# NTSB WPR14LA100: Ercoupe 415 C, N2076H, Poulsbo, WA, January 20, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 20, 2014, 15:40 local (23:40 UTC) - Place: Poulsbo, WA - Coordinates: 47.747222, -122.605003 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.7472&lon=-122.6050&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 8, 2015 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration FSDO - NTSB case key (mKey): 88691 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA100 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88691/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88691 - Page: https://openairdocs.org/ntsb/WPR14LA100 ## Probable cause The pilot's failure to confirm that the engine oil filler cap was secured before flight, which resulted in oil exhaustion and a subsequent total loss of engine power during cruise flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=0420322), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=0420322), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Health/Fitness: physical fitness](https://openairdocs.org/ntsb-findings/02013010): Personnel issues › Physical · Pilot; cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/02013010/cases.md?model=0420322), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/02013010/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=0420322), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=0420322), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=0420322), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Ercoupe 415-C, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=0420322), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Ercoupe 415-C, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0420322), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During the approach for an attempted forced landing into a clearing, the airplane struck trees and then collided with the ground in a nose-down attitude. The pilot sustained serious injuries during the impact but was able to call 911 on his cell phone. He subsequently died from complications related to his injuries about 2 weeks later. Postaccident examination revealed that the engine oil filler cap had not been secured. The oil filler neck and cap were intact and undamaged. Due to the engine's design, the engine oil filler cap was located at a low point on the engine; therefore, failure to secure the cap would have resulted in a rapid expulsion of engine oil and a subsequent engine seizure. Engine examination found damage consistent with oil exhaustion and engine seizure, and the aft section of the engine compartment was coated with oil, which extended out of the cowling and onto the airplane's belly. The pilot was operating without a valid medical certificate; the Federal Aviation Administration had denied his medical application 3 years before the accident due to a diagnosis of myelodysplastic syndrome. Although no evidence was found indicating that this medical condition was casual to the accident, it likely contributed to the pilot's death because it hindered his recovery from otherwise nonlife-threatening injuries. ## Factual narrative On January 20, 2014, about 1540 Pacific standard time, an Ercoupe 415 C, N2076H, collided with trees near Poulsbo, Washington, following a loss of engine power. The airplane was registered to, and operated by, the commercial pilot/owner under the provisions of 14 Code of Federal Regulations Part 91. The pilot died 16 days later due to complications from injuries incurred during the accident. The airplane sustained substantial damage to the forward fuselage and both wings. The local flight departed Auburn Municipal Airport, Auburn, Washington, about 1440. Visual meteorological conditions prevailed, and no flight plan had been filed. The Kitsap County Central Communications Center received a 911 call from the pilot about 1545, stating that he had been involved in an airplane accident. Emergency response personnel responded to the accident site, and located the pilot, who was seated outside and adjacent to the airplane. Due to the nature of his injuries, he could not recall the circumstances of the accident, and reported only that he had left Auburn earlier in the day. The airplane came to rest inverted, and was located at the edge of a clearing, bound by 50-foot-tall trees. It sustained crush damage to the upper fuselage from the firewall through to the aft cabin. The right wing remained attached to the fuselage; the left wing sustained leading edge crush damage and was folded aft about 45 degrees. The airplane's belly was coated in a layer of brown-colored oil that extended from the louvered lower lip of the engine cowling, through to the tailcone. Examination revealed that the combination engine oil filler cap/dipstick was not installed in the filler neck. The cap was subsequently located loose within the engine compartment, against the cowling. The cap appeared undamaged, with both its gasket and locking tabs