# NTSB WPR23LA295: Fish Larry W Lancair 360, N68XA, Renton, WA, July 31, 2023 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: July 31, 2023, 09:20 local (16:20 UTC) - Place: Renton, WA - Coordinates: 47.493139, -122.21575 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.4931&lon=-122.2157&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Lycoming Engines, Federal Aviation Administration - NTSB case key (mKey): 192762 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA295 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192762/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192762 - Page: https://openairdocs.org/ntsb/WPR23LA295 ## Probable cause A loss of electrical power due to low battery voltage, which resulted in an inflight shut down of the capacitor discharge ignition system and a loss of engine power. Contributing to the accident was the pilot’s failure to switch batteries after the electrical power loss. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Fish Larry W LANCAIR 360, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=05623JO), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) - [Ignition system: ignition power supply](https://openairdocs.org/ntsb-findings/01057410): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Fish Larry W LANCAIR 360, 1 case](https://openairdocs.org/ntsb-findings/01057410/cases.md?model=05623JO), [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01057410/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Fish Larry W LANCAIR 360, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05623JO), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis The pilot was preparing to land when the accident occurred. Once the airplane was established on the downwind leg of the traffic pattern, he extended the landing gear and the engine immediately began to lose power and the instruments started to flicker. Shortly thereafter, engine returned to full power and then lost all power. The pilot immediately turned toward the airport to make a midfield landing. He attempted to maneuver the airplane to align it with a runway, but a wingtip contacted the runway and the airplane impacted the ground, which resulted in substantial damage to the empennage. The airplane was equipped with an onboard capacitor discharge ignition (CDI) system instead of magnetos. The system operates on a 12-volt (v) battery. Postaccident examination revealed the main battery voltage was 3.67 volts and the auxiliary battery voltage was 12 volts. The pilot was operating the system off the main battery at the time of the power loss. The minimum supply voltage for starting the engine is 6.5 volts and the minimum operating voltage is 5.5 volts. There were no emergency procedures that would have required the pilot to switch batteries. However, as the functionality of the CDI was contingent on battery power, a logical and conscientious troubleshooting step would have been to verify battery voltage and switch batteries. The engine would have continued to run as the auxiliary battery voltage exceeded the minimum supply voltage for the CDI. The examination did not reveal any additional preimpact mechanical anomalies of the engine or airplane that would have precluded normal operation. The airplane’s onboard engine monitor did not capture the loss of power, likely because the unit had shut down when the loss of electrical power occurred. The CDI and airplane’s electronic systems were drawing power from the main battery, which was providing insufficient voltage at the time of the accident. The power loss likely occurred when the pilot extended the landing gear, which may have drawn enough power to place the battery beneath the minimum operating voltage of the CDI. This critically low voltage would have resulted in a loss of power to the electrical system and electronic magnetos, which would have resulted in a loss of power to the engine. The investigation also found that the battery terminal connections were likely in contact with their composite cover at the time of the accident, which resulted in their separation from the battery during the accident sequence due to overstress. ## Factual narrative On July 31, 2023, about 0920 Pacific daylight time, an experimental amateur-built Lancair 360 airplane, N68XA, was substantially damaged when it was involved in an accident near Renton, Washington. The private pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, the cross-country flight began in central California two days before the accident. His last fuel stop on the first day of flying was in Scappoose, Oregon, where he topped off the fuel tanks. He then departed with 43 gallons of fuel onboard and flew 1 hour to William R Fairchild International Airport (CLM), Port Angeles, Washington, where he stayed overnight. The following day he flew to Renton Municipal Airport (RNT), Renton, Washington, and then returned to CLM, for a total of about 50 minutes of flight time between the two flights that day. On the day of the accident (the next day), he flew back to RNT, which took about 25 minutes. After an uneventful flight, he entered a 45° approach to the downwind leg of runway 34 to enter the traffic pattern. Once the airplane was established on the downwind leg the pilot began the pre-landing checklist; however, after he deployed the flaps and landing gear, “the engine turned slower” and the instruments flickered. The pilot then informed air traffic control (ATC) that he needed to land. Almost immediately, the engine returned to full power, which the pilot reported to ATC as he figured the brief power loss was an isolated event. The pilot stated the engine then lost power, and the engine monitor turned off when the airplane was midfield during the downwind leg. Data retrieved from the engine monitor showed a portion of the accident flight; however, the unit did not capture the loss of power. The pilot selected a gap between two transport-category airplanes. He flew between and just above them. He then made a right turn to align the airplane with runway 34. Subsequently, the right wing dipped and the airplane stalled. According to the pilot he could not recount any further events. The airplane sustained substantial damage to the empennage. Postaccident examination of the airplane revealed no preimpact mechanical anomalies that could have precluded normal operation. The engine was equipped with a plasma capacitor discharge ignition (CDI) system, manufactured by Light Speed Engineering, LLC. According to the operation manual, all plasma CDI systems can be used with 12-volt electrical systems. The minimum supply voltage for starting is 6.5 volts and the minimum operating voltage is 5.5 volts. The CDI manual contains operating instructions for systems with main and auxiliary batteries. According to the manual, “Dual Systems only: If you have installed an aux battery per the LSE supplied drawing, monitor your voltmeter and do not switch to the aux battery until the supply voltage of the main battery is below 6.5 Volts or the engine is not runningsmoothly. After switching to the aux