Point Mugu, CA, USA
N2812
CHICCO MIGUEL E QUICKSILVER SPORT II
The two pilots, who were both qualified to fly the experimental light sport airplane, were conducting a local flight with two other similar airplanes from the same flight club. After takeoff, the three airplanes proceeded to the ocean shoreline and then flew slightly offshore along the coast. The flight was conducted at a low altitude, which, once over the ocean, was about 300 ft. Soon after reaching the ocean, both pilots noted a "skip" in the engine. They decided to climb for safety and turn around to return to their departure airport. Despite moving their respective throttles to the full throttle position, neither pilot was able to obtain full power from the engine to effect a climb, and the engine rpm began slowly decreasing. Because the airplane was no longer able to maintain altitude, control of the airplane was transferred to the pilot who held a flight instructor certificate. Due to the rocky coastline and traffic on the road along that coastline, the pilots determined that they would have to ditch in the ocean. After the ditching, both pilots escaped from the airplane, and, when the airplane began to sink, they began to swim to shore, which was about 200 ft away. Neither pilot appeared injured. No personal flotation devices were aboard the airplane or worn by the pilots. One pilot successfully swam to shore, but the other pilot drowned. The airplane washed ashore the following morning and was heavily damaged by wave action, contact with rocks, and the salt water immersion. Postaccident examination did not reveal evidence of any preaccident mechanical failures but obscuration or destruction of such evidence due to the ditching and subsequent environmental damage could not be ruled out. The examination revealed several maintenance-related discrepancies. The type of fuel line clamps used and the installation of the fuel pumps were not in accordance with the engine manufacturer's specifications, and this could have affected fuel delivery to the carburetors. After the accident, the throttle cable was found disconnected from the cockpit control, and it could not be determined whether that was a result of a partial slippage during flight, which would have limited or eliminated pilot control of the engine rpm and power. Although a similar airplane in the flight did not report any carburetor icing, the symptoms described by the surviving pilot were consistent with carburetor icing, and the ambient temperature and dew point values allowed for the possibility of carburetor icing. Despite such equipment being recommended by the engine manufacturer, the lack of carburetor heat provisions on the accident airplane prevented the pilots from being able to prevent carburetor icing, or counter carburetor icing if it did occur. Finally, although the engine manufacturer specified an overhaul interval of 300 hours, the flight club elected to adhere to a 450-hour overhaul interval advocated by a repair facility that was not approved by the engine manufacturer. At the time of the accident, the engine was about 127 hours beyond the manufacturer-recommended 300-hour overhaul interval. Although none of these discrepancies discovered during the investigation was able to be definitively linked to the accident, all were potential factors, and all were maintenance-related. The low glide ratio of the airplane (about 5:1) limited its range in the event of a loss of engine power, reducing the forced landing site options available to the pilots. The forced landing site options were further reduced by the pilots' decision to operate at 300 ft, a very low altitude. The pilots' over-water route and low cruise altitude were reported to be common for pilots in the flight club. Even though the altitude and route combination increased the likelihood of an ocean ditching in the event of a loss of engine power, neither the pilots nor the airplane were equipped for an ocean ditching. Precautions such as higher over-water cruise altitudes and water-ditching equipment, such as personal flotation devices, may have prevented this event from becoming a fatal accident.
