Winnsboro, LA, USA
N1126V
FAIRLEY GOOCH LANCAIR IV
The airline transport pilot was landing the airplane after a local test flight that involved calibrating the fuel system. According to several witnesses, they heard an increase in engine rpm consistent with the pilot adding power to perform a go-around. Several witnesses reported hearing a subsequent loss of engine power. The nose of the airplane rose and then dropped. The airplane was substantially damaged when it impacted terrain beyond the departure end of the runway. The damage to the airplane and the resultant ground scars were consistent with the airplane being in a stalled condition at the time of the accident. An examination of the airframe and engine revealed no anomalies that would have precluded normal operation. An examination of the fuel system revealed that the fuel selector was stiff and difficult to rotate. Further examination revealed that the O-rings on the fuel selector valve’s internal spindle were swollen past the plane of the shaft of the spindle, preventing easy rotation. The pilot was aware of the fuel selector valve anomaly; however, a service bulletin addressing the problem with the fuel selector O-rings had not yet been complied with. The fuel blighting evidence at the accident site and the quantity of fuel found in the right fuel tank suggest that the right wing contained fuel at the time of impact. Based on the circumstances of the accident, it is most likely that the engine lost power due to fuel starvation during the go-around with the fuel selector valve positioned to the left tank, and the pilot became distracted when he tried to switch fuel tanks and lost control of the airplane. Toxicological testing revealed the presence of antidepressant and cardiac medications in the pilot’s system. The blood level of the antidepressant medication was higher than usual therapeutic levels, indicating a high dose and prolonged use. The antidepressant medication in the pilot’s system comes with the warning that it may impair mental and/or physical abilities required for the performance of potentially hazardous tasks. In addition, depression is associated with significant cognitive degradation. A review of the pilot’s medical records revealed an extensive history of psychiatric and cardiac issues and subsequent difficulties obtaining a medical certificate for flight. Before the pilot’s most recent medical certification exam, he provided the Federal Aviation Administration (FAA) medical examiner with documentation indicating that he was no longer taking antidepressants. Required standardized neuropsychological testing placed the pilot at average, below average, or mildly impaired when compared with other (somewhat younger) pilots. Based on the levels of antidepressant medication in the pilot’s system, the pilot likely knowingly misreported his medication use to the FAA when he applied for his medical certificate. The pilot’s underlying depression, personality disorder, cognitive issues, and medication use likely contributed to his unwillingness to address the airplane’s fuel selector valve problem. In addition, these conditions would have adversely affected the pilot’s ability to maintain control of the airplane in an emergency.
HISTORY OF FLIGHT On September 6, 2012, approximately 1245 central daylight time, a kit-built Lancair IV experimental airplane, N1126V, was substantially damaged when it impacted terrain during a go-around at the Winnsboro Municipal Airport (F89), Winnsboro, Louisiana. The airline transport pilot was fatally injured. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a test flight. Visual meteorological conditions prevailed for the flight, which was operated without a flight plan. The local flight originated approximately 1100. According to a colleague, the pilot arrived at the airport about 1030 and fueled the airplane with 29 gallons of fuel. The pilot intended to depart with full fuel and fly in straight and level flight for 1 hour to calibrate the fuel system. The airplane was returning to the airport when the accident occurred. According to several witnesses, they heard an increase in engine rpm consistent with a pilot adding power to perform a go-around. Two witnesses came out of their hangar at the airport and observed the landing gear of the accident airplane retracting. The airplane flew from north to south directly over runway 18. Several witnesses reported hearing a subsequent loss of engine power. They observed the nose of the airplane rise and then drop. The airplane impacted the grass approximately 800 feet south of the departure end of runway 18. PERSONNEL INFORMATION The pilot, age 67, held an airline transport pilot certificate with airplane single and multiengine land ratings in addition to multiple type certificates. He was issued a third class airman medical certificate on August 21, 2012. The certificate contained the