# NTSB SEA08FA078: Lancair LC41, N621ER, Portland, OR, February 16, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 16, 2008, 08:28 local (16:28 UTC) - Place: Portland, OR - Coordinates: 45.583889, -122.618057 - Nearby events: https://openairdocs.org/map.md?lat=45.5839&lon=-122.6181&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 29, 2009 - Report: Approved by Office Director - Parties: Cessna Aircraft Company, Federal Aviation Administration, Teledyne-Continental Motors - NTSB case key (mKey): 67527 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08FA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67527/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67527 - Page: https://openairdocs.org/ntsb/SEA08FA078 ## Probable cause The pilot's failure to follow the missed approach procedure. Contributing to the accident were the fog and below landing minimums visibility conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action sequence](https://openairdocs.org/ntsb-findings/02041020): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/02041020/cases.md?model=5150001), [All aircraft, 77 cases](https://openairdocs.org/ntsb-findings/02041020/cases.md) - [Ceiling/visibility/precip: fog](https://openairdocs.org/ntsb-findings/03035055): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/03035055/cases.md?model=5150001), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03035055/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=5150001), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Lancair LC41-550FG, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=5150001), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis Prior to initiating the first ILS approach to runway 10R, the pilot was advised by the tower controller that the runway visual range (RVR) was 600 feet, followed by being given a landing clearance. A little more than 2 minutes later the pilot declared a missed approach and was given radar vectors for a second ILS approach. After turning inbound on the localizer the pilot was advised that the runway visual range was 600 feet, midfield 800 feet, and roll out 800 feet. The pilot was then cleared to land. When the tower controller observed the airplane turning to the south of the runway on her radar display, she issued missed approach instructions, which was followed by an inaudible transmission. There were no further transmissions from the pilot. The airplane impacted the top of an 85-foot tall tree with its right wingtip, 3,200 feet southeast of the approach end of the runway, then continued on the collision course before impacting the ground about 845 feet from the initial impact point with the tree. The airplane was subsequently consumed by fire. The weather minimums for the approach required a ceiling of 200 feet and an RVR of 1,800 feet or one-half mile; the decision altitude was 224 feet msl. The FAA published missed approach procedure instructed the pilot to climb to 900 feet, then climbing right turn to 4,000 feet, intercept the 160 degree radial of the VORTAC, and proceed to a DME fix and hold. The airplane's turn to the southeast was consistent with the missed approach course of 160 degrees; however, a climb to 900 feet is required prior to commencing the right turn, as outlined on approach plate's missed approach instructions. It appears the pilot likely misinterpreted the missed approach instructions by making the right hand turn prior to initiating a climb to 900 feet, which resulted in the subsequent impact with the tree. No preimpact anomalies were found during an examination of the airframe and engine. The airplane's avionics components revealed that they were too thermally and impact-damaged to provide any data. No anomalies were found during a post accident examination of the instrument landing system components. ## Factual narrative HISTORY OF FLIGHT On February 16, 2008, about 0828 Pacific standard time, a Lancair LC41 550-FG, N621ER, was destroyed after impacting terrain while maneuvering near the Portland International Airport (PDX), Portland, Oregon. The pilot, who was the sole occupant and registered owner of the airplane, was killed. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan had been filed and activated for the 14 Code of Federal Regulations (CFR) Part 91 personal cross-country flight. The flight departed the Klamath Falls Airport (LMT), Klamath Falls, Oregon, about 0630, with its destination as PDX. Prior to departure, at 0517 the pilot filed an IFR flight plan using the Federal Aviation Administration's (FAA) Direct User Access Terminal (DUAT) service for pilots; at 0551 the pilot received a route briefing using the same service. After departing LMT, the pilot contacted Air Traffic Control (ATC) at 0642 requesting his IFR clearance to PDX; the clearance was issued at 0643. At 0720, the pilot reported that he was level at 14,000 feet and proceeding direct to Corvallis. At 0744, ATC issued the pilot a descent clearance to 10,000, which the pilot acknowledged. At 0752, ATC instructed the pilot to change frequency to Portland Approach Control, which the pilot acknowledged. Subsequently, the pilot approached PDX from the southeast and received radar vectors to intercept the localizer course for the Instrument Landing System (ILS) runway 10R approach. At 0809, the PDX tower controller advised the pilot of possible wake turbulence from a de Havilland