HISTORY OF FLIGHT On July 8, 2017, about 1647 Pacific daylight time, a Quicksilver MXL-II Sport experimental light sport airplane, N2812, sustained unknown damage when it ditched in the Pacific Ocean near Point Mugu, California. The two pilots on board escaped from the airplane before it sank. One pilot successfully swam to shore, but the other pilot died during his attempted swim to shore. The airplane was owned by Sky Knights Flight Club (SKFC) and was operated by the pilots under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight that departed from Camarillo Airport (CMA), Camarillo, California, about 1630. According to the surviving pilot, he and the other pilot were both members of SKFC, which was based at CMA. Each of the pilots was qualified by the club to operate the airplane on his own. The club also owned two other experimental light sport airplanes similar to the accident airplane. These were a Quicksilver Sport IIS airplane, N1712, and a Quicksilver MXL Sport single-place airplane, N7712. On the day of the accident, a total of five persons, including the two accident pilots, planned to fly the three airplanes in loose formation south to the shoreline and then proceed southeast from there for a local flight. The accident airplane was equipped with side-by-side seats and dual controls. According to the surviving sport pilot, he took the left seat and the other pilot, who was a private pilot and a certificated flight instructor (CFI) for light sport aircraft, took the right seat, but this was not an instructional flight. They departed CMA via the "southeast pattern," which was one of three pre-specified routes to exit the CMA traffic area. They departed with about 10 gallons of fuel on board, and the sport pilot was the pilot flying. He estimated that it took about 15 minutes to reach the shoreline, which was about 7 miles south of CMA. At the shoreline, the three airplanes turned left, which put the shoreline off their left sides. Shortly after they passed a large rock outcrop known locally as "Mugu Rock," the sport pilot felt a "skip" in the engine. At that time, they were cruising off the shoreline and above the ocean at an altitude of about 300 ft. The skip repeated a few times, and the sport pilot then asked the private pilot whether he felt it too; the private pilot replied in the affirmative. They decided to reverse course and return to CMA and also advised the other two airplanes of their situation and intentions. They reversed course, the engine irregularity continued, and the two agreed that they should climb to gain altitude in case the situation deteriorated. At that time, the sport pilot advanced the throttle to climb, but the rpm only went to about 5,900, instead of the desired target value of 6,200 to 6,300 rpm. The sport pilot asked the private pilot to advance his throttle to increase the rpm. The private pilot pushed on his throttle but was unable to increase the rpm above 5,900. The rpm then slowly decreased. The airplane could not climb and then became unable to maintain altitude. Due to their different experience levels, the two pilots agreed that the private pilot should now become the flying pilot, and a transfer of control was effected. The rpm continued to decrease slowly over a period of 4 to 5 minutes, and it became apparent to the pilots that they would have to conduct a forced landing. Due to the rocky coast, hilly terrain, and crowded highway that paralleled the shoreline, the pilots realized that they would have to either continue flight to reach a sandy beach or ditch the airplane in the water. The continued decrease in rpm combined with the lack of a suitable landing location forced the pilots to ditch the airplane just offshore. The airplane touched down slowly and under control, and it initially remained afloat. The two occupants both successfully escaped from the airplane and stayed with it until it began to sink. They then began swimming to shore, which was about 200 ft away. The sport pilot was ahead of the private pilot, and they maintained verbal contact as they made their way to shore. The sport pilot kept verbally checking on the private pilot; initially the private pilot said he was fine, but later during the swim, the private pilot said that he was "getting tired." The sport pilot reached the shore, climbed out onto a rock, and then turned to see that the private pilot was face down in the water and was not moving. A bystander swam to the private pilot and pulled him to shore, where he and the pilot then pulled the private pilot from the water. The sport pilot and the bystander attempted to resuscitate the private pilot, as did the paramedics who arrived shortly thereafter. At least one of the other two airplanes in the formation orbited the ditching site for a short time, and both of those airplanes returned safely and uneventfully to CMA. Photographs indicated that the accident airplane appeared to remain intact after it ditched and then submerged in the water. The morning after the accident, the airplane was found washed ashore. The airplane incurred substantial damage as a result of exposure to the rocky coast and wave action. The airplane was recovered later that morning and transported to CMA for examination by NTSB and FAA personnel. PERSONNEL INFORMATION Sport Pilot (Left Seat) Federal Aviation Administration (FAA) records indicated that the person seated in the left seat held a sport pilot certificate with an airplane single-engine land rating