# NTSB WPR10LA063: Budd Lancair Legacy, N7JX, Watsonville, CA, November 21, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 21, 2009, 13:20 local (21:20 UTC) - Place: Watsonville, CA - Coordinates: 36.942501, -121.783607 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.9425&lon=-121.7836&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 19, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Teledyne Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 75083 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA063 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75083/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75083 - Page: https://openairdocs.org/ntsb/WPR10LA063 ## Probable cause A loss of engine power due to oil starvation and the pilot's failure to maintain airspeed while approaching the landing area resulting in an aerodynamic stall, rapid descent, and collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=056146P), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=056146P), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Incorrect service/maintenance; cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=056146P), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=056146P), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=056146P), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Budd John B LEGACY, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=056146P), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis While en route, the pilot contacted flight watch to declare an emergency and report that the airplane's engine lost power. He additionally stated the airplane was at 10,000 feet, and he was going to try to make it to the airport. He subsequently stated that the airplane was on fire. One minute and 42 seconds later, the pilot transmitted that he was at 5,000 feet, and that there was smoke; however, he could see the airport, and thought he could make it. The airplane subsequently impacted the ground vertically, 1/4-mile from the end of the runway. Documentation of the wreckage was consistent with an aerodynamic stall and rapid vertical descent. On scene examination of the airplane wreckage showed no evidence of a fire; however, the belly of the airplane was coated with oil. A postaccident examination of the engine revealed thermal discoloration and mechanical damage consistent with oil starvation. A review of the airplane and engine maintenance records documented a loss of oil pressure due to a broken oil return line about 3 months (26.6 aircraft hours) prior to the accident. The records also indicated that the airplane was not maintained by an appropriately certificated mechanic, and that the pilot performed most of the maintenance on the airplane, even though he was not certified to do so. Examination of the FAA airman records database revealed the pilot was never issued a Repairman Certificate for this airplane. Post-mortem toxicology testing of specimens from the pilot was consistent with the recent use of a typical dose of a prescription narcotic pain reliever. It is possible that the pilot's response to the emergency may have been adversely affected by the use of the medication or by the condition for which the medication was taken. ## Factual narrative HISTORY OF FLIGHT On November 21, 2009, about 1320 Pacific standard time, an experimental Budd Lancair Legacy, N7JX, crashed in an apple orchard 1/4 mile east of Watsonville Municipal Airport, Watsonville, California, after the pilot radioed a distress call reporting a loss of engine power. The commercial pilot operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot was killed, and the airplane was substantially damaged and fragmented. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated from Santa Barbara, California, and was destined to San Carlos, California. At 1316, the pilot contacted Oakland flight watch (automated flight service station-AFSS). He declared an emergency and stated that he had lost engine power. He said he was at 10,000 feet, 9.9 miles from the Watsonville Airport, and that he was going to try to make it to Watsonville. Oakland flight watch acknowledged the transmission. The pilot stated that he had a fire, and flight watch told him to squawk 7700. Flight watch followed with another transmission stating that they were getting a center frequency for the pilot to contact. About 1 minute 42 seconds after his initial distress call, the pilot transmitted that he was at 5,000 feet, there was smoke, he could see the Watsonville Airport, and he thought he could make it to the airport. Flight watch responded that they were contacting approach and for the pilot to continue to squawk 7700. The pilot asked flight watch to contact Watsonville Airport, that he did not have the frequency. No further transmissions from the pilot were received. The pilot never specified where the smoke was coming from or if there was smoke in the cockpit. The aircraft wreckage was located 1/4 mile from the approach end of runway 20 at Watsonville Airport. PERSONNEL