# NTSB SEA03LA011: Peterson Dragonfly, N2448, Mulino, OR, November 23, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 23, 2002, 12:40 local (20:40 UTC) - Place: Mulino, OR - Coordinates: 45.199443, -122.635559 - Nearby events: https://openairdocs.org/map.md?lat=45.1994&lon=-122.6356&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 18, 2003 - Report: Approved by Office Director - Parties: Portland FSDO - NTSB case key (mKey): 56115 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA03LA011 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56115/pdf - Page: https://openairdocs.org/ntsb/SEA03LA011 ## Probable cause Fuel starvation of the engine while in cruise flight due to the owner/builder's alteration of the fuel system from that shown in the aircrafts plans. Factors include very rough terrain in the area where the pilot found it necessary to make his forced landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - fluid,fuel - starvation (cause) - acft/equip,inadequate design, owner/builder (cause) - Forced landing, descent - emergency - On ground/water encounter with terrain/water, landing - flare/touchdown - terrain condition - rough/uneven (contributing factor) ## Analysis The student pilot, who was also the owner/builder of the experimental aircraft, was conducting a local personal pleasure flight when the aircraft's engine suddenly lost power. Because he was unable to get the aircraft restarted, the pilot elected to attempt a forced landing in a nearby field. During the attempted landing, the aircraft encountered very rough terrain and sustained substantial damage. Although an initial inspection of the aircraft disclosed no anomalies or malfunctions in the engine, it was later determined that the pilot had altered the fuel system from that shown in the aircraft plans. That alteration created a situation where the engine was starved of fuel when the pilot turned on the electric fuel pump that transferred fuel to the header tank from a line downstream of the gascolator. ## Factual narrative On November 23, 2002, approximately 1240 Pacific standard time, an experimental Peterson Dragonfly, N2448, impacted the terrain during an attempted forced landing in a rough field about three miles west of Mulino, Oregon. The student pilot, who was the sole occupant, received serious injuries, and the aircraft, which was built, owned, and operated by the pilot, sustained substantial damage. The 14 CFR Part 91 personal pleasure flight, which departed Mulino Airport, Mulino, Oregon, about 10 minutes prior to the accident, was being operated in visual meteorological conditions. No flight plan had been filed. The ELT, which was activated by the accident sequence, was turned off at the scene. According to the pilot, the aircraft's engine stopped suddenly while he was on a short flight to the west of Mulino. After the engine stopped, the pilot tried applying carburetor heat and then attempted a restart. When the engine did not start, he switched to the header tank and made sure that his electric fuel pump was on, and then tried a restart again, with no success. After attempting a third unsuccessful start, the pilot elected to attempt a forced landing in a nearby field. Although the pilot was able to make it to the field without engine power, during the touchdown on the very rough terrain, the aircraft sustained substantial damage. A post-accident inspection of the aircraft by the owner and an FAA Airworthiness inspector found no indication that there had been any anomaly or malfunction in the engine. A further inspection of the aircraft's systems revealed that the pilot had altered the fuel system from that described in the aircraft plans. The alteration performed by the pilot allowed fuel to be transferred to the header tank from a fuel line downstream of the gascolator bowl by way of an electrical fuel pump. In further discussions with the owner, the FAA inspector determined that just prior to the loss of power the pilot had turned on the subject pump. According to the inspector, both he and the owner agreed that the loss of power was due to the engine being starved of fuel when the pump was turned on in order to transfer fuel to the header tank. The aircraft, which had been manufactured in 2001, had been flown a total of about two hours. ## Aircraft - Registration: [N2448](https://openairdocs.org/aircraft/N2448), registered now, S/N 2000 (OpenAirDocs) - Reported make and model: Peterson Dragonfly - Registry model: [Peterson Jeffrey M DRAGON FLY](https://openairdocs.org/model/peterson-jeffrey-m-dragon-fly) (registry code 056090Z) (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: 2000 - Airframe hours: 2 - Engines: Hapi 60-20M 60 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Jeffrey M. Peterson - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, January 19, 2002, 2 hours before - Departed: 4S9, Mulino, OR - Destination: 4S9, Mulino, OR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 54; injuries: serious; student; medical: class 3; seat: left; flight hours: 90 total, 2 in this make and model, 52 as pilot in command, 12 in the last 90 days, 4 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 3,500 ft overcast - Temperature: 50 °F ## 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 20021123033839A](https://openairdocs.org/incident/20021123033839A), Nov 23, 2002: Amtr DRAGONFLY, Clackamascounty, OR, Substantial damage. (-23) Jeffrey m. peterson departed mulino (4S9) airfield. Mr. Peterson climbed to 2400 MSL for engine and aircraft phase I tests. He began a clearing turn for… 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.