Thursday, October 22, 2015

Van's RV-10, N62DN: Fatal accident occurred May 31, 2014 in Toledo, Oregon

NTSB Docket and docket items:

NTSB Identification: WPR14FA218
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 31, 2014 in Toledo, OR
Probable Cause Approval Date: 04/07/2015
Aircraft: NEBERT VANS RV-10, registration: N62DN
Injuries: 2 Fatal, 1 Serious.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The pilot, who was also the builder of the experimental kit airplane, departed for a cross-country flight from his home airport. The passenger reported that, following a normal departure, the airplane continued the takeoff climb through some cloud wisps and ascended above a lower cloud cover with an overcast layer above. Suddenly, the engine experienced a total loss of power. The pilot maneuvered the airplane toward the closest airport, but, when he realized that the airplane would not be able to glide to the airport, he attempted to make an off-airport landing. The airplane stalled and then collided with terrain in an open area of a paper mill. Ground scar analysis and wreckage fragmentation revealed that the airplane descended in a steep, near-vertical, nose-down, left-wing-down attitude before it impacted terrain. The pilot installed a fuel flow transducer about 2 to 3 weeks before the accident and used heavy applications of room temperature vulcanization (RTV) silicone to seal the fuel lines. A friend of the pilot, who was also a mechanic, reported that he had observed the pilot about a year earlier using heavy applications of RTV silicone to seal parts during a condition inspection and that he had mentioned to the pilot that this was an improper practice. A bead of RTV silicone was found in the fuel line, and it is likely that it blocked the inlet of the transducer and starved the engine of fuel. Additionally, subsequent to the loss of engine power, the pilot failed to maintain sufficient airspeed while maneuvering to locate a suitable off-airport landing site and flew the airplane beyond its critical angle-of-attack, which resulted in a stall and loss of airplane control.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

A total loss of engine power due to fuel starvation because of a blocked fuel line that resulted from the pilot’s improper maintenance practices and the pilot’s subsequent failure to maintain adequate airspeed while attempting a forced landing, which led to the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall. 


On May 31, 2014, about 1620 Pacific daylight time, a single-engine experimental Nebert Vans RV-10, N62DN, experienced a loss of power and departed controlled flight while the pilot was maneuvering for a forced landing in Toledo, Oregon. The airplane was substantially damaged. The private pilot and four-year old passenger were fatally injured; the adult passenger sustained serious injuries. The airplane was registered to and being operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The personal cross-country flight departed Newport Municipal Airport, Newport, Oregon, with a planned destination of Seattle, Washington. Visual meteorological conditions prevailed and no flight plan had been filed.

Numerous witnesses located in Toledo reported observing the airplane flying at a low altitude from the north. The witnesses reported hearing no sound from the airplane's engine and saw it progressively descend in altitude. The airplane approached the Georgia Pacific paper mill and made a steep turn to the left. The airplane subsequently made a rapid descent and impacted terrain in a nose-low, near-vertical attitude.

The surviving passenger recalled the flight, although was heavily medicated during the recounting of the events that transpired. She stated that she was in the aft right seat and her daughter was buckled in a car seat positioned in the aft left seat. Luggage was strapped in the front right seat in an effort to compensate for the aft weight. The departure seemed normal and the pilot commented that the engine sounded better than it had in awhile. The airplane continued the takeoff climb through some cloud wisps and ascended above a lower cloud cover, with an overcast layer above.

The passenger further stated that suddenly the engine experienced a total loss of power, which she described as the airplane stopping forward motion, and there was no engine sound. An alarm sounded, and shortly thereafter all of the airplane's electrical system failed. She recalled observing the screen in front of the pilot flickered and then went blank. The pilot was busy pressing buttons and maneuvering levers, and indicated that they were going to land at the closest airport [which was the Toledo State Airport]. The airplane descended through clouds heading toward the airport. The pilot stated that they were going to make it to the airport, and that he was looking for a place to land. The airplane made an alert sound, which she thought indicated the airplane was moving too slow. The pilot made a left turn and tried to pull up, but the airplane spiraled down harder to the ground.