that was issued in May 2012. He did not hold an FAA medical certificate, nor was he required to hold one to exercise the privileges of his sport pilot certificate. Despite several requests of the pilot, the National Transportation Safety Board (NTSB) investigator-in-charge was unable to obtain information regarding the pilot's flight experience. Private Pilot (Right Seat) FAA records indicated that the person seated in the right seat held a private pilot certificate with an airplane single-engine land rating and a flight instructor certificate with a sport rating. His most recent FAA third-class medical certificate, which was issued in April 2008, had expired; he was not required to hold a medical certificate to fly as a sport pilot. Copies of some of the most recent pages of the private pilot's flight logbook were provided to the investigation. The most recent entry in the flight logbook was dated April 1, 2017. As of that date, the private pilot had logged about 377 total hours of flight experience, including about 64 hours in light sport aircraft. The logbook also indicated that he had logged about 34 hours as a flight instructor. The private pilot's most recent flight review was completed in September 2016. SKFC Mechanic One individual at SKFC was primarily responsible for the maintenance and inspection activities on the three SKFC airplanes. He reported that he had been a full-time member of SKFC for about 3 to 4 years and that he was not compensated by SKFC for his services as the SKFC mechanic. He held a private pilot certificate, an aircraft mechanic certificate with airframe and powerplant ratings, and a light sport aircraft repairman certificate. In the spring of 2017, he successfully completed two Rotax-approved training courses, one for two-stroke engines and one for four-stroke engines. AIRCRAFT INFORMATION The airplane was a high-wing ultralight-like design with conventional flight controls. The structure consisted of an uncovered aluminum and steel tube framework with two side-by-side seats and a tricycle-configuration wheel landing gear. It was powered by a Rotax 582 model 99-series engine that was mounted atop the airframe in a pusher configuration. The airplane was not equipped with any type of whole-airplane emergency parachute. FAA records contained conflicting information regarding when the airplane was built. One document indicated that the airplane was built in 2001, while several other documents indicated a 2007 or 2008 build year. The builder of the airplane was a member of SKFC. The airplane was purchased by and registered to SKFC in April 2013. In June 2013, the airplane was involved in a non-fatal engine power loss accident (NTSB accident WPR13LA318). That power loss was caused by a mechanically deficient muffler. Maintenance Records Information Review of the maintenance records indicated that the most recent annual condition inspection was completed in January 2017. As of that inspection, the airframe had a total time (TT) in service of about 3,111 hours, and the engine had a time since major overhaul of about 349 hours. According to the engine maintenance records, the engine serial number was 4655502. The engine was installed on the airplane on August 23, 2015. The records indicated that at that time the engine had "0 hours since M/O/H" [major overhaul], and that the "Hobbs" hour meter indicated a time of 2,756.7 hours. The records indicated that the previous time on the engine was unknown. At the time of the accident, the engine had accumulated a TT of 427.9 hours since its most recent overhaul. The Rotax Maintenance Manual (MM) specifies a major overhaul interval of 300 hours. The 2015 overhaul, as well as a previous 2013 overhaul, were accomplished by a repair facility in Naples, Florida. According to several representatives of SKFC, including the SKFC mechanic, and independently confirmed with the Naples facility, the SKFC-adopted overhaul interval of 450 hours was the interval recommended by that repair facility for Rotax 582-series engines. According to Rotax, that repair facility is not a Rotax-approved service facility for Rotax engines. METEOROLOGICAL INFORMATION The 1656 automated weather observation from Point Mugu Naval Air Station (NTD), located about 3 miles northwest of the accident site, included winds from 260° at 8 knots, visibility 9 miles, few clouds at 6,500 ft, temperature 25°C, dew point 17°C, and an altimeter setting of 29.81 inches of mercury. The above temperature and dew point values indicated that the relative humidity was about 60%. When the intersection of the two temperature values was located on an FAA-provided chart that depicted carburetor ice envelopes, the point was in the region denoted as "Serious Icing at Glide Power." When plotted on another FAA-provided icing potential chart, the point was in the region denoted as "carburetor icing possible." COMMUNICATIONS The pilots communicated with the CMA air traffic control tower (ATCT) to depart from CMA, and then with the NTD ATCT for clearance to transit south to the east of NTD. The pilots were not in communication with these or any other air traffic facilities at the time of the power loss or ditching. WRECKAGE AND IMPACT INFORMATION Summary The remnants of the airplane were removed from the shore on the morning of July 9, transported to the SKFC hangar, and rinsed with fresh water. Detailed examination of the engine, as well as some airframe components, was conducted by NTSB and FAA personnel