WPR09LA166

NTSB accident investigation · Reimus Sonex FR1 · Paso Robles, CA · March 25, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
March 25, 2009, 10:40 local (17:40 UTC)
Place
Paso Robles, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1006NReimus Sonex FR1
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report December 15, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO
FAA report
20090325004739A
Case key
73553

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

A total loss of engine power during cruise flight due to the pilot/builder’s failure to follow the engine manufacturer’s maintenance instructions and apply the correct torque to the rocker arm nuts during maintenance.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

During cruise flight the engine of the experimental amateur-built airplane began to run rough and then lose all power. The pilot/builder then performed a forced landing in a vineyard. During the landing sequence, the airplane struck a trellis and sustained substantial damage to the firewall and right wing. Postaccident examination of the engine revealed that the valve clearance for three of the cylinder head rocker arms was beyond adjustment tolerances; additionally, one of the pushrods was loose within the cylinder head and did not make contact with its associated rocker arm. The pilot performed maintenance about 24 flight hours prior to the accident flight which included adjusting the rocker arm valve clearance. The pilot noted in the engine logbook that the valves were gapped at the manufacturer’s recommended setting. The pilot was not aware of the engine manufacturer's requirement to apply a specific torque to the valve rocker adjustment nuts during adjustment, and as such, did not tighten the nuts to the recommended torque level.

Factual narrative

The factual narrative464 words

HISTORY OF FLIGHT On March 25, 2009, about 1040 Pacific daylight time, an experimental amateur-built Reimus Sonex FR1, N1006N, collided with terrain during a forced landing near Paso Robles, California. The pilot/builder was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The certificated sport pilot sustained serious injuries; the airplane sustained substantial damage to the firewall and right wing. The local flight departed Paso Robles Municipal Airport about 1010. Visual meteorological conditions prevailed, and no visual flight rules flight plan had been filed. The pilot reported departing Paso Robles Municipal Airport and flying for about 30 minutes when the engine began to run rough. He changed heading towards the airport in preparation for a precautionary landing, but shortly thereafter the engine lost all power. The pilot then performed a forced landing in a vineyard; during the landing the airplane struck a trellis. The airplane came to rest intact in a nose down attitude with the tail section resting on a 5-foot-tall trellis. First responders reported the presence of fuel on the ground in the area surrounding the nose of the airplane. One propeller blade was observed undamaged; the second blade was fractured midspan with aft bending of the tip. AIRCRAFT INFORMATION The two-seat, experimental amateur-built airplane was issued a Special Airworthiness Certificate on October 18, 2006. It was powered by a four-cylinder, air-cooled, AeroConversions Inc. AeroVee 2180cc engine, and equipped with a two-blade wooden propeller. AeroConversions supplied the engine to the pilot as a kit in 2005. The pilot completed the assembly of the engine later that year, 50.2 flight hours prior to the accident. According to the engine maintenance logbook, the last documented maintenance was performed on February 14, 2008, 23.42 flight hours prior to the accident. The entry, signed by the pilot, stated, "Retorqued head, valves at 0.006 gap changed oil. Reset maintenance to 25.0 hours." TESTS AND RESEARCH Post accident examination of the engine revealed that the number four cylinder head exhaust valve rocker arm adjustment nut was loose, and had rotated towards the end of its travel. Additionally, the valve clearances for the number one cylinder exhaust and intake valves, and the number four cylinder intake valves, were between 3/16 and 3/8 inches. The associated pushrods were observed loose within their cylinder heads; the pushrod for the number four exhaust valve did not make contact with the rocker arm. The AeroVee engine assembly manual recommended that the rocker arm valve clearance be set to 0.006 inches. Additionally, it stated that the torque for the rocker arm adjusting nuts be set to 14 foot-pounds. The pilot reported that he was not aware of the manufacturer’s recommendation to apply a torque of 14 foot-pounds to the rocker arm nuts during the adjustment of the valve clearance.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N1006N
Reported as
Reimus Sonex FR1
Category
Airplane, amateur-built
Serial number
001
Airframe hours
50
Engine
Aerovee, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental light sport (Special)
Last inspection
Condition · February 14, 2008 · 23 hours before
Departed
PRB · Paso Robles, CA
Destination
PRB · Paso Robles, CA
Flight plan
Unknown
Airport
PRB · Paso Robles Municipal Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
75
Injuries
Serious
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Last flight review
October 20, 2008
Seat
Left
Flight hours
116 total · 3 in this make and model · 3 as pilot in command · 5 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
55 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
PRB, 3 nm away

Docket · 8

The files NTSB released with the investigation on October 2, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.