INFORMATION The pilot, age 58, held a commercial pilot certificate for helicopters with private pilot privileges for airplane single engine land, and instrument airplane, issued on February 13, 2008. He held a second-class airman medical certificate issued on January 29, 2008, with the limitation that he possess corrective glasses for near vision. The pilot's logbook was not located for examination. On the pilot's January 29, 2008, medical application he reported that he had 2,000 plus flight hours at that time, and had flown over 40 hours within the previous 6 months. The pilot did not hold an airplane and power plant(A&P) mechanic certificate, and the FAA airman records database does not show the pilot was ever issued a Repairman Certificate for this airplane. The pilot was known to perform his own maintenance on the airplane. AIRCRAFT INFORMATION The two-seat, low-wing, retractable landing gear airplane, Lancair Legacy, serial number L2K-187, experimental category airplane was manufactured by John B. Budd in 2003. It was powered by a Teledyne Continental Motors IO-550-N, 310-hp engine, with a Hartzellconstant speed propeller. A review of a copy of an aircraft record book that was located within the airplane wreckage showed that the airplane had received annual inspections on July 17, 2007, July 17, 2008, and August 10, 2009; however, none of the inspections were signed airworthy by a certificated A&P mechanic. None of the maintenance contained in the record was signed by an A&P mechanic. A maintenance entry dated August 25, 2009, at aircraft time of 707.6 hours, stated that the engine lost oil pressure due to a broken oil return line from the oil separator. The broken line was repaired and 4 quarts of oil added. An oil and oil filter change was performed on October 22, 2009, at 728.6 aircraft hours. The last entry was dated November 21, 2009, with an airplane out time of 734.2 hours, flying from SDL (Scottsdale, AZ) to SQL (San Carlos, CA). WRECKAGE AND IMPACT INFORMATION The wreckage was located in an apple orchard, and was examined on-scene by a Federal Aviation Administration (FAA) inspector. The entire airplane wreckage was located in a compact area, with no evidence of a debris path. The airplane was extremely fragmented with no evidence of a fire. The entire belly of the airplane was coated with oil. The engine had holes in the top of the crank case, which were in line with the associated connecting rods. The engine was removed from the airframe and shipped to the manufacturer for further examination under the supervision of an FAA inspector. The manufacturer's examination report states, "The engine exhibited impact damage concentrated at the lower area of the assembly. The crankcase was breached above and in line with the number 2, 4 and 5 cylinders. The magnetos and starter were separated from their mounting positions. The oil pump drive separated near the splined shaft section. The piston head was fractured in two pieces. The crankshaft number 1 through 4 journals and bearings, connecting rods, and bearings 2 through 6 exhibit lubrication distress and mechanical damage." Abundant metal shavings and slivers were observed in the oil sump, and oil filter elements. The oil pump was disassembled and "the oil pump cavity contained light scratches and exhibited normal operating signatures. The oil pump gear teeth exhibited normal operating signatures. The oil pressure relief valve and seat contained no obstructions and exhibited signatures of proper seating." "The crankshaft and counterweight assembly exhibited lubrication distress, thermal damage, and mechanical damage concentrated at all connecting rod and main bearing journals except the number one connecting rod and number five main bearing journals. The crankshaft main bearing journals exhibited signs of lubrication distress. The number one and two connecting rod journals were intact and exhibited mechanical damage. The number three, four, five and six connecting rod journal exhibited signs of lubrication distress, thermal discoloration, mechanical damage and displacement of thejournal material. The oil transfer passages were open and unrestricted. The rear set of counterweight assemblies exhibited mechanical damage and had free and unrestricted movement on the hanger blades. The forward set of counterweight assemblies exhibited mechanical damage and had free and unrestricted movement on the hanger blades. All of the counter weight pins and plates were intact. Alternator drive face gear teeth were intact and undamaged. The oil transfer collar was intact and exhibited lubrication distress. The oil transfer plug was tight and in position. The crankshaft cluster gear was intact and exhibited normal operating signatures. The gear bolts were tight and safetied and the gear teeth were undamaged." MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on November 24, 2009, by the Santa Cruz County Sheriff Coroner. The report stated that the cause of death was attributed to lacerations of the brain and heart. Forensic