Dash 8 on short final, and that the wind was calm. The controller cleared the pilot to land on Runway 10R, and was also advised that the runway visual range (RVR) was 600 feet. The pilot acknowledged the controller's transmissions. At 0812, the pilot transmitted to the tower controller, "I'm not seeing the airport. I'll be missed approach." The controller replied, "Columbia one echo romeo, tower. Fly heading one zero zero, maintain two thousand." The pilot replied, "one zero zero to two thousand." At 0812, the tower controller transmitted to the pilot, "Columbia one echo romeo, turn left heading zero five zero. Maintain three thousand." The pilot responded, "left zero five zero and three thousand." At 0813, the tower controller instructed the pilot, "Columbia one echo romeo, contact approach on one two four point three five." The pilot responded, "Twenty four thirty five, one echo romeo." At 0824, the pilot transmitted, "Portland tower, Columbia six two one echo romeo is inbound on the localizer." The tower controller replied, "Columbia six two one echo romeo, tower, runway one zero right, rvr six hundred, mid eight hundred, rollout eight hundred, runway one zero right cleared to land." The pilot replied, "Cleared to land, one echo romeo." At 0827, the tower controller transmitted, "Columbia one echo romeo, ah, maintain two thousand and turn right heading one four zero." The pilot replied with an unintelligible transmission, followed by "we're gonna crash." The tower controller attempted several times to contact the pilot with no response. A review of the radar data depicting the approach, which was overlayed on a 2-dimensional site map, revealed that the airplane was stabilized on the localizer just prior to the runway threshold, which occurred at 0826:59. At 0827:09, radar depicted the airplane about 500 feet east of taxiway Bravo-1 and the runway threshold starting a right turn. Radar depictions at 0827:13, 0827:18, and 0827:23 indicate that the airplane had made a right turn to a south-southeasterly heading. PERSONNEL INFORMATION The pilot, age 62, held a commercial pilot certificate with ratings for airplanes single-engine and multiengine land, and instrument airplane. A review of the pilot's personal logbook revealed that he had accumulated a total of 5,152 hours of flight time, with 429 hours in the accident make and model, 516 hours of actual instrument time, and 119 hours of simulated instrument time. The pilot's most recent flight review was accomplished on December 31, 2007. Training records revealed that the pilot had successfully completed the Columbia 400 ground and flight training course on December 14, 2005, which was conducted at the Columbia Aircraft Manufacturing Facility in Bend, Oregon. The pilot's most recent airman's medical examination was performed on June 19, 2007, with the limitation "Must wear corrective lenses." AIRCRAFT INFORMATION The airplane is a pre-mold, composite built, semi-monocoque, four seat, single engine, low wing, tricycle design airplane, and is certified in the utility category. A review of the airplane's logbook revealed that the last annual inspection was dated July 1, 2007, at a total airframe time of 297.2 hours. The airplane was equipped with a Teledyne-Continental Motors TSIO-550-C(9) engine. An examination of the engine logbook indicated that a 100-hour inspection had been conducted on July 1, 2007, at an engine total time of 297.2 hours. AIRPORT INFORMATION The Portland International Airport (PDX), is a public, controlled airport located about 4 miles northeast of Portland, Oregon. The airport features three asphalt-grooved runways, Runway 10R/28L, which is 11,000 feet by 150 feet, Runway 10L/28R, is 8,000 feet by 150 feet, and Runway 03/21, is 7,001 feet by 150 feet. Runway 10R was equipped with high intensity runway lighting (HIRL), centerline lighting (CL), airport lighting system with sequenced flashers II (ALSF2), Touchdown Zone Lights (TDZL), and a Precision Approach Path Indicator (PAPI) located on the right side of the runway. Runway 10R was configured for precision and non-precision approaches, which include ILS and global positioning (GPS) approaches. The ILS approach to runway 10R at PDX included an inbound course with a magnetic heading of 101 degrees. The minimum descent altitude for the inbound section of the approach was 224 feet mean sea level (msl) when established on the localizer with a glideslope intercept altitude of 2,000 feet at YORKY intersection, which is also the final approach fix. The YORKY intersection was located 8 nautical miles (nm) distance measuring equipment (DME) on the approach course. The distance from YORKY intersection to the runway threshold is 5.9 nm. The published missed approach procedure instructed the pilot to "climb to 900, then a climbing right turn to 4,000 [feet] via BTG R-160 to MULES Int/BTG VORTAC 17.7 DME and hold." According to the Federal Aviation Administration (FAA) Daily Record of Facility Operation, on February 16, 2008, at 1715, the Portland International Airport's Runway 10R instrument landing system was flight checked with no anomalies noted. METEOROLOGICAL INFORMATION At 0753, about 35 minutes prior to the accident, the PDX Automated Surface Observing System (ASOS) reported wind from 240 degrees at 3 knots, visibility 1/8 statute mile, Runway 10R Runway Visual Range 600 feet variable to 700 feet, fog, broken clouds at 100 feet, overcast clouds at 900 feet, temperature 1 degree C, dew point 1 degree C, altimeter setting 30.35 inches of Mercury; remarks, tower visibility 200 feet. At 0853, about 25 minutes after the accident, the PDX ASOS reported, wind calm, visibility 1/4 statute mile, Runway 10R Runway Visual Range 800 feet variable 1,400 feet, fog, broken clouds at 100 feet, overcast clouds at 900 feet, temperature 2 degrees C, dew point 2 degrees C, altimeter setting 30.37 inches of Mercury; remarks, tower visibility 1/4 mile. