- Date
- April 3, 2011, 12:53 local (19:53 UTC)
- Place
- Pleasant Grove, CA
- Injuries
- 1 fatal
- Damage
- Substantial damage
- Phase of flight
- Takeoff
- Aircraft
- N8113NTomei S12 XL
- Defining event
- Takeoff: Loss of control in flight
- Weather
- Instrument (IMC) · Day
- Status
- Completed · report August 7, 2012
- Report
- Approved by Office Director
- NTSB office
- Western Pacific Region
- Parties
- FAA FSDO
- FAA report
- 20110403007029A
- Case key
- 78748
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 pilot’s failure to allow the airplane’s engine to properly warm up before applying takeoff power, which resulted in the forward cylinder's piston seizing and a subsequent loss of engine power. Also causal was the pilot's failure to maintain an adequate airspeed after the loss of engine power, which resulted in a stall-spin.
Findings · 5
NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.
Sequence of events
The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.
Analysis
A pilot-rated witness said that the airplane was airborne within “a couple of minutes” after the engine was started and that, when the airplane reached an altitude of 200 to 300 feet above the ground during climb out, it appeared to slow. The witness said that the airplane then banked left and descended in a spiral until it impacted the ground. Postaccident examination of the engine revealed evidence of abnormal piston wear and cylinder damage, including mechanical scoring and vertical grooves along the forward cylinder walls and piston skirt. A representative of the engine manufacturer reported that the observed cylinder and piston damage was consistent with an in-flight cold seizure of the piston (a condition where the piston seizes within the cylinder). About 17 years before the accident, the engine manufacturer issued a Service Information Letter (SIL) that addressed the potential for such a piston seizure. The SIL stated in part “...Putting a cold engine to hard work without uniform and correct warm up will cause the piston to expand quicker than the cylinder, minimizing clearance and creating piston scuffing and seizure.” It is likely that the pilot did not allow enough time for the engine to warm up before taking off.
Factual narrative
HISTORY OF FLIGHT On April 3, 2011, about 1253 Pacific daylight time, an experimental amateur built Tomei Rans S12 XL airplane, N8113N, collided with the ground shortly after takeoff from a private airstrip near Pleasant Grove, California. The certificated sport pilot was fatally injured. The airplane sustained substantial damage to the forward fuselage, empennage and wing assembly. The airplane was registered to the pilot, and operated under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. A pilot rated witness, who was an acquaintance of the pilot, stated that the airplane landed at the private airstrip about 1150. The witness reported that he and the pilot talked for 30-45 minutes and among other things, discussed flying to another airstrip south of their location as a flight of two. The witness reported that while he was doing a run-up, he watched the accident airplane depart to the northwest. Shortly after takeoff, as the accident airplane reached an altitude between 200 to 300 feet above ground level, it appeared to slow down, bank to the left, and subsequently spiraled to the ground. During a separate conversation, the witness reported that the accident airplane was airborne “a couple of minutes” after the engine was started. TESTS AND RESEARCH The airplane was equipped with a 2-stroke Rotax 582 liquid cooled, 2-cylinder piston engine; serial number 4656067. Engine total time since new was 318.6 hours. Post accident examination of the engine revealed evidence of abnormal piston wear. Mechanical scoring and vertical grooves were noted along the forward (mag) cylinder walls and forward piston skirt. Both piston rings were intact; however, were seized within their ring lands. The associated piston wrist pin, wrist pin bearings and connecting rod were in place with no damage noted. Detailed exam notes are contained in the public docket. A representative of the engine manufacturer reported that the observed cylinder and piston wear and damage signatures was indicative of an in-flight “cold seizure” of the piston; a condition where the piston seizes within the cylinder. The manufacturer’s representative stated that this occurs when there is a thermo-imbalance of the piston and cylinder caused by a lack of engine warm-up or excessive temperature coolant difference inlet to outlet on the engine. ADDITIONAL INFORMATION In a manufacturer issued Service Information Letter (SIL) dated July 1994, Rotax addressed, in part, the potential for piston seizure. The letter stated in part “...Putting a cold engine to hard work without uniform and correct warm up will cause the piston to expand quicker than the cylinder, minimizing clearance and creating piston scuffing and seizure.”
Aircraft
- Registration
- N8113N
- Reported as
- Tomei S12 XL
- Category
- Airplane
- Serial number
- 07960735
- Airframe hours
- 306
- Engine
- Bombardier ROTAX (ALL), 65 horsepower, reciprocating
- Damage
- Substantial damage
- Flight
- Personal · Part 91
- Operator
- Tomei Ed J
- Registered owner
- Tomei Ed J
- Airworthiness certificate
- Special, Experimental light sport (Special)
- Last inspection
- Condition · February 21, 2011
- Departed
- PVT · Pleasant Grove, CA
- Destination
- PVT · Pleasant Grove, CA
- Airport
- PVT · Private, runway 30, 2,300 × 50 ft, dirt
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
- 53
- Injuries
- Fatal
- Certificate
- Sport Pilot
- Airplane ratings
- Single-engine land
- Medical
- Class 3, Unknown
- Seat
- Left
- Toxicology
- Performed
- Flight hours
- 165 total · 165 in this make and model · 140 as pilot in command
Weather
- Conditions
- Instrument (IMC) · Day
- Wind
- 330° at 18 knots
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 63 °F, dew point 37 °F
- Altimeter
- 30.06 inHg
- Observed at
- KSMF, 24 nm away
Docket · 6
The files NTSB released with the investigation on June 17, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.8 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.