A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the pilot, age 51, held a private pilot certificate with airplane rating for single-engine land, which was issued in March 2008. He additionally held a Repairman Experimental Aircraft certificate. His most recent third-class medical was issued on January 04, 2013, with no limitations.

According to the pilot's flight logbook he had about 785 hours of total flight experience, of which about 375 was amassed in the accident airplane. Based on the airport identifiers listed in the logbook for flight origin and destination points, the pilot accumulated the majority of his flying hours around Newport, his home airport and where the airplane was based. The pilot recorded having flown 6.4 hours in the preceding 30 days, which was accumulated over 6 different flights.

The pilot was a member of the Experimental Aircraft Association (EAA) since August 1991, and had numerous EAA technical counselor visits during the building process.


The Vans RV-10 is an amateur-built experimental airplane that is sold as a kit. The low-wing airplane was equipped with four seats, fixed tricycle landing gear, and traditional flight control surfaces. The accident airplane, serial number (s/n) 40546, received a special airworthiness certificate in the experimental category for the purpose of being operated as an amateur-built aircraft in August 2010; the pilot purchased the kit in October 2009. The airplane was equipped with a Lycoming O-540-B4B5 engine, s/n L-7862-40C, and, according to the manufacturer, is rated at 235 shaft horse power (SHP). The powerplant contained a data tag labeling it as a Lycoming O-540-B1AB, which contained the vibropeened identification next to the stamp of "B4B5."

The airplane's test flight hours were completed in September 2010. Thereafter, the logbooks indicated that the pilot estimated that the airplane's stalling speed in the landing configuration (Vso), at a weight of 1,858 lbs and a CG of 108.5 inches aft of datum, was 58 knots.

Fuel System Design

The airplane's fuel system was a gravity-fed design where fuel flowed from the metal tanks in the inboard section of each wing, through a selector valve, and continued to a fuel filter. From the filter, the fuel was routed to an electric fuel pump and then to a transducer where it was plumbed through the firewall to the gascolator. Thereafter, the fuel was directed to the engine-driven fuel pump, and finally enter into the carburetor.

The Van's Aircraft build manual states in section 37, Fuel System, "When installing fluid fittings with pipe threads do not use Teflon tape. Use instead, fuel lube or equivalent pipe thread sealing paste."


According to the aircraft maintenance records and the recording tachometer in the cockpit, the airplane had accumulated a total time in service of 375.4 hours. The most recent condition inspection was recorded as completed by the pilot on October 4, 2013, 71.5 hours prior to the accident. Examination of the logbook revealed that the last maintenance that had occurred was an oil change and the tightening of the left magneto on February 09, 2014 at a total time of 354.2 hours.

From the pilot's photographs on his website blog, the original build, the pilot did not install the fuel transducer.

A friend of the pilot, who was also a FAA certified mechanic, stated that about two to three weeks prior to the accident, the pilot had installed the fuel transducer. The pilot commented to him that he had not installed the unit previously because it needed a certain amount of space (needed to be about seven to nine inches from the filter) and he would have to bend some of the fuel lines to make it fit. The pilot borrowed a flaring tool from him to complete the installation. The friend noted that earlier in the year, when the pilot was performing a condition inspection and the airplane's cowling was removed, he observed that the pilot had used heavy applications of red/orange RTV(room temperature vulcanization) silicone to seal everything, including the area around the airbox (oval-shaped) where it attaches to the carburetor (square-box-shaped). He mentioned to the pilot that this was an improper practice.

Another friend of the pilot stated that the pilot had installed a fuel transducer about one to two weeks prior to the accident flight, and noted at the time that the unit did not have a bypass. The friend also observed that the pilot had not connected the electrical wires for the transducer to be operational, but had installed the unit.

Lycoming Manual

According to the engine's maintenance manual, the rated horsepower was 235 at 2,575 rpm. To obtain the maximum recommended service life of the engine, the manual recommends that the cylinder head temperature be maintained below 435 degrees Fahrenheit (F) during high-performance cruise operation, with a maximum temperature of 500 degrees F. The Lycoming manual additionally stated that the fuel pressure requirements were a minimum pressure of .5 psi and a maximum of 8 psi.