limitation “Not valid for any class after 08/31/2013.” One pilot logbook was located during the course of the investigation. The first flight logged was dated December 5, 1964. Eleven pages of logbook entries followed through December 5, 1969. A twelfth page with dates ranging from June 16, 2012, through September 5, 2012, documented four flights, all of which were logged in the make and model of the accident airplane. The pilot had logged approximately 12 hours in the make and model of the accident airplane, 3 hours and 20 minutes of which were in the accident airplane. Investigators were unable to determine the date of the pilot’s last flight review. At the time of his medical certificate application, the pilot estimated his total flight time as 14,000 hours; 25 hours had been logged in the previous 6 months. AIRCRAFT INFORMATION According to Federal Aviation Administration (FAA) records, the experimental amateur-built airplane, Gooch Lancair IV (serial number L2K289) had been manufactured by the pilot. It was registered with the FAA on a special airworthiness certificate for experimental operations. A Continental Motors TSIO-550-E1B engine rated at 350 horsepower at 2,700 rpm powered the airplane. The engine was equipped with a metal three-blade, Hartzell propeller. The airplane was equipped with two fuel tanks, each of which held 46 gallons of fuel. The airplane was maintained under a condition inspection program. The airplane maintenance records were not located during the investigation. According to a local designated airworthiness representative, the airplane entered Phase I testing on August 2, 2012, and the airplane had been test flown by an experienced test pilot. According to the test pilot, the airplane was less finished than most airplanes he had tested; however, it was airworthy and exhibited normal flight characteristics for that model of Lancair. During one flight, he experienced problems with the operation of the fuel selector valve. He stated that it was difficult to move and it required him to loosen his seatbelt and use his entire forearm to move the valve. He recommended to the pilot that the valve be either reworked or replaced. METEOROLOGICAL INFORMATION The closest official weather observation station was Monroe Regional Airport (KMLU), Monroe, Louisiana, located 28 nautical miles (nm) northwest of the accident site. The elevation of the weather observation station was 79 feet mean sea level (msl). The routine aviation weather report (METAR) for KMLU, issued at 1253, reported, wind calm, visibility 10 miles, sky condition clear, temperature 34 degrees Celsius (C), dew point temperature 24 degrees C, altimeter 29.92 inches. Calculations of relevant meteorological data indicated that the density altitude was 2,600 feet. WRECKAGE AND IMPACT INFORMATION The accident site was located south of the departure end of runway 18, in level terrain vegetated by short grass. The accident site was at an elevation of 79 feet msl, and the airplane impacted on a magnetic heading of 180 degrees. Wreckage debris extended approximately 70 feet from the initial ground scar to the main wreckage. The initial ground scar was 5 feet long, 1 foot at its widest point and 5 inches deep. Dirt from the scar was displaced towards the south. Broken plexiglass, broken fiberglass, and clear and blue lens fragments were located within the initial ground scar. A second ground scar was found just to the south of the initial ground scar and measured 10 feet long, 2 feet at its widest point, and 4 inches deep. Broken fiberglass was located within the second ground scar. A third ground scar, located to the south and east of the second ground scar measured 16 feet long, 7 feet at its widest point and 10 inches deep. Broken fiberglass and Plexiglas were located within the third ground scar. Dirt from the scar was displaced towards the south. At the southernmost end of the third ground scar was a fourth ground scar, which ran perpendicular to the third ground scar. This scar measured 10 feet long, 10 inches wide, and 5 inches deep. Clear lens fragments were located at the far west end of the fourth ground scar. Discoloration of the grass was noted from the start of the second ground scar and continued south for 68 feet towards the main wreckage. The area of discoloration was 68 feet long and 13 feet at its widest point and was consistent with fuel blighting. Debris was scattered within this area of discoloration. Broken plexiglass, broken fiberglass, engine components, and personal effects were located within the debris field. Several smaller ground scars were located in the area of discoloration between the initial impact point and the main wreckage. The main wreckage came to rest upright on an oriented heading of 010 degrees, 800 feet south of the departure end of runway 18. The main wreckage included the engine and propeller assembly, the