# NTSB SEA94LA119: Hallstrom BD-5B, N224FH, St. George, UT, May 17, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: May 17, 1994, 09:55 local (15:55 UTC) - Place: St. George, UT - Coordinates: 37.180156, -113.600028 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.1802&lon=-113.6000&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 18, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 41925 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA94LA119 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/41925/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=41925 - Page: https://openairdocs.org/ntsb/SEA94LA119 ## Probable cause CARBURETOR CONTAMINATION AND LOW OUTPUT, AND THE PILOT'S IMPROPER DECISION TO ATTEMPT TO CONTINUE THE APPROACH. A FACTOR WAS THE PILOT'S LACK OF RECENT FLIGHT EXPERIENCE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - vfr pattern - downwind - fuel system,carburetor - contamination (cause) - fuel system,carburetor - output low (cause) - Forced landing, emergency landing - In flight collision with terrain/water, emergency landing - in-flight planning/decision - improper, pilot in command (cause) - lack of recent experience, pilot in command (contributing factor) ## Analysis THE PILOT DEPARTED FROM RWY 16 ON THE EXPERIMENTAL AIRCRAFT'S FIRST FLIGHT, AND REMAINED LOW AND CLOSE IN THE PATTERN. THE ENGINE WAS HEARD RUNNING ROUGH ON DOWNWIND. WHILE TURNING BASE THE ENGINE LOST POWER, AND THE PILOT ATTEMPTED TO CONTINUE HIS APPROACH RADIOING '... I'M GOING TO TRY TO MAKE IT.' THE AIRPLANE IMPACTED UPSLOPING TERRAIN APPROX 1000 FT SHORT OF THE RUNWAY. THE PILOT'S FLIGHT LOG REFLECTED A TOTAL OF APPROX 2 HRS FLIGHT TIME IN THE PRECEDING 4 YRS. EXAMINATION OF THE ENGINE REVEALED THAT THE LEFT CARBURETOR FUEL/AIR MIXTURE SCREW WAS MISADJUSTED, AND THAT THE RIGHT CARBURETOR SLOW IDLE JET WAS PLUGGED WITH SAND. ## Factual narrative On May 17, 1994, approximately 0955 hours mountain daylight time (mdt), a Hallstrom BD-5B homebuilt aircraft, N224FH, registered to and being flown by Floyd P. Hallstrom, a certificated commercial pilot, crashed on approach to runway 17 at the St. George Municipal Airport, St. George, Utah. The aircraft was destroyed during the ground impact and post crash fire, and the pilot was fatally injured. Visual meteorological conditions existed at the time, and no flight plan had been filed. The flight, which was personal in nature, was to have been conducted in accordance with 14CFR91, and originated from the St. George airport approximately 0950. According to witnesses, and the absence of any logged flight time in the BD-5B aircraft within the pilot's flight log, the accident flight was the first flight for the aircraft. Witnesses reported the aircraft departing on runway 16, turning downwind, and remaining low within the pattern. One witness reported that the engine was running rough on the downwind. All witnesses agreed hearing a loss/reduction of power during the base turn to runway 16. One witness, who was monitoring the airport UNICOM frequency on a hand held transceiver, reported that "after he rolled out on final he made a call "BD5 I've lost power - I'm going to try to make it"." The aircraft impacted rapidly rising terrain approximately 1000 feet south of the threshold of runway 16 and at an elevation below the runway (refer to photographs). PERSONNEL INFORMATION Pilot Hallstrom's fourth logbook was reviewed and a total flight time of 1166 hours was recorded as of May 3, 1994. The last completed page contained the following information: DATE: ACFT: TOT: DUAL: REMARKS: 02-24-90 C170A 1.5 0.0 T/O & LDGS (3 @ SGU & 6 @ 1L8) 02-27-90 C170A 1.0 0.0 T/O & LDGS (1 @ SGU & 1 @ 1L8) 03-03-91 C170A 0.3 0.3 T/O & LDGS 02-17-94 PA-28 1.0 0.7 T/O & LDGS 05-03-94 AA-5 0.7 BFR & CHECKOUT GRUMMAN AA5 AEROWEST ARTHUR G. JONES CFII MEL #1748219 AIRCRAFT INFORMATION The aircraft's logbook was reviewed. The latest entry was logged on May 5, 1994. This and all previous entries consisted of engine runs and taxi tests, but no actual flight time. The logbook entry for March 20, 1994, read "Eng (sic) cut out four of the six runs? Running very rich?" On the last page of the aircraft log which contained entries, a piece of scrap paper was found paperclipped. The paper had a listing of ten items of which the tenth read "Reset carb jet needle to #1 position both carb. Carb. running very rich. 3-26-94." This item had been lined out. AIRPORT INFORMATION The St. George Municipal Airport is situated atop a bluff several hundred feet above the surrounding terrain and with steeply upsloping terrain at the approach ends of both runways. MEDICAL AND PATHOLOGICAL INFORMATION Post mortem examination was conducted by Edward A. Leis, M.D., on May 18, 1994, at the facilities of the Office of the Medical Examiner, 48 North Medical Drive, Salt Lake City, UT 84113. The cause of death was reported as "blunt force injuries." Toxicological evaluation of samples from the pilot was completed by the FAA's Toxicology and Accident Research Laboratory and were