A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) in Newport reported that at 1635 there was an overcast cloud layer at 1,900 feet above ground level (agl) with 5 miles visibility. It recorded the temperature at 52 degrees Fahrenheit; dew point 50 degrees Fahrenheit.


No record exists of the pilot, or a pilot using the airplane's registration number, contacting any Air Traffic Control tower, or Common Traffic Advisory Frequency, during the duration of the flight.


The accident site was located in the paper mill adjacent to the Yaquina River in Toledo, Oregon, with the debris confined to the immediate area near the main wreckage. The Global Positioning System (GPS) coordinates for the main wreckage were approximately 44 degrees 36 minutes 53 seconds north latitude and 123 degrees 56 minutes and 14 seconds west longitude, at an elevation about 10 feet mean sea level (msl). A complete pictorial of the wreckage location and surrounding terrain is contained in the public docket for this accident.

The closest airport to the accident was in Toledo, Oregon and was located 0.7 nm from the accident site on a heading of 192 degrees. The wreckage came to rest in a flat area, which was a portion of dirt road on the perimeter of the mill. Surrounding the site were 20 foot (ft) high stacked bales of crushed cardboard boxes, and a railroad track with parked train cars. Additionally, a northwest-southeast oriented 12 ft-diameter tubular conveyer was observed near the accident site that was about 70 feet high and 1,625 feet long. The airplane departed from Newport, Oregon which was located 5.6 nautical miles (nm) from the main wreckage on a heading of 248 degrees.

The main wreckage, which consisted of nearly the entire airplane, came to rest on a heading of 310 degrees. The initial point of impact consisted of a ground scar and disrupted dirt located about 25 feet and on the heading of 220 degrees from the cockpit section of the main wreckage. Embedded in the dirt were fragments of red lens and shards of paint and fiberglass, consistent with the left wing impacting first.

From the red lens fragments there was disrupted dirt and ground scars up to blue paint rub marks on an adjacent woodpile. On an exposed yellow pipe embedded in the ground were numerous blue paint transfer marks, which at 16 feet from the red lens, was consistent with being a signature of the undercarriage contacting it (the airplane's wingspan was about 32 feet). In a ditch just below the pipe was a 7-ft section of the inboard left wing from the leading edge at to about the spar. From the pipe, on a heading of about 020 degrees, was engine casing debris and lower engine pieces, including the oil drain plug.


The Lincoln County Medical Examiner completed an autopsy of the pilot and passenger. The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on the pilot. According to CAMI's report (#201400089001) the toxicological findings were negative for carbon monoxide and tested drugs.


A detailed examination report with accompanying pictures is contained in the public docket for this accident.


The main wreckage cockpit area was open, with the engine and firewall twisted toward the right wing. Most of the upper cabin area had broken free from the airframe; the section that remained attached consisted of fiberglass on the aft right side about four feet forward of the bulkhead.
The throttle, propeller, and mixture control levers were bent in their respective control quadrant, which was consistent with them being in the full-forward position at the time of impact.

The right wing remained attached to the fuselage at all attach points, and the flap and aileron control surfaces remained attached to their respective hinges. The right wingtip aft section and fragments of a blue/green lens were located just below the right wing adjacent to a concrete divider. Around the divider was evidence of blithe, and numerous areas of vegetation had been crushed, which was consistent with fuel exposure. The right wing sustained major skin deformation crushing from the aft outboard tip to about three feet inboard; this was consistent with the size and orientation of the concrete divider that was located immediately below it. The wing sustained aft crush deformation, with the bottom leading edge skin folded into itself, giving it an accordion-type appearance. The crush was nearly uniform through the entire length of the wing. The leading edge displayed characteristics consistent with hydrodynamic deformation. Control continuity was confirmed in the right wing up to the crush deformation in the cockpit area.