fuselage, empennage, and the right and left wings. The right wing separated from the fuselage and was adjacent to the main wreckage. The separated wing included part of the right aileron and the right flap. The outboard portion of the wing was fragmented with the remaining portion measuring 118 inches. A section of the right aileron remained attached to the right wing at the control arm. The aileron control arm/push rod was continuous from the aileron inboard to the separation point on the wing. The separation point was consistent with overload and impact damage. The right flap remained attached to the wing and was positioned in the flap track approximately 1 inch from a fully extended position, at both the inboard and outboard track. The inboard portion of the flap was broken. The right wing contained an unmeasured amount of fuel. The outboard portion of the wing, including portions of the fuel tank, was impact damaged. The control cable for the “speed brake” was continuous from the separation point to the speed brake. The speed brake was covered and secured to the right wing with a silver tape. The right side of the fuselage, forward of the right side windscreen, was broken and fragmented. The front and side windscreen were fragmented. The fuselage from the side windscreen aft to the empennage on the right side was otherwise unremarkable. The empennage separated from the fuselage. The empennage included the horizontal and vertical stabilizer, elevator, and rudder. The right horizontal stabilizer was unremarkable. The right elevator could not be moved and was jammed forward during the impact. Dirt and grass was noted in the outboard trailing edge of the control. The right elevator was otherwise unremarkable. The rudder separated from the empennage and the upper and lower portion of the control was impact damaged. The vertical stabilizer was unremarkable. The outboard 20 inches of the left horizontal stabilizer separated and remained attached to a 39-inch piece of the left elevator. The inboard leading edge of the left horizontal stabilizer was otherwise unremarkable. The rudder cables remained attached to the rudder horn and were continuous forward to the rudder pedals. The elevator push tube separated from the aft elevator due to impact. The elevator push tube was separated in several additional locations, all consistent with impact damage. Continuity was established through these points of separation. The left side of the fuselage, forward of the left side windscreen and cabin door, was broken and fragmented. The cabin door separated from the airplane and was located in the debris field. The fuselage from the cabin door aft to the empennage was otherwise unremarkable. The left wing remained partially attached to the fuselage through the main carry-through spar. The left wing included the left aileron and left flap. Control continuity for the left aileron was established from the aileron inboard to the fuselage. The left aileron was difficult to manipulate due to impact damage. The left wing contained a trace amount of fuel and the fuel tank was impact damaged. The left flap appeared to be in the “up” or “retracted” position. The speed brake was covered and secured to the left wing with a silver tape. The fuselage included the forward and aft cabin, two forward seats, both main landing gear, and the instrument panel. The upper portion of the fuselage separated and was fragmented. The floor of the fuselage separated from the fuselage and was fragmented. The instrument panel was crushed up and aft and was fragmented. The landing gear were retracted and secured within their gear compartment. Both landing gear doors were closed and unremarkable. Investigators were not able to determine the configuration of the pilot’s seatbelt at the time of the accident. The following positions and readings were noted on the instrument panel, engine, and fuel controls: Fuel selector valve – Right tank Throttle – Full forward Mixture – Full rich Propeller – mid range The engine remained attached to the firewall and nose landing gear and included the 3-bladed propeller assembly. The propeller blades were labeled A, B, and C for identification purposes in the report. Blade A was bowed aft at least 45 degrees and exhibited leading edge polishing. Blade B was bowed aft slightly and exhibited leading edge polishing and scratches on the face of the blade. Blade C was bowed aft at least 45 degrees and exhibited leading edge polishing and scratches on the face of the blade. The top bank of sparkplugs were removed. Examination of the spark plugs exhibited signatures consistent with normal operation when compared to a Champion spark plug chart. The propeller was removed from the engine and the engine rotated by hand at the propeller flange. Engine continuity was established and air movement was noted on five of the six cylinders. The intake valve cover was impact