battery, your voltmeter will read the voltage remaining in your aux battery.” The manual did not include any emergency procedures that required the pilot to switch batteries inflight. The electrical system was powered by a 12-volt main battery with an additional 12-volt auxiliary battery. Two solenoids drew power from the main and auxiliary batteries to deliver power to the starter motor. The pilot can toggle between both batteries using switches located on the instrument panel labeled “IGN A” and “IGN B.” The switches are used to select either the main or auxiliary batteries to run the electronic ignition system (“IGN A” runs 4 spark plugs and “IGN B” runs another 4 spark plugs). The airplane was equipped with a voltage meter located within the display of the onboard engine monitor and a low voltage light. The pilot reported that he did not observe the light illuminate throughout most of the flight; however, he reported that he was not focused on it after the instrument panel went “dark.” According to the onboard engine monitor, the voltage indicated 14vdc about one hour and 20 minutes prior to the accident. Figure 1: Battery switches on instrument panel Both batteries remained within their respective bays between the instrument panel and engine firewall. The negative terminal of the main battery was fractured and exhibited evidence of arcing. The positive leads were secured to the positive terminal of the battery and were unremarkable, as were both terminals on the auxiliary battery. The main battery voltage measured 3.67 volts and the auxiliary battery voltage was 12 volts when tested with a multimeter. The examination also revealed two indentations on the lining of the composite battery compartment cover. The location of the indentations corresponded with the position of the negative and positive terminal connections (see Figure 2). Figure 2: Composite battery compartment cover with aux and main battery positions A metallurgical examination of the negative main battery terminal revealed that it fractured in overstress. There was also evidence of arcing on the nut of the negative terminal. The remelt spot in the arcing exhibited elevated copper relative to the surrounding areas. Figure 3: Main battery, negative terminal Postaccident examination of the engine revealed no additional preimpact mechanical anomalies or malfunctions that would have precluded normal operation. All four electronic ignition boxes remained securely attached to their mounts and each ignition harness was securely connected to both its respective ignition box and spark plug. The top spark plugs were all tightly secured and each plug exhibited coloration consistent with normal wear when compared to the Champion Check-A-Plug chart (AV-27). Metallurgical examination of the positive terminal fracture signatures revealed they were consistent with ductile overstress from torsional loads. The fracture surfaces of the negative terminal weremostly smeared consistent with sliding contact between the mating fracture faces under mostly shear loading with limited tensile stresses in the fracture plane. Arc damage was found on the negative terminal that had peaks associated with copper. ## Aircraft - Registration: [N68XA](https://openairdocs.org/deregistered/N68XA-2023-11-09), registration cancelled 2023-11-09, S/N 943-320-783-SFB (OpenAirDocs) - Reported make and model: FISH LARRY W LANCAIR 360 - Registry model: [Fish Larry W LANCAIR 360](https://openairdocs.org/model/fish-larry-w-lancair-360) (registry code 05623JO) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360-B1H](https://openairdocs.org/engine/lycoming-aeio-360-b1h) (registry code 41884, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 943-320-783-SFB - Airframe hours: 393.1 - Engines: Lycoming AEIO-360-B1H 200 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, May 6, 2023, 23.1 hours before - Departed: CLM, Port Angeles, WA - Destination: Same as departure - Airport: RNT, Renton Muni, runway 34, 5,382 × 200 ft, asphalt - Equipment: Handheld GPS, Auto-pilot, Angle of attack indicator, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: serious; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review September 4, 2021; seat: left; restraint: 4-point; flight hours: 1,077 total, 256 in this make and model, 988 as pilot in command, 28 in the last 90 days, 15 in the last 30 days, 8 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 52 °F - Altimeter: 30.16 inHg - Observed at: KRNT - METAR: KRNT 311623Z 36005KT 10SM CLR 19/11 A3016 RMK AO2 T01890106 ## 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 20230731013589A](https://openairdocs.org/incident/20230731013589A), Jul 31, 2023: Fish Larry W LANCAIR 360, Renton, WA, Destroyed. While approaching the downwind the aircraft experienced a loss of engine power, along with a temporary loss of instrumentation power. The pilot proceeded… ## Docket (11 files) The files NTSB released with the investigation on February 20, 2025, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192762. 34.9 MB in all. - Engine data monitor - specialist's factual report (item 1, PDF, 9 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17298243&FileExtension=pdf&FileName=WPR23LA295%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report (item 2, CSV, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17297944&FileExtension=csv&FileName=WPR23LA295%20Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Materials laboratory factual report 24-017 (item 3, PDF, 8 pages, 10 photos, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17018805&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2024-017-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 4, PDF, 10 pages, 13.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17277593&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Correspondence with pilot (item 5, PDF, 15 pages, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17277417&FileExtension=pdf&FileName=correspondence%20with%20pilot_Redacted-Rel.pdf - NTSB wreckage examination report (item 6, PDF, 7 pages, 763 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17312496&FileExtension=pdf&FileName=WPR23LA295%20aircaft%20exam%20report-Rel.pdf - Engine logbook excerpt (item 7, PDF, 4 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17192565&FileExtension=pdf&FileName=engine%20log_Redacted-Rel.pdf - Plasma CDI excerpt (item 8, PDF, 2 pages, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17277279&FileExtension=pdf&FileName=Excerpt%20from%20plasma%20CDI%20manual-Rel.pdf - Aircraft logbooks (item 9, PDF, 5 pages, 11.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17192680&FileExtension=pdf&FileName=aircraft%20log_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 10, PDF, 1 page, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17305275&FileExtension=pdf&FileName=party%20member%20form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 2 pages, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17277219&FileExtension=pdf&FileName=release_Redacted-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.