toxicology was performed on specimens from the pilot by the FAA Forensic Toxicology Research Team CAMI, Oklahoma City, Oklahoma. The toxicology report stated no carbon monoxide cyanide, or ethanol was detected in blood. The following drugs were detected; 17.55 ug/ml of Acetaminophen detected in urine, 0.037 ug/ml dihydrocodeine detected in urine, dihydrocodeine detected in blood, 0.079 ug/ml hydrocodone detected in urine, 0.023 ug/ml hydrocodone detected in blood, and 0.091 ug/ml hydromorphone detected in urine. The FAA toxicology staff noted that the blood specimen from the pilot tested by the FAA Forensic Toxicology Research Team had "No collection site indicated." A report of toxicology testing performed for Santa Cruz County noted, "Hydrocodone - free; 13 ng/mL; peripheral blood." The pilot's most recent application for second-class Airman Medical Certificate, dated January 29, 2008, indicated "No" in response to "Do You Currently Use Any Medication," and to all items under "Medical History," including specifically "Frequent or severe headaches." ## Aircraft - Registration: [N7JX](https://openairdocs.org/deregistered/N7JX-2017-05-22), registration cancelled 2017-05-22, S/N L2K-187, built 2003 (OpenAirDocs) - Reported make and model: BUDD Lancair Legacy - Registry model: [Budd John B LEGACY](https://openairdocs.org/model/budd-john-b-legacy) (registry code 056146P) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: L2K-187 - Airframe hours: 734 - Engines: Continental IO-550 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Lampert Gary M - Registered owner: Lampert Gary M - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, August 10, 2009, 32 hours before - Departed: KSBA, Santa Barbra, CA - Destination: KSQL, San Carlos, CA - Airport: KWVI, Watsonville Municipal Airport, runway 20, 4,501 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; commercial, private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; toxicology performed; flight hours: 2,000 total, 367 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 57 °F, dew point 43 °F - Altimeter: 30.07 inHg - Observed at: KWVI, 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 20091121022409A](https://openairdocs.org/incident/20091121022409A), Nov 21, 2009: Amtr LEGACY2000, Freedom, CA, Destroyed, 1 fatal. On 11/21/09 at approximately 1315 PST aircraft N7JX, a Lancair, was inbound to san carlos airport, san carlos, CA when the aircraft experienced an engine… ## Docket (15 files) The files NTSB released with the investigation on July 8, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75083. 17.2 MB in all. - Witness Statements (item 1, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350305&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - ATC Personnel Statements (item 2, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348703&FileExtension=.PDF&FileName=ATC%20Personnel%20Statements-Redacted.PDF - FAA Inspector's Statement (item 3, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348705&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF - Photo 1 - wreckage overview (item 4, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348693&FileExtension=.PDF&FileName=Photo%201%20-%20wreckage%20overview-Master.PDF - Photo 2 - View above wreckage (item 5, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348694&FileExtension=.PDF&FileName=Photo%202%20-%20View%20above%20wreckage-Master.PDF - Photo 3 - View of airplane's nose and cockpit area (item 6, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348695&FileExtension=.PDF&FileName=Photo%203%20-%20View%20of%20airplane%27s%20nose%20and%20cockpit%20area-Master.PDF - Photo 4 - Engine (item 7, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348696&FileExtension=.PDF&FileName=Photo%204%20-%20Engine-Master.PDF - Photo 5 - Engine cowling (item 8, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348697&FileExtension=.PDF&FileName=Photo%205%20-%20Engine%20cowling-Master.PDF - Audio File (item 9, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348698&FileExtension=.PDF&FileName=Audio%20File-Master.PDF - Teledyne Continental Motors Engine Examination Report (item 10, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350306&FileExtension=.PDF&FileName=Teledyne%20Continental%20Motors%20Engine%20Examination%20Report-Redacted.PDF - Toxicological Report (item 11, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348700&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Medical Records Information (item 12, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347317&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 602 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348777&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 14, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348821&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Aircraft Records (item 15, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40348702&FileExtension=.PDF&FileName=Aircraft%20Records-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.