at the hangar on July 10, 2017. No evidence of preimpact mechanical malfunction was noted during the examination, but it was determined that the ocean immersion and wave action obscured or destroyed a significant amount of evidence. Airframe The recovered airframe was a large mass of fractured tubing held together by some connectors, the wing cloth, and numerous structural and control cables. The fuselage and wing structures had lost all their shape due to the numerous fractures and bends of the structural tubing. Some components (such as the instrument panel) were missing, and some (such as the seats, propeller, and fuel tank) sustained scrapes, cracks, dents, or crushing damage. The wing cloth was shredded, and the engine bore numerous impact marks on all exposed sides. Corrosion and salt and sand infiltration were extensive. The airplane was equipped with a center-mounted overhead console unit that housed several components, including the engine hour meter, electric fuel pump, and electrical switches. Damage to the console precluded reliable determination of the pre-impact settings or functionality of the switches. Engine General Because the engine was mounted upright in a pusher-configuration, in this report, left, right, up, down, fore, and aft denote orientation with respect to the airplane's longitudinal axis. Rotax uses the following abbreviations to refer to the cylinder and engine aspects: - PTO denotes the power take-off end, which is where the propeller gearbox and propeller attach - MAG denotes the magneto end, which is the opposite end from the PTO. The engine data plate was no longer attached to the engine, but the engine's appearance and configuration were consistent with a Rotax 582 Model 99 "Blue Head" series liquid-cooled, two-cylinder, two-stroke cycle version, which the maintenance records indicated was installed in the airplane. The engine remained attached to its mounting pad, which remained attached to the fuselage structure. The propeller hub remained attached to the engine gearbox flange, but all three composite blades were fracture-separated from the propeller hub. The engine exhibited significant impact damage, corrosion, and sand infiltration. The engine could not be rotated manually. There was no external evidence of any catastrophic failure of any engine component. Engine Controls Each pilot station was provided with a separate throttle lever located outboard of each seat. A throttle lever was attached to each end of a transversely-mounted control rod. The rod was attached to the fuselage so that in normal operation, it would rotate about the rod's central axis. A single throttle push-pull control cable attached to a fitting near the lateral center of the throttle control rod. The throttle control rod was partially fracture-separated from its fuselage pivot mount. Both throttle levers remained securely affixed to their respective ends of the rod. The throttle control cable had been pulled from its connection to the rod, but its swaged end remained captive in the connector on the rod. The investigation was unable to determine the pre-accident security of the throttle cable to rod attachment, or when the cable disconnected from the rod. The throttle mechanical stop arms remained securely attached to the rod, but, due to damage, their functionality and range adjustments could not be determined. Representatives of SKFC reported that the occupant lap restraint belts could droop down between the seats if not properly secured and stowed, and interfere with throttle control travel. Occupant egress and damage precluded determination of whether such a condition occurred during the flight. In an email communication to the NTSB, the surviving pilot wrote "4 Point seat belt secured, adjusted and checked. Any excess strap after adjustment is tucked under the lap belt to keep from flapping in the wind." Ignition System The breakerless dual capacitor discharge ignition incorporated an integrated generator that separately powered two ignition coils. Each coil powered one spark plug in each cylinder. Spark/ignition timing was a function of crankshaft rotation angle, and was not user adjustable. The integrated generator was not examined. Both coils remained attached and appeared intact. The ignition leads to the spark plugs were partly damaged and/or separated from the engine. All four spark plug bases were found securely installed in the engine. All four spark plugs were missing the bulk of their upper insulator sections, which were fracture-separated, consistent with rock impact damage. No spark plug model numbers were available on the remaining portions. The four spark plug bases were removed and examined. All were contaminated and/or corroded, consistent with salt water immersion. The electrode gaps were found to be larger than the Rotax specifications, but the reasons for this, which included corrosion, wear, or improper maintenance, could not be determined. Damage precluded the testing of the ignition system, or of any of its individual components. Fuel System The fuel system, particularly the f
A partial loss of engine power for reasons that could not be determined during postaccident examination in combination with the low cruise altitude selected by the pilots, which resulted in an ocean ditching. The lack of personal flotation devices likely contributed to the drowning of one of the pilots.
Source: NTSB Aviation Accident Database
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