# NTSB WPR19LA189: Vans RV14, N365EM, Aumsville, OR, July 16, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: July 16, 2019, 13:21 local (20:21 UTC) - Place: Aumsville, OR - Coordinates: 44.8875, -122.871948 - Nearby events: https://openairdocs.org/map.md?lat=44.8875&lon=-122.8719&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: Minor injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA-FSSDO, Van's Aircraft - NTSB case key (mKey): 99859 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99859/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99859 - Page: https://openairdocs.org/ntsb/WPR19LA189 ## Probable cause An inflight fire that originated in the engine compartment for reasons that could not be determined based on available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Mitchell Eugene W VANS RV-14A, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=056365P), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Mitchell Eugene W VANS RV-14A, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=056365P), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/deregistered/N365EM-2021-04-03), registration cancelled 2021-04-03, S/N 140249, built 2018 (OpenAirDocs) - Reported make and model: Vans RV14 (A) - Registry model: [Mitchell Eugene W VANS RV-14A](https://openairdocs.org/model/mitchell-eugene-w-vans-rv-14a) (registry code 056365P) (OpenAirDocs) - Registry engine: [Lycoming YIO-390 series](https://openairdocs.org/engine/lycoming-yio-390-series) (registry code 42418, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 140249 - Year built: 2018 - Airframe hours: 220 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: minor; 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 ## 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 20190716016639A](https://openairdocs.org/incident/20190716016639A), Jul 16, 2019: Mitchell Eugene W VANS RV-14A, Aumsville, OR, Destroyed. Aircraft caught fire in flight at 1500 feet. Pilot felt heat in floor and saw flames. Pilot shut down the engine and made emergency landing in a hay field on… ## Docket (6 files) The files NTSB released with the investigation on February 15, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99859. 7.2 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12259308&FileExtension=pdf&FileName=Form6120_Redacted-Rel.pdf - Pilot's email (item 2, PDF, 1 page, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13241568&FileExtension=pdf&FileName=Pilot%20email_Redacted-Rel.pdf - Field exam (item 3, PDF, 14 pages, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13256673&FileExtension=pdf&FileName=Field%20Notes%20-%20WPR19LA189-Rel.pdf - Service bulletin 00006 (item 4, PDF, 3 pages, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12259390&FileExtension=pdf&FileName=SB-00006-Rel.pdf - Statement of party representatives to NTSB investigation (item 5, PDF, 1 page, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12259318&FileExtension=pdf&FileName=Party%20Form%20(N365EM%20Signed%20by%20Vans)_Redacted-Rel.pdf - Photos (source unknown) (item 6, PDF, 2 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12259380&FileExtension=pdf&FileName=Photos-Rel.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.