negative with the exception of "salicylate detected in Urine" (refer to attached Toxicology report). TESTS AND RESEARCH The BMW R90S engine and twin Dellorto carburetors were disassembled and examined under the control of FAA Inspector Brent A. Robinson, at Hatz's Custom Cycle, on May 18, 1994. The left carburetor air\fuel mixture screw was found to be turned out 1.5 turns, which, according to the owner of the cycle shop, was the expected bench test setting. However, the owner advised Inspector Robinson that at the elevation of the St. George airport, an adjustment of 2.5 turns would be normal. The right carburetor air\fuel mixture screw was found to be turned out 2.25 turns. However, the slow idle jet was observed to be plugged with sand (refer to Engine Teardown Report of Inspector Robinson). ADDITIONAL INFORMATION On site investigation was conducted by FAA Inspector Brent Robinson. The wreckage was released by Inspector Robinson to Richard Newcomb (refer to Inspector Statement). The aircraft logbook and pilot log #4 were returned via certified mail to Mrs. Hallstrom on October 26, 1994. ## Aircraft - Registration: [N224FH](https://openairdocs.org/deregistered/N224FH-2006-04-06), registration cancelled 2006-04-06, S/N 2248, built 1994 (OpenAirDocs) - Reported make and model: HALLSTROM BD-5B - Registry model: [Hallstrom Floyd P BD-5B](https://openairdocs.org/model/hallstrom-floyd-p-bd-5b) (registry code 11307M7) (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: 2248 - Engines: BMW R-R R90S reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Hallstrom, Floyd P. - Registered owner: Hallstrom, Floyd, P. - Airworthiness certificate: Special, Experimental (Special) - Airport: SGU, St. George Muni ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; commercial; airplane ratings: single-engine land; medical: class 1, valid medical--w/ waivers/lim; seat: front; toxicology performed; flight hours: 1,166 total, 1,000 as pilot in command, 2 in the last 90 days, 1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 25 °F - Altimeter: 29.00 inHg - Observed at: SGU, 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 19940517011169A](https://openairdocs.org/incident/19940517011169A), May 17, 1994: Amtrbd BEDEBD5B, Saint George, UT, Destroyed, 1 fatal. First flight homebuilt. Lost power on final. Hit rising terrain short of runway. Sand in carburetor. Improper mixture ## Docket (9 files) The files NTSB released with the investigation on June 6, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=41925. 819 KB in all. - Witness Statements (item 1, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466984&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466985&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Engine Tear Down Report (item 3, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466986&FileExtension=.PDF&FileName=Engine%20Tear%20Down%20Report-Master.PDF - Toxicological Report (item 4, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466987&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1. A view of the initial ground impact site (near the wheel). Note the wing downslope and main wreckage (upper right corner). No negative provided. (item 5, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40019672&FileExtension=.PDF&FileName=Photo%201.%20%20A%20view%20of%20the%20initial%20ground%20impact%20site%20(near%20the%20wheel).%20%20Note%20the%20wing%20downslope%20and%20main%20wreckage%20(upper%20right%20corner).%20%20No%20negative%20provided.-Master.PDF - Photo 2. A view taken from the airport perimeter road near the threshold of runway 16 and at the aircraft's final location. No negative provided. (item 6, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40019673&FileExtension=.PDF&FileName=Photo%202.%20%20A%20view%20taken%20from%20the%20airport%20perimeter%20road%20near%20the%20threshold%20of%20runway%2016%20and%20at%20the%20aircraft%27s%20final%20location.%20%20No%20negative%20provided.-Master.PDF - Photo 3. A closeup view of the main wreckage. Note the pusher propeller (right). No negative provided. (item 7, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40019674&FileExtension=.PDF&FileName=Photo%203.%20%20A%20closeup%20view%20of%20the%20main%20wreckage.%20%20Note%20the%20pusher%20propeller%20(right).%20%20No%20negative%20provided.-Master.PDF - Photo 4. A closeup view of the aircraft's left wing at the crash site. No negative provided. (item 8, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40019675&FileExtension=.PDF&FileName=Photo%204.%20%20A%20closeup%20view%20of%20the%20aircraft%27s%20left%20wing%20at%20the%20crash%20site.%20%20No%20negative%20provided.-Master.PDF - Photo 5. A closeup view of the aircraft's right wing at the crash site. No negative provided. (item 9, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40019676&FileExtension=.PDF&FileName=Photo%205.%20%20A%20closeup%20view%20of%20the%20aircraft%27s%20right%20wing%20at%20the%20crash%20site.%20%20No%20negative%20provided.-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.