The left wing was attached to the fuselage at all attach points, and the flap and aileron control services remained attached to their respective hinges. The left flap was attached to the two inboard respective hinges and creased at the center hinge in an upward crush. The left aileron was found wedged underneath the main wreckage cockpit area. The leading edge displayed characteristics consistent with hydrodynamic deformation. Control continuity was confirmed in the left wing up to the crush deformation in the cockpit area.

The right and left horizontal stabilizers and elevator remained intact with creasing noted on some of the surfaces; continuity to the cockpit was established. The vertical stabilizer and rudder remained intact with a slight crease on the rudder control surface about six inches from the top and consisted of a four inch bend. The rudder was attached to its control cables and continuous to the rudder pedals and secured. The elevator was attached to the push-pull tube, which was continuous up to the cockpit area. Both control sticks were attached and safetied.


The engine mount support tubes were severed by investigators between the engine and firewall, which essentially separated the engine from the airframe. An external visual examination of the engine revealed that it had sustained crush damage to the bottom of the crankcase, with the majority of damage to the left side. There were dark stains to the left of the upper spark plug holes, which was consistent with oil staining.

The spark plugs were removed and no mechanical damage was noted; the electrodes and posts exhibited a light ash white coloration, which according to the Lycoming representative was consistent with a very lean operation(s). The ignition harnesses were attached from both magnetos to their respective spark plugs. The right magneto was secured to its respective mounting pad. Upon rotation, investigators observed spark produced at all posts. The left magneto sustained varying degrees of damage that rendered the unit inoperative and therefore, could not be functionally tested.

The crankshaft was rotated by hand utilizing the propeller. The crankshaft was free and easy to rotate in both directions. "Thumb" compression was observed in proper order on all six cylinders. The complete valve train was observed to operate in proper order, and appeared to be free of any pre-mishap mechanical malfunction. Normal in uniform "lift action" was observed at each rocker assembly. Clean, uncontaminated oil was observed at all six rockerbox areas. Mechanical continuity was established throughout the rotating group, valve train and accessory section during hand rotation of the crankshaft.

The cylinders' combustion chambers were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers remained mechanically undamaged, and there was no evidence of foreign object ingestion. The valves were intact and undamaged. There was no evidence of valve to piston face contact. The chambers and valve faces all displayed little combustion signatures and there was a whitish light ash coloration; the exhaust valve faces were slightly darker, exhibiting a white-orange-coloration. This white residue/soot was additionally seen throughout the remainder of the exhaust system.

The Hartzell propeller, model HC-C2YK-1BF, serial number 40546, remained attached to the engine crankshaft. All propeller mounting bolts remained in the hub and exhibited no signatures consistent with shear stress. The propeller blades remained attached at the hub. The spinner was displaced from the propeller hub. The propeller blades were straight and did not show any evidence of rotational forces applied at the crankshaft at the time of impact. Removal of the propeller governor disclosed that the screen was free of contaminants.

Fuel System

The fuel selector was found with the handle pointing to the "LEFT" tank position. Later, it was confirmed by a friend of the pilot that the handle was installed with the handle giving a reverse indication, which meant that the fuel would be selected in the "OFF" position. The position of the fuel selector valve, manufactured by Andair, LTD, was off with both lines shut off. The selector was found in several pieces: the handle (which was still attached to the airframe), the extender (which was located loosely in the wreckage adjacent to the pilot seat), the upper coupling (which had broken free from its remaining core and was found loosely in the wreckage), the valve (which was found loosely in the wreckage near the firewall). There was no evidence that the extender had been safetied to either couplings.

The fuel filter, manufactured by Airflow Performance, was disassembled and the screen was found to be clean. Investigators located a Facet automotive electric fuel pump within the wreckage and upon supplying power source the pump was found to activate. The transducer, a FloScan 201 A-6 flow sensor (s/n 179922), was found in the wreckage. The fuel line from the electric fuel-pump to the transducer was separated at the pump's B-nut fitting as a result of post impact forces. An approximate one-inch portion of the line remained attached on the inlet side of the transducer and the end was crimped tightly together and bent. Investigators pried open the crimped section and found an oval bead of red/orange RTV that measured about 0.25 inches in length. According to the manufacture, the inlet hole (metering orifice) is reamed to approximately 0.114 to 0.116 inches. Removal of both the inlet and outlet fittings revealed that RTV was in the threads of both the nipples and the surrounding casing.

