# NTSB SEA05LA172: MK II Legacy Sport, N359L, Madras, OR, August 16, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: August 15, 2005, 19:40 local (Aug 16, 2005, 02:40 UTC) - Place: Madras, OR - Coordinates: 44.466667, -120.998886 - Nearby events: https://openairdocs.org/map.md?lat=44.4667&lon=-120.9989&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report March 28, 2006 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 62217 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA05LA172 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62217/pdf - Page: https://openairdocs.org/ntsb/SEA05LA172 ## Probable cause The pilot's failure to maintain adequate airspeed while maneuvering which resulted in an inadvertent stall/spin and subsequent collision with the ground. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - airspeed - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane was observed by a witness about 9 miles from the accident site at about 1,000 feet agl making a "knife edge turn." Another witness about 8 miles from the accident site observed the airplane "doing knife-edge straight flight that ended in pulling up and slowing dramatically into level flight." Two other witnesses "heard an airplane motor sputtering" and then "observed the plane going down in a spiraling motion towards the ground." Examination of the accident site by local authorities and an FAA inspector revealed evidence indicating the airplane impacted the ground in a vertical descent with no forward speed. Control continuity was confirmed from the control surfaces to the cockpit controls. Disassembly of the engine found no evidence of catastrophic engine failure. ## Factual narrative On August 15, 2005, about 1940 Pacific daylight time, a MK II Legacy Sport experimental airplane, N359L, impacted terrain in an uncontrolled descent approximately 20 miles southeast of Madras, Oregon. The airplane sustained substantial damage, and the private pilot and the passenger received fatal injuries. The airplane was registered to JCB5 Inc. of Redmond, Oregon, and operated by the pilot. Visual meteorological conditions prevailed for the local personal flight conducted under 14 CFR Part 91, and no flight plan was filed. The flight departed from Roberts Field Airport in Redmond about 1910. According to the General Manager of Lancair, Inc., of Redmond, the pilot was employed by Lancair as a salesman. Lancair manufactures and sells kits for several models of single engine airplanes. The accident airplane was a Lancair Legacy Sport, used by the company for demonstration and training flights. The purpose of the accident flight was to maintain the pilot's currency. The passenger was a friend of the pilot; he was not a Lancair customer or employee. According to records obtained by the FAA inspector who responded to the scene of the accident, the airplane was fueled immediately prior to the flight with 20 gallons of 100LL fuel. Ten gallons were added to each wing tank. The General Manager of Lancair stated that at maximum power, the airplane's fuel burn rate would be about 16 gallons per hour. During a telephone interview conducted by an NTSB investigator, a witness, who was at her residence approximately 9 miles southwest of the accident site, reported observing the airplane maneuvering about 1,000 feet agl. The witness stated that the airplane made a "knife edge turn" and then "flipped back over" before it flew out of sight to the northwest. In a written statement, a witness, who was at his residence approximately 8 miles south-southeast of the accident site, reported observing the plane "above and NE of our home doing extreme maneuvers." The witness watched the airplane "quite closely with 10 x 50 Bushnell binoculars doing knife-edge straight flight that ended in pulling up and slowing dramatically into level flight." As the maneuvers were repeated, "the engine and propeller sounds were dramatic and constant." According to the witness, "the last knife edge maneuver was toward us from the NE - the plane pulled up, leveled, slowed dramatically and flew slowly toward the NW." The witness did not see the airplane crash "only its exit from our area with slow, normal engine sounds." According to a report by an officer with the Jefferson County Sheriff's Office who responded to the scene of the accident, two witnesses "heard an airplane motor sputtering" and then "observed the plane going down in a spiraling motion towards the ground." The witnesses lost sight of the airplane and then "heard a boom/crash." They called 911, and local authorities started a search and located the accident site about 2052. The officer reported that the airplane was resting upright in a level attitude. The wings and tail section remained attached to the fuselage, and the canopy was separated and lying on the ground in front of the nose. The officer found "no skid/sliding marks." An on scene examination of the wreckage was conducted under the supervision of an FAA inspector on August 16, 2005. Flight control continuity was established from the control surfaces to the cockpit controls. The flaps appeared to be in the up position. Both wing fuel tanks were compromised by impact damage and contained no fuel. The fuel selector valve was in the left tank position. Fuel was found in the line leading from the left tank to the fuel selector valve. Fuel was also found in the mechanical fuel pump and the fuel distribution spider. The engine remained attached to the airframe, and the propeller remained attached to the engine crankshaft. One of the two propeller blades was bent aft at the tip and displayed chordwise scratches. The other propeller blade displayed minimal damage. On August 18, 2005, the engine was disassembled under the supervision of the FAA inspector at the facilities of Lancair, Inc. in Redmond. According to a report on the engine disassembly prepared at the FAA inspector's request by Lancair's Director of Maintenance, "no evidence was found during [the] engine tear-down that would have caused a catastrophic engine failure." An autopsy of the pilot was performed by the Medical Examiner Division of the Oregon State Police in Clackamas, Oregon. Toxicology tests were performed by the FAA's Toxicology and Accident Research Laboratory. The tests were negative for carbon monoxide, cyanide, and ethanol. Morphine at 0.702 ug/ml and thebaine at an unquantified level were detected in urine. According to an FAA report entitled "Poppy Seed Consumption or Opiate Use: The Determination of Thebaine and Opiates of Abuse in Postmortem Fluids and Tissues," thebaine is a naturally occurring opiate that is introduced into the body, along with morphine and codeine, following consumption of poppy seeds. According to the pilot's wife, they had purchased poppy seed muffins two days before the accident, and he probably consumed poppy seed muffins on the day of the accident and the day prior to the accident. ## Aircraft - Registration: [N359L](https://openairdocs.org/deregistered/N359L-2007-10-09), registration cancelled 2007-10-09, S/N LS-100, built 2003 (OpenAirDocs) - Reported make and model: MK II Legacy Sport - Registry model: [MK II LEGACY SPORT](https://openairdocs.org/model/mk-ii-legacy-sport) (registry code 05615DP) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: LS-100 - Airframe hours: 160 - Engines: Superior TNIO-360-B1AA 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, March 1, 2005 - Departed: RDM, Redmond, OR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: fatal; private; airplane ratings: single-engine land; medical: class 1, without waivers/limitations; seat: left; toxicology performed; flight hours: 249 total, 28 in this make and model, 42 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 28 °F - Altimeter: 29.95 inHg - Observed at: RDM, 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 20050815017769A](https://openairdocs.org/incident/20050815017769A), Aug 15, 2005: LEGACYSPORT, Madras, OR, Destroyed, 2 fatal. (-23) Witness revealed seeing the aircraft doing extreme maneuvers at altitudes below 1500' AGL in the area of the accident. Investigation revealed that the… 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.