damaged on the number five cylinder. The combustions chambers were unremarkable. The ignition harness on both magnetos was impact damaged. Impact damage was noted to the propeller governor, several induction tubes and the exhaust system. The left magneto was fractured free of the engine, and the right magneto remained partially attached to the engine. The vacuum pump was fractured free of the engine. The intercoolers and the right turbocharger were fractured free of the engine. Three of the four engine mount legs were fractured, and the oil sump was crushed upward. The mixture control arm was positioned at mid-range. MEDICAL AND PATHOLOGICAL INFORMATION The autopsy was performed by the Franklin Parish Coroner’s Office on September 7, 2012. The autopsy concluded that the cause of death was multiple injuries and the manner was accident. The FAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy (CAMI Reference #201200184001). Testing of the blood revealed 0.579 ug/ml citalopram, clopidogrel, and metoprolol. Atorvastatin, citalopram, metoprolol, and desmethylcitalopram were detected in the liver. Tests were negative for cyanide and ethanol. The specimens were unsuitable for carbon monoxide analysis. A review of the pilot’s FAA medical file revealed an extensive history of both cardiac and psychiatric disease. His diagnoses included post-traumatic stress disorder, dysthymic disorder, major depressive disorder (recurrent), and personality disorder not otherwise specified with mixed obsessive compulsive and narcissistic traits. In addition, he had hypertension and coronary artery disease that had required bypass surgery in 1994. The pilot had been denied medical certification on several occasions due to his psychotropic medication use and cardiac health issues. Most recently, the pilot applied for a third class medical certificate and stated that he had stopped taking all psychotropic medications. He also supplied letters from his aviation medical examiner, cardiologist, and psychiatrist regarding his use of medications. The pilot received the special issuance third class medical certificate on August 21, 2012. ADDITIONAL INFORMATION Engine Examination The engine was crated and sent to Mobile, Alabama, for further examination. Dye penetrant revealed multiple cracks in the propeller flange and further examination revealed that the propeller flange was bent 0.187 (187 thousandths). The exhaust system, oil sump, and number one cylinder were impact damaged. All six cylinders exhibited signatures of normal operations. The top and bottom bank of spark plugs exhibited signs of normal operations when compared to the Champion Spark Plug chart. The oil sump had RTV along the gasket area consistent with a recent removal. Fuel injector nozzles were free of contamination and the number two nozzle was impact damaged. The fuel manifold was unremarkable. The right and left magneto harnesses were impact damaged. Both harnesses were removed from their respective magnetos and replaced with slave harnesses for the purposes of running on the test bench. A blue spark was observed on each lead of the left and right magneto. The engine driven fuel pump was mounted to a flow bench and functioned within design parameters. No anomalies were noted with the engine that would have prevented it from performing prior to impact. Fuel Selector Valve The fuel selector valve (part number FU560) was retained for further examination. The selector was found positioned to the right fuel tank. When examined for continuity, the handle was very stiff and difficult to rotate. Internal examination of the assembly revealed that the O-rings on the internal spindle were swollen past the plane of the shaft of the spindle. Further examination revealed no other anomalies. Lancair Service Bulletin (SB) SB020-894, “LANCAIR IV Fuel Selector Valves,” which was issued August 20, 1994, discussed that the O-rings on the internal spindle of the fuel valve “do swell somewhat and this swelling can cause rotational stiffness beyond acceptable levels.” SB020-894 further described that “all Fuel Selector Valves with part #FU560 must have the three O-rings replaced. … If you need the new O-rings…they will be immediately shipped at no charge.”
The pilot’s failure to maintain control of the airplane after a loss of engine power during a go-around. Contributing to the accident was the difficult-to-operate fuel selector valve and the pilot’s continued operation of the airplane with a known mechanical anomaly. Also contributing to the accident was the pilot’s depression, personality disorder, cognitive issues, and medication use, which adversely affected his ability to maintain control of the airplane during the emergency and likely affected his decision not to address the airplane’s fuel selector valve problem.
Source: NTSB Aviation Accident Database
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