircraft. The pilot's flight logbook was not made available for review, however, during the pilot's last Federal Aviation Administration medical examination, he reported a total flight time of 250 hours, with zero hours in the preceding six months. The pilot was issued a third class medical certificate on June 14, 2000, with a restriction that he must wear corrective lenses. AIRCRAFT INFORMATION The accident pilot, who did not hold a mechanic or repairman/experimental aircraft builder certificate (according to the FAA airman registry), had bought the aircraft from a previous owner. The engine installed at the time the accident pilot bought the aircraft, an IO-360 series aircraft engine, was subsequently replaced with a Mazda 13B rotary automobile engine. An airworthiness inspector from the FAA's Portland, Oregon, Flight Standards District Office (FSDO) had approved the automotive engine installation. According to the FAA aircraft registry, the aircraft was issued an experimental/amateur-built airworthiness certificate on June 7, 2001, and an airworthiness update was accomplished on September 24, 2001. An FAA inspector reported that the accident flight was the pilot's first flight in the accident aircraft. Prior to the maiden flight, witnesses at the airport reported that the pilot had accomplished several high speed taxi tests. During one of these taxi runs, the aircraft was observed to have inadvertently lifted off the taxiway. The aircraft then landed hard and ran off the taxiway damaging one of the airplane's main landing gears. The pilot also reported that the airplane had been pulling to the right during these taxi tests. The pilot's wife and several people at the airport reported that during conversations with the pilot, he had been trying different fuel/oil mixtures for the engine. Each time the pilot ran the engine, the spark plugs would get fouled. METEOROLOGICAL INFORMATION The 1254 Eugene, Oregon, airport hourly METAR weather observation reported conditions there as: wind from 350 degrees true at 9 knots; visibility 10 statute miles; overcast at 3,200 feet; temperature 13 degrees C; dew point 8 degrees C; and altimeter setting 30.19 inches Hg. WRECKAGE AND IMPACT INFORMATION The accident site was located in a level open field covered with short grass approximately one mile west of the Creswell Airport. The fuselage was completely consumed and destroyed by the post-crash fire. Both the left and right wings were laying flat on the ground and oriented in place to the fuselage. Fire had consumed the majority of both wings out to the tips. The engine was positioned at the nose of the airplane. The nose of the engine was pointing straight up. The propeller remained attached to the crankshaft. FAA inspectors who responded to the accident site and performed an on-site examination of the aircraft wreckage reported that they found no evidence of malfunctions in the aircraft's airframe or flight controls. MEDICAL AND PATHOLOGICAL INFORMATION The Chief Deputy Medical Examiner from the Lane County Health and Human Services Medical Examiner's Office reported that the pilot's cause of death was due to blunt force injuries in chest and abdomen. Samples for toxicology were sent to the Federal Aviation Administration Civil Aeromedical Institute, Oklahoma City, Oklahoma, for analysis. The results of the analysis were negative. ADDITIONAL INFORMATION Following the FAA inspectors' on-site wreckage examination, the aircraft's engine was moved to the service facility of Kiefer's Eugene Mazda in Eugene, Oregon, where a disassembly examination of the engine was conducted by a Mazda service technician under the supervision of the FAA inspectors on April 23, 2002. The disassembly examination disclosed that the engine was seized, with both rotors, an oil pump, and the rotor bearing surfaces exhibiting galling and burn damage consistent with oil starvation. The inspectors reported that a metering oil pump, which supplies oil to the combustion chambers, was noted to be missing from the engine installation, with its drive absent. The Mazda service technician reported that further examination disclosed that the oil injection nozzles associated with the missing metering oil pump were also missing from the combustion chambers, and that the nozzle holes were plugged with a non-metallic substance. ## Aircraft - Registration: [N41RG](https://openairdocs.org/deregistered/N41RG-2002-08-28), registration cancelled 2002-08-28, S/N RG-1, built 1987 (OpenAirDocs) - Reported make and model: Gallagher Taylor "Coot" - Registry model: [Gallagher Robert William TAYLOR "COOT"](https://openairdocs.org/model/gallagher-robert-william-taylor-coot) (registry code 9570777) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: RG-1 - Engines: Mazda 13B reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: James R West - Airworthiness certificate: Special, Experimental (Special) - Departed: 77S, Creswell, OR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 250 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 3,200 ft overcast - Temperature: 55 °F, dew point 46 °F - Altimeter: 30.19 inHg - Observed at: EUG, 15 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 20020421010349A](https://openairdocs.org/incident/20020421010349A), Apr 21, 2002: Amtr COOTAMPHIB1A, Creswell, OR, No damage, 1 fatal. (-23) On Sunday April, 2002 at approximately 130 5 PDT, after take off from the hard surface runway at the Creswell, Oregon airport, private pilot james… ## Docket (10 files) The files NTSB released with the investigation on May 1, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54568. 1.6 MB in all. - FAA Record of Conversation with Witness (item 1, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408826&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20with%20Witness-Redacted.PDF - Lane County Sheriff's Office Witness Statements (item 2, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408830&FileExtension=.PDF&FileName=Lane%20County%20Sheriff%27s%20Office%20Witness%20Statements-Redacted.PDF - FAA Statement of Engine Teardown (item 3, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408828&FileExtension=.PDF&FileName=FAA%20Statement%20of%20Engine%20Teardown-Redacted.PDF - Engine Teardown Report - Kiefer's Mazda (item 4, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408831&FileExtension=.PDF&FileName=Engine%20Teardown%20Report%20-%20Kiefer%27s%20Mazda-Redacted.PDF - Toxicological Report (item 5, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181793&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1. View of field and accident site. Airport beyond tree line. (item 6, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181794&FileExtension=.PDF&FileName=Photo%201.%20%20View%20of%20field%20and%20accident%20site.%20%20Airport%20beyond%20tree%20line.-Master.PDF - Photo 2. Left rear quartering view of wreckage. (item 7, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181795&FileExtension=.PDF&FileName=Photo%202.%20%20Left%20rear%20quartering%20view%20of%20wreckage.-Master.PDF - Photo 3. Left side view of wreckage. (item 8, .PDF, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181796&FileExtension=.PDF&FileName=Photo%203.%20%20Left%20side%20view%20of%20wreckage.-Master.PDF - Photo 4. Forward view of wreckage. (item 9, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181798&FileExtension=.PDF&FileName=Photo%204.%20%20Forward%20view%20of%20wreckage.-Master.PDF - Photo 5. View of engine. (item 10, .PDF, 239 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40181799&FileExtension=.PDF&FileName=Photo%205.%20%20View%20of%20engine.-Master.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.