# NTSB WPR16LA050: Moore Onex, N1950J, Fresno, CA, January 10, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 10, 2016, 11:35 local (19:35 UTC) - Place: Fresno, CA - Coordinates: 36.732223, -119.820274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.7322&lon=-119.8203&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 25, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 92554 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA050 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92554/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92554 - Page: https://openairdocs.org/ntsb/WPR16LA050 ## Probable cause The pilot/builder's failure to properly align the Force One Main Bearing, which resulted in a blockage of the oil transfer hole and culminated with a total engine power loss. Contributing to the accident was the pilot's failure to arrest the bank and sink rate prior to impact. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Owner/builder (probable cause); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=05634O7), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05634O7), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05634O7), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=05634O7), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05634O7), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Moore Ronald J ONEX, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05634O7), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot/builder was carrying out the initial flight test after recently building the amateur experimental airplane. Shortly after takeoff, the airplane's engine experienced a total power loss and the pilot initiated a descending left turn in order to avoid an airport fence. Subsequently, the airplane impacted terrain, in a nose down attitude with the left wing low. An examination of the engine revealed that the Force One Main Bearing seized to the crankshaft. Further, there were multiple circular impressions on the bearing surface. Based on this evidence, it is likely that while building the experimental engine, the pilot did not properly align the Force One Main Bearing, and the oil feed hole was inadvertently used as the dowel pin hole, which resulted in a blockage of the oil transfer hole, thus preventing oil into the bearing and resulted in engine seizure and total power loss. ## Factual narrative On January 10, 2016, about 1135 Pacific standard time, an experimental amateur built airplane, Moore Onex, N1950J, experienced a loss of engine power shortly after takeoff from the Fresno Chandler Executive Airport (FCH), Fresno, California. The commercial pilot, who was the sole person on board, was fatally injured. The airplane sustained substantial damage during the forced landing. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The pilot received serious injuries during the accident and succumbed to his injures several days after the accident. At 11:24, airport security camera video showed the accident airplane taxi to the run-up area to prepare for its initial flight test. At 11:34, the video showed the airplane depart from runway 29 and climb out normally through about 200 feet above ground level (agl). Another video from a witness, who was located near the taxiway, depicts the engine failure. The video audio echoed a smooth and complete engine shutdown that occurred in about 1.5 seconds. According to the pilot, shortly after the engine failure, he initiated a descending, left turn, in order to avoid an airport fence. Multiple witnesses, located at the airport, observed the airplane enter a steep left bank and rapidly descending as it pitched down. Subsequently, the airplane impacted terrain in a nose down, left wing low attitude. The accident airplane was equipped with a Garmin GPS 296, which revealed the airplane's flight path. The data revealed that the accident flight was about 46 seconds in duration. During the last 13 seconds of recorded data, the airplane was initially at an airspeed of 72 knots. The data then showed a continuous and rapid loss of airspeed. Additionally, the data showed the airplane starting to descend at that time. About the last 7 seconds of recorded data, the airplane made a left turn off the runway centerline that continued to the accident site. The data stopped recording at 11:35. Postaccident examination revealed that the airplane came to rest upright, nearly 180° from the runway heading and 800 ft from the runway threshold. The ground scars and airplane damage were consistent with the airplane impacting the ground in a nose down attitude, with left bank. The engine was partially attached to the airframe and found to be seized A disassembly was accomplished of the experimental engine. During the teardown examination, about 24 ounces of oil drained from the sump and internal portions of the engine. The oil screen was examined and was clear of metal contamination. The engine was disassembled and the center main bearing was galled, but was not seized, to the crankshaft journal. The force one main bearing was observed to be seized to the crankshaft. According to the Airframe & Powerplant mechanic and the Federal Aviation Administration (FAA)inspector, during the assembly of the engine, improper indexing of the Force One Main Bearing to the crankcase resulted in a complete misalignment of the oil passages. This misalignment blocked the oil transfer hole to the bearing, near the bearing retention dowel pin, thus preventing oil flow into the bearing. Circular impressions were observed on the force one main bearing crankshaft surface and on the crankcase bearing support, which would be consistent with the misalignment, where the oil feed hole was inadvertently used as the dowel pin hole. In the airplane engine assembly manual, it states: "First, check the fit of the Force One Main Bearing. Take one dowel pin and place it in the engine case bearing dowel pin hole. You have to place the dowel pin at the end of a drill and use a file to remove several thousandths from it's diameter to get it to fully seat in the dowel pin hole. When the dowel pin is installed, place the bearing in position, lining up the dowel pin hole in the bearing with the dowel pin in the engine case. Make sure the bearing is not held from seating fully in the case by a down pin that is too "high" by completing a visual check." Following this passage, the manual states: "Be careful not to mistake the oil feed hole for the dowel pin hole!" ## Aircraft - Registration: [N1950J](https://openairdocs.org/deregistered/N1950J-2016-05-24), registration cancelled 2016-05-24, S/N ONX0118, built 2015 (OpenAirDocs) - Reported make and model: MOORE ONEX - Registry model: [Moore Ronald J ONEX](https://openairdocs.org/model/moore-ronald-j-onex) (registry code 05634O7) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: ONX0118 - Year built: 2011 - Airframe hours: 0 - Engines: VW Type 1VW reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Last inspection: Condition, December 30, 2015 - Departed: FCH, Fresno, CA - Destination: FCH, Fresno, CA - Flight plan: Unknown - Airport: FCH, Fresno Chandler Executive Apt, runway 29L, 8,008 × 150 ft, grass/turf - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; commercial; airplane ratings: single-engine land; medical: sport pilot; seat: front; restraint: 4-point; flight hours: 484 total ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 3,000 ft broken - Temperature: 54 °F, dew point 45 °F - Altimeter: 30.21 inHg - Observed at: KFAT, 7 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 20160110000519A](https://openairdocs.org/incident/20160110000519A), Jan 10, 2016: Moore Ronald J ONEX, Fresno, CA, Destroyed, 1 fatal. On Sunday, jan 10, 2016, at 11:24 am, airport security camera footage showed amatuer built experimental aircraft N1950J taxi to the runup area to prepare for… ## Docket (7 files) The files NTSB released with the investigation on July 26, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92554. 3.7 MB in all. - Global Positioning System Device - Specialist's Factual Report (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454587&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Global Positioning System Device - Specialist's Factual Report - Attachment 1 (item 2, .CSV, 3 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454588&FileExtension=.csv&FileName=Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report%20-%20Attachment%201-Master.csv - Record of Email Correspondence (item 3, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454589&FileExtension=.PDF&FileName=Record%20of%20Email%20Correspondence-Master.PDF - Airframe and Engine Examination Report (5 Embedded Images) (item 4, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454590&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination%20Report%20(5%20Embedded%20Images)-Master.PDF - Airplane Registration (item 5, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454591&FileExtension=.PDF&FileName=Airplane%20Registration-Master.PDF - Inspection Log (item 6, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454592&FileExtension=.PDF&FileName=Inspection%20Log-Master.PDF - Video File (item 7, 3GP, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454593&FileExtension=3gp&FileName=Video%20File-Master 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.