WPR18LA036

NTSB accident investigation · Doshier Wilbert A GT-500 · Willows, CA · November 25, 2017

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
November 25, 2017, 15:15 local (23:15 UTC)
Place
Willows, CA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N599RADoshier Wilbert A GT-500
Defining event
Takeoff: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA
FAA report
20171125024359A
Case key
96370

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A loss of engine power during takeoff due a coolant leak and the subsequent overheating of the engine, and the student pilot's failure to maintain airspeed and his exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall and collision with terrain. Contributing to the accident was inadequate maintenance inspection and the flight instructors delayed remedial action.

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.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededDoshier Wilbert A GT-500: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotDoshier Wilbert A GT-500: 1 caseAll aircraft: 9,295 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotDoshier Wilbert A GT-500: 1 caseAll aircraft: 200 casesProbable cause

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

The flight instructor and the student pilot, who was the pilot flying, departed for the third leg of the cross-country flight. The student pilot indicated that shortly after takeoff, when the airplane was about 70 ft above the runway, the engine sputtered and then lost power. He stated that he attempted to land straight ahead but did not maintain proper airspeed. The video from an onboard camera showed that after the engine lost power, the student pilot pulled back on the yoke, and the airplane rapidly descended toward the runway and impacted the ground likely following an aerodynamic stall. Postaccident examination of the engine revealed that the radiator coolant level was low enough that the fluid was not visible through the radiator cap. The examination revealed a coolant leak around the water pump housing nipple due to an improper seal of the hose to the nipple attachment. In addition, the radiator recovery and overflow bottle were improperly installed, which prevented the system from refilling coolant into the radiator during the engine cooling period in between flights. The intake port sides of the cylinders had antifreeze particles embedded into their surfaces consistent with overheating. The top portion of the No. 1 piston exhibited melted metal deposits from spark plug electrodes consistent with preignition and detonation, and the No. 2 piston exhibited discoloration and burnt-on carbon deposits consistent with the piston overheating for a period of time. It is likely that the airplane had lost a significant amount of coolant during the previous legs of the cross-country flight, which led to an overheated cylinder and subsequent engine failure. In addition, the student pilot failed to maintain airspeed after the partial loss of engine power. The airplane exceeded its critical angle of attack, which resulted in an aerodynamic stall at an altitude too low to recover.

Factual narrative

On November 25, 2017, about 1515 Pacific standard time, an amateur-built Quicksilver GT-500, N599RA, was substantially damaged when it was involved in an accident near Willows, California. The flight instructor and the student pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student pilot, who was the pilot flying, reported that the accident flight was the third leg of a cross-country flight. He stated that after topping off both fuel tanks, the flight was departing from Willows-Glenn County Airport (WLW), Willows, California; when the airplane was about 70 ft above ground level and halfway down the runway, the engine momentarily sputtered and then experienced a total loss of power. He indicated that he attempted to land straight ahead but did not maintain proper airspeed, which, in his opinion, resulted in an aerodynamic stall and impact with terrain. Video from an onboard camera on the airplane’s left outboard wing showed the airplane lifting off about 4 minutes 25 seconds after the engine start. During the initial climb, the airplane was right of the runway centerline, and 22 seconds after liftoff, the engine lost power. The engine can be heard detonating about 15 seconds after full throttle application, and it started to seize until it completely lost power. The student pilot pulled back on the control yoke, and the airplane rapidly descended toward the runway and impacted the ground hard, which resulted in substantial damage to the fuselage and left-wing strut. A postaccident engine examination revealed that the radiator coolant level was low enough that the fluid was not visible through the radiator cap. Draining the remaining coolant from the system allowed investigators to estimate that about 1/4 of the antifreeze was missing from the cooling system before the accident. The radiator overflow and recovery bottle had fluid in it. However, the hose leading from the radiator to the recovery bottle was improperly attached at the top of the bottle instead of the bottom. The 90° fitting installed into the top of the recovery bottle extended into the bottle less than 1 inch (in), so the system could not replenish any lost coolant in between flights during the cool-down cycle. The normal hose connection nipple used for installation was plugged. A small leak was found on the water pump inlet hose, water pump housing, case halves, and motor mount plate on the exhaust side of the engine where the water pump and coolant hoses are mounted on. The hose that was attached to the water pump housing nipple measured 1 inch (in) in diameter, while the water pump housing nipple measured between 0.904 in and 0.978 in. Examination of both cylinders showed signs of lack of coolant. The intake port sides of the cylinders had antifreeze particles embedded in their surfaces consistent with overheating. Both spark plug electrodes on the No.1 cylinder were melted, indicative ofpreignition and subsequent detonation within that cylinder, and both spark plug electrodes on the No.2 cylinder showed signs of overheating. Black carbon deposits were observed around the perimeter on the spark plugs which indicated that the engine ran rich. The top portion of the No. 1 piston exhibited melted metal deposits (from the spark plug electrodes), indicative of preignition and detonation. In addition, the outside surface of the piston around the pin and the ring gap exhibited black burn marks consistent with preignition/detonation high-pressure/temperature gases escaping between the ring end gap and burning away the aluminum portion of the piston. The carbon build-up and the aluminum discoloration on the bottom side of the piston were consistent with exposure to excessive temperatures for a long period of time. The No. 2 piston exhibited discoloration and burnt-on carbon deposits consistent with the piston overheating for a period of time. Two vertical striations noted on the intake side of No. 2 piston indicated an area of high pressure consistent with a piston that overheated and expanded, reducing the cylinder-to-piston wall clearance to below tolerance. Both carburetors' needle jets, jet needles, and all the moving parts within the carburetor showed signs of significant wear. Inspection of the crankshaft, main bearings, and connecting rod bearings showed no anomalies.

Aircraft

Registration
N599RA
Reported as
Doshier Wilbert A GT-500 (NO SERIES)
Category
Airplane, amateur-built
Serial number
0151
Built
2009
Airframe hours
1,451.3
Engine
Rotax 582UL-99, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 9, 2016
Departed
WLW · Willows, CA
Destination
0O4 · Corning, CA
Airport
WLW · Willows-Glenn County, runway 16, 4,125 × 100 ft, asphalt
Equipment
Airframe parachute, Handheld GPS

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
49
Injuries
Minor
Certificate
Student
Last flight review
November 18, 2017
Seat
Front
Restraint
3-point
Flight hours
200 total · 145 in this make and model
Role
Flight instructor
Age
80
Injuries
Minor
Certificate
Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
June 7, 2017
Seat
Rear
Restraint
3-point
Flight hours
2,835 total · 4 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 55 °F
Altimeter
29.98 inHg
Observed at
KOVE, 28 nm away

Docket · 4

The files NTSB released with the investigation on December 31, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 32.7 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.