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site on February 17, 2008. The examination revealed that the airplane initially impacted the top of an 85-foot tall tree with its right wingtip, about 3,200 feet southeast of the approach end of Runway 10R, on a magnetic heading of about 160 d ## Aircraft - Registration: [N621ER](https://openairdocs.org/deregistered/N621ER-2009-04-13), registration cancelled 2009-04-13, S/N 41527, built 2005 (OpenAirDocs) - Reported make and model: LANCAIR LC41 (550FG) - Registry model: [Lancair LC41-550FG](https://openairdocs.org/model/lancair-lc41-550fg) (registry code 5150001) (OpenAirDocs) - Registry engine: [Continental TSIO-550 series](https://openairdocs.org/engine/continental-tsio-550-series) (registry code 17043, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 41527 - Airframe hours: 383 - Engines: Teledyne Continental TSIO-550 C9 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Richard E. Otoski - Registered owner: Richard E. Otoski - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2007, 86 hours before - Departed: LMT, Klamath Falls, OR - Destination: PDX, Portland, OR - Flight plan: IFR - Airport: PDX, Portland International, runway 10R, 11,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review December 31, 2007; seat: left; toxicology performed; flight hours: 5,152 total, 429 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 240° at 3 knots - Visibility: 0.25 statute miles - Lowest ceiling: 100 ft broken - Temperature: 34 °F, dew point 34 °F - Altimeter: 30.35 inHg - Observed at: PDX, 1 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 20080216011079A](https://openairdocs.org/incident/20080216011079A), Feb 16, 2008: Lancar LC41550FG, Portland, OR, Destroyed, 1 fatal. (-23) Aircraft impacted ground approximately 2500 feet south of runway 10R. One person on board, the pilot, sustained fatal injuries. Appears to have been a… ## Docket (15 files) The files NTSB released with the investigation on December 24, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67527. 12.2 MB in all. - Wreckage Diagram (item 1, .PDF, 827 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305169&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Weather Data (item 2, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305176&FileExtension=.PDF&FileName=Weather%20Data-Redacted.PDF - Transcript of Radio Communications (item 3, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305177&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Redacted.PDF - FAA Radar Data (item 4, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305179&FileExtension=.PDF&FileName=FAA%20Radar%20Data-Master.PDF - Teledyne Continental Motors Final Report (item 5, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305180&FileExtension=.PDF&FileName=Teledyne%20Continental%20Motors%20Final%20Report-Redacted.PDF - Cessna Aircraft Company Final Report (item 6, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305181&FileExtension=.PDF&FileName=Cessna%20Aircraft%20Company%20Final%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305182&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305183&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 9, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305184&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Image 1. View of main wreckage looking southeast. (item 10, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305186&FileExtension=.PDF&FileName=Image%201.%20View%20of%20main%20wreckage%20looking%20southeast.-Master.PDF - Image 2. View of main wreckage looking southwest. (item 11, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305187&FileExtension=.PDF&FileName=Image%202.%20View%20of%20main%20wreckage%20looking%20southwest.-Master.PDF - Image 3. View of main wreckage looking west. (item 12, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305188&FileExtension=.PDF&FileName=Image%203.%20View%20of%20main%20wreckage%20looking%20west.-Master.PDF - Image 4. View #1 looking northwest along debris path to tree impact area. (item 13, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305189&FileExtension=.PDF&FileName=Image%204.%20View%20%231%20looking%20northwest%20along%20debris%20path%20to%20tree%20impact%20area.-Master.PDF - Image 5. View #2 looking northwest along debris path to tree impact area. (item 14, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305190&FileExtension=.PDF&FileName=Image%205.%20View%20%232%20looking%20northwest%20along%20debris%20path%20to%20tree%20impact%20area.-Master.PDF - Image 6. View looking northwest from main wreckage to tree impact area. (item 15, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40305191&FileExtension=.PDF&FileName=Image%206.%20View%20looking%20northwest%20from%20main%20wreckage%20to%20tree%20impact%20area.-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.