WPR19LA189

NTSB accident investigation · Vans RV14 · Aumsville, OR · July 16, 2019

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
July 16, 2019, 13:21 local (20:21 UTC)
Place
Aumsville, OR
Injuries
1 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N365EMVans RV14
Defining event
Enroute-cruise: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA-FSSDO, Van's Aircraft
FAA report
20190716016639A
Case key
99859

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

On this page

Probable cause

An inflight fire that originated in the engine compartment for reasons that could not be determined based on available evidence.

Findings · 1

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.

Not determinedNot determined › Not determined · Unknown/Not determinedMitchell Eugene W VANS RV-14A: 1 caseAll aircraft: 2,247 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 airplane was in cruise flight when all electrical instrumentation was suddenly lost, and the pilot started to smell burning wires. A few seconds later, the smoke began to fill the cockpit and fire started to enter the lower part of the cockpit by the left side rudder pedals. The pilot initiated an emergency descent and subsequently landed in a field. The pilot egressed the airplane and the fire continued to burn until first responders arrived. Postaccident examination of the airplane revealed extensive thermal damage to the engine and its surrounding area, which precluded identifying the exact origin of the fire. However, there was significantly more charring and fire damage to the left side of the engine compartment and engine mount powder coating. Based on the pilot’s statement and the charring of the engine mount powder coating, it is likely that the fire started on the left side of the engine compartment. A service bulletin issued by the airplane manufacturer identified a potential leaking of Kavlico pressure sensors that were installed in the aluminum manifold located on the upper left side of the airplane’s firewall. However, the accident airplane’s manifold and both sensors were destroyed by the postaccident fire. Although a sensor failure is a possible cause, there are many potential failure points in fuel and oil supply and pressure indication lines that could have resulted in the fire. Due to the extensive thermal damage, the origin of the fire could not be determined based on available evidence.

Factual narrative

On July 16, 2019, about 1321 Pacific daylight time, an experimental, amateur built Vans RV 14A airplane, N365EM, was destroyed in an accident near Aumsville, Oregon. The pilot sustained minor injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot departed Aurora State Airport (UAO), Aurora, Oregon at 1235, with the intended destination to Corvallis Municipal Airport (CVO), Corvallis, Oregon. The pilot reported that about 1 hour into the flight, at a cruise altitude of 1,500 ft above ground level, he lost all electrical instrumentation and smelled burning wiring. He initiated an emergency descent a few seconds later when the smoke began to fill the cockpit and the fire started to enter the lower part of the cockpit by the left side rudder pedals. He conducted a forced landing to a field and evacuated the airplane that continued to burn until the first responders extinguished the fire. The pilot informed investigators that the day before the accident, he changed the oil and replaced the oil filter. When he removed the engine cowling, there was no indication of an oil leak. After the oil change, the pilot started the engine and ran it up to average temps (oil pressure was 75 pounds per square inch) and then shut it down. When he inspected for leaks, he did not locate any. The new oil filter was safety-wired. Postaccident examination of the airplane revealed extensive thermal damage, especially in the engine and cockpit area; charring of the engine mount powder coating indicated that the fire was more significant on the left side of the airplane. About 13 gallons of aviation fuel was present in the left tank and about 6 gallons was in the right tank. Due to extensive thermal damage to the engine and its surrounding area, it was not possible to determine the exact origin of the fire. On May 6, 2020, Van’s Aircraft released a service bulletin that warned about the potential leaking of Kavilco pressure sensors, whihc are commonly used in fuel, oil, and manifold pressure applications on all RV models. The exact cause (manufacturing, installation, fatigue etc.) of the Kavilco pressure sensors failures has not been determined. The accident airplane was equipped with an aluminum manifold located on the upper left side of the aircraft’s firewall, which was where both the oil and fuel pressure sensors were mounted. The manifold and both sensors were destroyed by the fire.

Aircraft

Registration
N365EM
Reported as
Vans RV14 (A)
Category
Airplane, amateur-built
Serial number
140249
Built
2018
Airframe hours
220
Engine
Lycoming IO-390-EXP10, 210 horsepower, reciprocating
Damage
Destroyed
Fire
Both
Flight
Personal · Part 91
Operator
Mitchell Eugene W
Airworthiness certificate
Standard, Aerobatic
Last inspection
Annual · February 10, 2019
Departed
AUO · Aurora, OR
Destination
CVO · Corvallis, OR
Equipment
Auto-pilot, Data recorder, ADS-B, Stall warning system, Electronic multifunction display

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
73
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
November 11, 2017
Seat
Left
Restraint
4-point
Flight hours
2,203 total · 229 in this make and model · 1,923 as pilot in command · 40 in the last 90 days · 17 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
2,500 ft broken
Observed at
SLE, 8 nm away

Docket · 6

The files NTSB released with the investigation on February 15, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.2 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.