# NTSB WPR14LA315: Ercoupe 415 C, N2013H, Susanville, CA, July 27, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: July 27, 2014, 10:45 local (17:45 UTC) - Place: Susanville, CA - Coordinates: 40.305, -120.755836 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3050&lon=-120.7558&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report July 11, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 89757 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14LA315 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89757/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89757 - Page: https://openairdocs.org/ntsb/WPR14LA315 ## Probable cause The pilot’s failure to follow the checklist while starting the engine and to lock the engine primer plunger, which resulted in the partial loss of engine power during cruise flight in high density altitude conditions. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ercoupe 415-C, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=0420322), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ercoupe 415-C, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=0420322), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Ercoupe 415-C, 2 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=0420322), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Ercoupe 415-C, 2 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=0420322), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Ercoupe 415-C, 6 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=0420322), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing: 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 The commercial pilot reported that, before the first flight leg of the day, he used the engine primer during a cold engine start. He did not use the primer before he departed for the accident flight leg. He stated that, during cruise flight, he began to slowly climb the airplane to cross a ridgeline, and, as he pushed the throttle up, the engine did not respond. He pumped the throttle numerous times, and the engine finally responded; however, the airplane had lost altitude and airspeed, and he was forced to land the airplane in a wooded area. Examination of the wreckage revealed that the spark plugs' electrode areas were dark and sooty, indicative of a rich-mixture condition. The engine primer plunger was found in the unlocked-and-extended position, and it was undamaged and would lock when the lugs were engaged. The primer position and the condition of the spark plugs indicated that the engine power loss was likely due to an overly rich mixture, which resulted from excess fuel being pulled through the primer into the engine's intake system when power was applied. The Starting checklist procedures indicated that, after using the primer, the primer plunger should be locked. An unsecured primer plunger can cause the engine to run richer than normal and result in a rough-running engine, loss of power, and blackened spark plugs. It is likely that, when the pilot used the primer while starting the engine before the first flight leg, he did not ensure that it was locked before initiating the accident flight in accordance with the Starting checklist and that this led to the subsequent in-flight loss of engine power. The calculated density altitude at cruise altitude at the time of the flight was about 9,240 ft, which would have further degraded the engine's performance. ## Factual narrative On July 27, 2014, about 1045 Pacific daylight time, an Ercoupe, 415-C, N2013H, sustained substantial damage during a forced landing following a reported loss of engine power during cruise flight near Susanville, California. The commercial pilot and passenger sustained minor injuries. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The local flight departed Rogers Field Airport (O05), Chester, California, about 0940. A family member of the pilot reported the airplane overdue to local law enforcement on the afternoon of July 27, 2014, after becoming concerned when the pilot had not arrived at his planned destination. The Federal Aviation Administration (FAA) issued an Alert Notification (ALNOT) for the missing airplane. The wreckage was located by law enforcement personnel about 1922 on July 27, 2014, in rugged terrain. In a written statement to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the pilot stated that during the first flight leg that day, the airplane primer was used during a cold engine start. The next flight was the accident leg, and due to the short period the engine was shutdown, the primer was not used for engine start during this leg. On the accident flight, the pilot stated that while in cruise flight about 6,500 feet mean sea level (msl), he began a slow climb to cross a ridgeline and as he pushed the throttle up, the engine did not respond. He pumped the throttle numerous times and the engine finally responded but the airplane had lost altitude and airspeed and he was forced to land the airplane in a wooded area. Subsequently, the passenger and him egressed and hiked to safety. Utilizing the weather conditions at the nearest reporting station, the density altitude was calculated by the IIC to be about 9,240 feet for the cruise altitude about the time of the accident flight. An examination of the airplane wreckage was conducted by a FAA inspector at the accident site. The airplane's fuselage and wings were observed to have been substantially damaged. All major structural components of the airplane were present in the wreckage. The inspector observed that the engine primer plunger was in the unlocked and extended position. The primer plunger was observed to be undamaged and would appropriately lock when the lugs where engaged. Further, the recently installed spark plugs were removed and observed to be dark in color. No additional anomalies were observed that would preclude normal operation of the engine. The airplane's manual, starting cockpit checklist states to use the primer 2 to 6 strokes and then to lock the primer plunger. ## Aircraft - Registration: [N2013H](https://openairdocs.org/deregistered/N2013H-2020-05-01), registration cancelled 2020-05-01, S/N 2636, 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 A&C75 series](https://openairdocs.org/engine/continental-a-c75-series) (registry code 17005, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2636 - Year built: 1946 - Airframe hours: 2347 - Engines: CONT MOTOR A&C75 SERIES 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 15, 2014 - Departed: O05, Chester, CA - Destination: O05, Chester, CA - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: sport pilot, unknown; last flight review May 14, 2013; seat: left; restraint: 3-point; flight hours: 8,475 total, 15 in this make and model, 7,995 as pilot in command, 8 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 27 °F - Altimeter: 30.22 inHg - Observed at: RTS, 53 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 20140727013129A](https://openairdocs.org/incident/20140727013129A), Jul 27, 2014: Ercoupe 415-C, Susanville, CA, Substantial damage. On initial start-up on a personnel flight around several airports in the mountainous northern California area, the engine was primed with several pumps.… ## Docket (3 files) The files NTSB released with the investigation on May 25, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89757. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 597 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437166&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Email (item 2, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437167&FileExtension=.PDF&FileName=Record%20of%20Email-Master.PDF - Airplane Manual Excerpt (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437168&FileExtension=.PDF&FileName=Airplane%20Manual%20Excerpt-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.