WPR24LA198

NTSB accident investigation · Warren B Cox COX Breezy · Albuquerque, NM · June 13, 2024

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
June 13, 2024, 12:10 local (18:10 UTC)
Place
Albuquerque, NM
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N409WCWarren B Cox COX Breezy
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA
FAA report
20240613021259A
Case key
194494

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

The pilot’s exceedance of the airplane’s critical angle of attack while maneuvering for landing following a partial loss of engine power after takeoff, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was maintenance personnel’s failure to properly secure the No. 1 cylinder valve lash adjustment screw jam nut, which resulted in the loss of engine power.

Findings · 4

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelWarren B Cox COX BREEZY: 1 caseAll aircraft: 320 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenanceWarren B Cox COX BREEZY: 1 caseAll aircraft: 373 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleWarren B Cox COX BREEZY: 1 caseAll aircraft: 1,310 cases
Performance/control parameters: lateral/bank controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedWarren B Cox COX BREEZY: 1 caseAll aircraft: 390 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 pilot was departing in the experimental, amateur-built airplane to accumulate hours under its Phase I flight testing. He reported that, during the initial climb, about 100 ft above the ground, the engine started running rough. He attempted to troubleshoot the problem and elected to turn toward an adjacent taxiway. During the turn, the left wing dipped. He corrected the bank, but the left wing dipped a second time, and the nose dropped. The airplane impacted the ground, substantially damaging the right wing, right horizontal stabilizer, and the fuselage. The pilot stated that he shut the engine down before he egressed the airplane. Postaccident examination of the airframe and engine revealed dirt located in the air intake and the carburetor air inlet, likely as a result of impact. Each of the spark plugs were carbon fouled. Further examination found that the No. 1 cylinder compression was low. The No. 1 cylinder valve cover was removed, and the exhaust valve adjustment screw jam nut was found loose inside the valve cover and the rocker arm had excessive movement. The cylinder was removed; the oil control ring on the piston was stuck in the piston groove and there were rub marks on the piston and cylinder walls. No additional anomalies were noted with the airframe or engine. The loose exhaust valve adjustment screw jam nut likely caused the exhaust valve to stop operating properly, which resulted in a loss of compression to the No. 1 cylinder. The stuck oil control ring and rub marks in the cylinder likely resulted from the inoperable exhaust valve. The engine was overhauled about three years before the accident and at the time of the accident, had accumulated 31 hours of operation since overhaul. The exhaust valve lash adjustment screw jam nut was likely not secured properly by maintenance personnel during the overhaul. The accident is consistent with the pilot’s exceedance of the airplane’s critical angle of attack while maneuvering for landing following a partial loss of engine power, which resulted in an aerodynamic stall and loss of control. The loss of engine power likely resulted from an improperly secured lash adjustment screw jam nut during engine overhaul.

Factual narrative

On June 13, 2024, about 1210 mountain daylight time, an experimental, amateur-built Breezy, N409WC, was substantially damaged when it was involved in an accident near Albuquerque, New Mexico. The pilot received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The purpose of the flight was to accumulate flight hours on the airframe as part of its Phase I flight testing. The pilot reported that, shortly after takeoff from runway 4 at Double Eagle II Airport (AEG), Albuquerque, New Mexico, about 100 ft above ground level, the engine started running rough. He attempted to troubleshoot; however, he was unable to restore engine power and attempted to land on an adjacent taxiway. During the left turn toward the runway, the left wing dipped into a steep bank. He corrected the bank, but the left wing dipped a second time. While trying to correct the steep bank, the airplane impacted a dirt field, substantially damaging the right wing, right horizontal stabilizer, and the fuselage. The pilot stated that he shut down the engine before he egressed the airplane. The wreckage was recovered to a secure location and examined. Dirt was found in the air intake and carburetor air inlet. The spark plugs were removed and all eight spark plugs exhibited carbon fouling. An engine compression check revealed that the No. 1 cylinder compression measured 80/10. The No. 1 cylinder valve cover was removed, and the exhaust lash adjustment screw jam nut was found loose under the intake valve spring retainer. The No. 1 cylinder was removed, and the oil control ring was found stuck in the ring land. There were rub marks on both the piston and cylinder walls. There were no additional anomalies noted during the examination of the airframe and engine. According to the airplane’s maintenance logs, the engine was overhauled about three years before the accident and at the time of the accident had accumulated about 31 hours since overhaul. The most recent condition inspection was completed on August 4, 2023.

Aircraft

Registration
N409WC
Reported as
Warren B Cox COX Breezy
Category
Airplane, amateur-built
Serial number
COX 01
Built
2020
Airframe hours
31
Engine
Lycoming O-235-C1, 108 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · August 4, 2023 · 29 hours before
Airport
AEG · Double Eagle II, runway 04/22, 7,398 × 100 ft, asphalt
Equipment
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane, Powered-lift, Helicopter
Medical
Sport pilot, Without waivers/limitations
Last flight review
February 28, 2023
Seat
Front
Restraint
Lap only
Flight hours
3,798 total · 31 in this make and model · 2,350 as pilot in command · 20 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 27 °F
Altimeter
30.23 inHg
Observed at
KAEG
METAR
KAEG 131750Z 09005KT 10SM CLR 34/M03 A3023

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.