The upper cap section and mounts of the gascolator remained attached to the firewall; the metal bowl was located under the right wing and there was no evidence it had been secured/safetied to its attachment arm/ thumb-tightening screw; the screen was additionally found loose under the right wing and was clean. The engine-driven fuel pump was displaced from the engine. Disassembly of the fuel pump revealed that is was free of internal mechanical malfunction and obstruction to flow; the diaphragm was intact. Liquid contained in the body was collected and tested for water; there is no indication water was present.

The carburetor was not attached at its forward mounts; it had remained attached to the aft mounts, coming to rest bent aft with the body flush against the case, and partially embedded in the oil sump casing. The casing of the carburetor had been broken apart and the plastic floats were in pieces.


All occupants appeared to have had both their lap and shoulder belts secured during the accident sequence. The child passenger was seated in Graco booster seat, model 1781044 (s/n 0784129). According to the manufacture, the seat is designed to sustain g-loading as specified in Federal Safety Standard 213. This includes a space envelope of 32 inches for the head and 36 inches for the knees. The seat's manual specifically prohibits usages in aircraft, which states is due to the limitation of no shoulder harnesses available.

by Mike Danko

Experimental amateur-built aircraft crash more often than those assembled in a factory. 

The Australian Transport Safety Bureau found that, when compared to factory-built aircraft used in similar flight operations, amateur-built aircraft crash three times as often. 

Our own National Transportation Safety Board studied the amateur-built accident rates and made similar findings.

One might expect that, because they are built by an amateur, an experimental aircraft’s wings would tend to fall off more often than those of a factory-built aircraft. 

But that doesn’t seem to be the case.

Most experimental aircraft are structurally sound. 

Rather, according to NTSB data, the biggest issue is engine failure, often because of fuel flow problems.

And that’s exactly what brought down an experimental Van’s RV-10 aircraft in Toledo, Oregon, in June 2014. 

The aircraft lost power on takeoff, killing the pilot and his 4 year-old passenger. 

The NTSB concluded the engine failed because it wasn’t getting fuel. 

Investigators found broken fragments of sealant in the aircraft’s fuel line where, of course, it wasn’t supposed to be.   

There are no statistics on how often the companies who sell kits get sued, but it’s hardly ever.  

After all, who is responsible for the defect in the aircraft’s manufacture or design that caused the crash? 

The company who sold the kit? 

Or the guy who spent several years putting the kit together in his garage? 

While some builders follow the kit maker’s directions to the letter, many do not, taking it upon themselves to modify at least some portion of the aircraft. 

That's allowed by regulations and seems to be part of the fun of building the aircraft. 

For example, John Denver was killed years ago when the amateur-built aircraft he was piloting crashed off the California coast.  

The amateur who put the kit together thought he had a better way of doing it and installed the aircraft fuel valve in a place other than as recommended by the kit's seller.  

The NTSB ultimately determined that it was that modification that led to the crash. 

But even if the victim’s lawyer proves it was the kit maker, and not the builder, who was responsible for the defect, few kit makers carry insurance. 

That means a verdict against the aircraft company may be impossible to collect.

Despite the hurdles, the family of the girl killed in the Toledo crash has filed suit against Van’s Aircraft Inc., blaming it for exploiting FAA “loopholes” that allow it to sell aircraft  that have not been properly tested and are thus unproven and unsafe.  

The suit goes on to allege that not only are Van’s aircraft designs untested and unsafe, but its assembly instructions are also inadequate and unsafe.

The suit goes on to allege that the fuel flow transducer that Van's supplied with the kit was dangerous because it was not capable of dealing with a blockage, as would be required of on a fuel flow transducer mounted on a factory-built aircraft.

We can expect Van’s to argue that their experimental aircraft are just that – experimental. 

They are not intended to have all the safety features included with factory-built aircraft.  

That is why the word “experimental” is required by law to be prominently displayed inside each one.  

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