in place. The filler neck remained attached to the engine sump, and its locking lugs were intact. The aft section of the engine compartment was coated in oil, which continued along the lower firewall, and out of the left side of the cowling and onto the airplane's belly. The oil coating was in an area that was obscured from the pilot's view while in flight. FAA Medical History The pilot first obtained a third-class aviation medical certificate in 1964, and routinely renewed it in the second or third class with the only limitation being the need to wear corrective lenses. In 1998 he reported a diagnosis of hypertension, which was being treated with blood pressure medication. Subsequent to that, the Aviation Medical Examiner (AME), who was also the pilot's treating physician, issued him a third-class medical certificate, which was confirmed by the Federal Aviation Administration (FAA). The pilot continued to report his hypertension and its treatment, and continued to receive third-class medical certificates. In 2006 and 2008, the pilot reported additional medications for the treatment of high cholesterol, and was awarded a third-classmedical certificate on both occasions. In August 2010, the pilot applied for another third-class medical certificate and continued to report hypertension. In addition, he reported "low platelet count, no symptoms"; the AME noted the low platelet count was the result of myelodysplastic syndrome and deferred the certification decision to the FAA. In September 2010, the FAA asked for additional information regarding the condition, along with records regarding the diagnosis and care. The pilot was referred to a hematologist and further testing was performed. After it assessed the results, the FAA, in October 2010, denied the pilot a medical certificate because of his myelodysplastic syndrome and low platelet count. The FAA medical certification file contained a letter from the pilot to the FAA requesting reconsideration. In the letter, the pilot stated "Although I have flight instructor and commercial pilots licenses, I no longer give any instruction and of course since I am requesting a third-class medical, I do no commercial flying. I have over 1,800 hours and own part of a Beechcraft Bonanza, which I only fly for the pleasure of it." He went on to say, "I have no symptoms of anything wrong with me. I exercise daily and eat a balanced diet. If not for the blood tests I would consider myself to be the picture of health." The pilot included a letter from his hematology/oncologist that described his condition and stated that the pilot "should be competent as a recreational pilot." The FAA responded on November 22, 2010, that the pilot's request for reconsideration was denied, and asked that if the pilot again requested a reconsideration he supply evidence that his platelet count had improved. There were no further documents in the FAA medical certification file. Postaccident Hospital Admission Following the accident, the pilot was transported by helicopter to a nearby Level I Trauma Center. There he was diagnosed with pulmonary contusions and multiple rib fractures. He quickly developed worsening shortness of breath and was placed on a ventilator in the emergency department. Over the next 2 weeks, his bone marrow function worsened and transfusions of multiple types of blood products were required. He developed acute respiratory distress syndrome, his kidneys failed, and he had multiple infections. He died 16 days after the accident. Toxicology Toxicology testing was performed by the FAA Civil Aerospace Medical Institute (CAMI) on blood obtained from the pilot during the first portion of his hospital stay. Results identified Amlodipine, Midazolam, and Ondansetron in blood. According to the emergency department medical records, Midazolam and Ondansetron were administered as part of the pilot's initial resuscitation efforts. According to CAMI, Amlodipine is a calcium channel blocker heart medication used in the treatment of hypertension. The 70-year-old-pilot held a certified flight instructor certificate with ratings for airplane single-engine land,and instrument airplane. His most recent FAA third-class medical certificate was issued in August 2008, with limitations that he must have glasses available for near vision. No personal flight records were located for the pilot; however, at the time of his last medical application he reported a total flight experience of 1,837 hours with 28 logged in the last 6 months. Engine Examination The four-cylinder normally aspirated engine was manufactured by Continental Engines. It was equipped with a 4-quart oil sump located at the bottom of the crankcase. The oil filler neck protruded from the sump to a level just below the cylinder heads. The engine was examined and disassembled by an Aircraft Mechanic following recovery. The mechanic reported that the engine had completely seized, and exhibited damage consistent with oil exhaustion. He found fragments of metallic components