# NTSB WPR11LA183: Tomei S12 XL, N8113N, Pleasant Grove, CA, April 3, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 3, 2011, 12:53 local (19:53 UTC) - Place: Pleasant Grove, CA - Coordinates: 38.871944, -121.470832 - Nearby events: https://openairdocs.org/map.md?lat=38.8719&lon=-121.4708&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report August 7, 2012 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 78748 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA183 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78748/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78748 - Page: https://openairdocs.org/ntsb/WPR11LA183 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=0590075), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=0590075), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=0590075), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/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: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0590075), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0590075), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=0590075), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0590075), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Tomei ED S12 XL, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=0590075), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N8113N-2013-03-01), registration cancelled 2013-03-01, S/N 07960735, built 1999 (OpenAirDocs) - Reported make and model: TOMEI S12 XL - Registry model: [Tomei ED S12 XL](https://openairdocs.org/model/tomei-ed-s12-xl) (registry code 0590075) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 07960735 - Airframe hours: 306 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; injuries: fatal; 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 ## 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 20110403007029A](https://openairdocs.org/incident/20110403007029A), Apr 3, 2011: Tomei Ed S12 XL, Pleasant Grove, CA, Destroyed. Aircraft operated light sport airplane initial: crashed under unknown circumstances in a grassy fiels shortly after take-off from a grassy field at approx.… ## Docket (6 files) The files NTSB released with the investigation on June 17, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78748. 2.8 MB in all. - Witness Statement (item 1, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369028&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Follow-up Witness Statement (item 2, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369029&FileExtension=.PDF&FileName=Follow-up%20Witness%20Statement-Redacted.PDF - Airframe and Engine Examination (5 Embedded Photos) (item 3, .PDF, 5 photos, 444 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369031&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination%20(5%20Embedded%20Photos)-Master.PDF - Rotax Investigaton Report (50 Embedded Photos) (item 4, .PDF, 50 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369033&FileExtension=.PDF&FileName=Rotax%20Investigaton%20Report%20(50%20Embedded%20Photos)-Redacted.PDF - Rotax Service Information Letter (item 5, .PDF, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369067&FileExtension=.PDF&FileName=Rotax%20Service%20Information%20Letter-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40369068&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.