in the crankcase, and reported that the camshaft, along with the connecting rod for cylinder No.1, had failed. GPS Receiver The airplane was equipped with a Garmin GPSMap 295 GPS receiver. The unit was not damaged, and contained track data for the entire flight leading to the accident. The data revealed that the airplane departed Auburn Airport and flew directly west across Commencement Bay, just north of Tacoma. It then turned to the north, climbed to 2,300 ft msl, and flew directly to Jefferson County International Airport, Port Townsend, Washington. The pilot performed a touch-and-go landing at 1521, and on climbout initiated a left turn to the south towards Poulsbo. The airplane reached Poulsbo at 1538, and then began to descend from 1,759 ft, and reached an altitude of 876 ft about 80 seconds later. Over the next 30 seconds, the airplane made a descending 180-degree left turn to the last recorded position, at an elevation of 374 ft. The airplane was located at an elevation of 374 ft, just north of the last recorded track position. The airplane struck the top of trees prior to reaching the clearing. ## Aircraft - Registration: [N2076H](https://openairdocs.org/deregistered/N2076H-2014-07-30), registration cancelled 2014-07-30, S/N 2699, built 1946 (OpenAirDocs) - Reported make and model: ERCOUPE 415 C - Registry model: [Ercoupe 415-C](https://openairdocs.org/model/ercoupe-415-c) (registry code 0420322) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2699 - Year built: 1946 - Airframe hours: 1249 - Engines: CONT MOTOR C85 SERIES 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 4, 2013, 15 hours before - Departed: S50, AUBURN, WA - Destination: S50, AUBURN, WA - Airport: S50, Auburn Muni - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; restraint: lap only; toxicology performed; flight hours: 1,837 total, 30 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 43 °F, dew point 34 °F - Altimeter: 30.29 inHg - Observed at: KPAE, 20 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 20140120000199A](https://openairdocs.org/incident/20140120000199A), Jan 20, 2014: Ercoupe 415-C, Poulsbo, WA, Substantial damage, 1 fatal. On January 20, 2014, approx. 1545 PST, Ercoupe model 415C, registration number N2076H, due to unknown circumstances,experienced a force landing into a clear… ## Docket (14 files) The files NTSB released with the investigation on July 28, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88691. 19.9 MB in all. - Record of Conversation – Mechanic (item 1, .PDF, 552 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429899&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20Mechanic-Master.PDF - Image 1: Flight Route Derived from GPS Data (item 2, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429902&FileExtension=.PDF&FileName=Image%201%3A%20Flight%20Route%20Derived%20from%20GPS%20Data-Master.PDF - Image 2: Flight Route Derived from GPS Data (item 3, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429903&FileExtension=.PDF&FileName=Image%202%3A%20Flight%20Route%20Derived%20from%20GPS%20Data-Master.PDF - Image 3: Flight Route Derived from GPS Data (item 4, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429904&FileExtension=.PDF&FileName=Image%203%3A%20Flight%20Route%20Derived%20from%20GPS%20Data-Master.PDF - Raw GPS Data (Text Document) (item 5, .TXT, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429911&FileExtension=.txt&FileName=Raw%20GPS%20Data%20(Text%20Document)-Master.txt - Medical Factual Report (item 6, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429912&FileExtension=.PDF&FileName=Medical%20Factual%20Report-Master.PDF - Evidence Control - GPS (item 7, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429916&FileExtension=.PDF&FileName=Evidence%20Control%20-%20GPS-Master.PDF - Toxicological Report (item 8, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429913&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1: Airplane at Accident Site (item 9, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429905&FileExtension=.PDF&FileName=Photo%201%3A%20Airplane%20at%20Accident%20Site-Master.PDF - Photo 2: Airplane at Accident Site (item 10, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429906&FileExtension=.PDF&FileName=Photo%202%3A%20Airplane%20at%20Accident%20Site-Master.PDF - Photo 3: Oil Cap (item 11, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429907&FileExtension=.PDF&FileName=Photo%203%3A%20Oil%20Cap-Master.PDF - Photo 4: Oil Cap (item 12, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429908&FileExtension=.PDF&FileName=Photo%204%3A%20Oil%20Cap-Master.PDF - Photo 5: Oil Filler Neck (item 13, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429909&FileExtension=.PDF&FileName=Photo%205%3A%20Oil%20Filler%20Neck-Master.PDF - Photo 6: Oil Filler Neck (item 14, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429910&FileExtension=.PDF&FileName=Photo%206%3A%20Oil%20Filler%20Neck-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.