Saturday, April 8, 2017

Lancair 320, N7ZL: Fatal accident occurred January 09, 2015 near Van Nuys Airport (KVNY), California

Dr. Alberto Behar
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The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Van Nuys, California 
Lycoming Engines; Agoura Hills, California 

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Docket And Docket Items - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary  -   National Transportation Safety Board:   https://app.ntsb.gov/pdf

http://registry.faa.gov/N7ZL

NTSB Identification: WPR15FA081
14 CFR Part 91: General Aviation
Accident occurred Friday, January 09, 2015 in Van Nuys, CA
Probable Cause Approval Date: 04/04/2017
Aircraft: GIBBS LANCAIR 320, registration: N7ZL
Injuries: 1 Fatal.

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 commercial pilot was taking off for a personal, cross-country flight. Several witnesses reported that, shortly after takeoff, when the airplane was about 400 ft above the ground, they heard the engine "pop" at least twice, sputter, and then go silent, consistent with a loss of engine power. About this time, the pilot reported to the tower controller very quickly but not very clearly that "I have an engine failure I think." The tower controller subsequently issued the pilot the current altimeter setting and attempted to contact the pilot but did not receive any further radio transmissions. The airplane continued straight, turned right, and then spun to the ground. A postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The airplane was last refueled before its previous flight in Flagstaff, Arizona, 4 days before the accident; the airplane was then flown from Flagstaff to the Van Nuys Airport, Van Nuys, California. Although a narrow stream of what smelled like gasoline and engine oil was found near the wreckage, there was no fuel remaining in the fuel tanks.

The airplane was equipped with an electronic flight instrument system (EFIS), which has a low fuel alert that is set by the pilot or a mechanic. When fuel decreases to the specified amount, an alert pops up front and center on the EFIS, and it will not disappear until the pilot acknowledges it. Given that the pilot mostly conducted his own maintenance, it is highly likely he was familiar with the EFIS and knew that the airplane was low on fuel and how much fuel remained but decided to take off anyway. As a result of his decision, the engine lost engine power shortly after takeoff due to fuel exhaustion at too low of an altitude for the pilot to recover from the stall and subsequent spin.

A friend of the pilot reported that the pilot texted him about 1249 when he arrived at the airport. He said that the pilot normally arrived about 1230. The pilot seemed to be in a rush that day because he was supposed to fly home the day before, and apparently he and his wife had argued about the issue. In addition, the pilot's friend noted that the pilot had recently become more conscious about where he bought fuel. Based on the directions the pilot received from the air traffic controller to stay below 2,000 ft if flying to Burbank, the friend believes it is likely the pilot was attempting to fly to Whiteman Airport about 5 nautical miles away that had cheaper fuel before continuing to his destination. 

According to the air traffic control recordings, the pilot first contacted the ground and tower controllers about 1308, and he was cleared for takeoff at 1311. Just before takeoff, the pilot's work e-mail documented nine messages, three of which were sent by the pilot, the last of which was sent at 1311. In the emails, the pilot indicated confusion about an issue, which may have been a further distraction to him. The evidence indicates that the pilot was rushed and sending e-mails, which likely distracted him during the taxi and takeoff and decreased his vigilance about the airplane's fuel status.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's improper decision to take off despite low fuel alerts, which resulted in a total loss of engine power due to fuel exhaustion, his subsequent failure to maintain adequate airspeed and his exceedance of the airplane's critical angle of attack, which led to an aerodynamic stall and loss of control at too low of an altitude to recover. Contributing to the accident was the pilot's distraction due to his sending e-mails and being rushed during taxi and takeoff, which resulted in reduced vigilance about the airplane's fuel status.


Dr. Alberto Behar

HISTORY OF FLIGHT

On January 9, 2015, about 1313 Pacific standard time, a Lancair 320, N7ZL, impacted terrain shortly after takeoff from Van Nuys Airport (VNY), Van Nuys, California. The commercial pilot (sole occupant) sustained fatal injuries, and the airplane sustained substantial damage. The airplane was registered to and was being operated by the pilot as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The flight was destined for Scottsdale Airport (SDL), Scottsdale, Arizona. 

The pilot contacted VNY ground control about 1308 and requested to taxi from the northwest side of the airport to runway 16R. Ground control cleared him to taxi to runway 16R via taxiways A and C. The pilot then contacted the control tower and requested to take off from runway 16R. The tower controller informed him to stand by for traffic. About 1311, the tower controller informed the pilot of traffic in the area and directed him to fly straight ahead to highway 101 and to stay below 2,000 ft if flying to Burbank; he then cleared the flight for takeoff. 

About 1313, the pilot reported very quickly but not very clearly that "I have an engine failure I think, N7ZL." The tower controller issued the pilot the current altimeter setting and attempted to contact the pilot but did not receive any further radio transmissions. The airport's crash response team was immediately alerted. 

Several witnesses reported that, shortly after takeoff, when the airplane was about 400 ft above the ground, they heard the engine "pop" at least twice, sputter, and then go silent. The airplane continued straight then turned right. Some witnesses mentioned that the airplane appeared to be very slow when the right wing and nose dropped. The airplane started to spin and impacted a nearby street in a nose-low attitude. 

PERSONNEL INFORMATION

The pilot, age 47, held an air transport pilot certificate for airplane multiengine land and helicopters issued on November 18, 2011, and a commercial pilot certificate for single-engine land. The pilot also held an instrument rating and a flight instructor certificate for airplane single- and multi-engine land, helicopter, and instrument. In addition, the pilot held an airframe and powerplant mechanic certificate issued on February 1, 2012. The pilot's first-class medical certificate was issued on December 4, 2014, with the limitation that he must have available glasses for near vision. During his most recent medical examination, the pilot reported 2,349 total flight hours, 150 hours of which were in the previous 6 months. 

AIRCRAFT INFORMATION

The four-seat, low-wing, tricycle-gear airplane, serial number 137, was manufactured in October 1996. It was powered by a Lycoming IO-0320 BIA 160-horsepower engine and equipped with a Hartzell Propeller Inc., model AC-F24L-1BF controllable-pitch propeller. The maintenance logbooks were not located for examination. The tachometer and the Hobbs meter were electronic, and damage precluded determining the current readings. 

The airplane's last known refueling occurred on January 5, 2015, at the Flagstaff Pulliam Airport (FLG) Flagstaff, Arizona, when 28.2 gallons of fuel was added. The airplane was fueled during the airplane's last known flight before the accident flight, during which the pilot took off from SDL and stopped at FLG for fuel before finishing the flight at VNY. The total amount of fuel on board the airplane at the time of the accident was not determined.

Electronic Flight Instrumentation System

The airplane was equipped with a GRT Avionics Horizon HX electronic flight instrument system (EFIS), which is a panel-mounted display that consolidates multiple instruments into a compact view to aid in pilot situational awareness. The Horizon HX EFIS has a flight data recording function that needs to be enabled, and a USB drive must be inserted into the EFIS for the data to record. The multifunctional display was shipped to the National Transportation Safety Board recorders laboratory for examination. The device powered on normally, and the data recording feature setting was determined to be inactive. Therefore, the device contained no pertinent information related to the accident.The Horizon HX EFIS has a low fuel alert, which is programmed by the pilot and/or mechanic to notify the pilot when the fuel reaches a specified level. This notification pops up front and center on any screen, and it does not leave the screen until the pilot acknowledges it. 

METEOROLOGICAL INFORMATION

At 1251, the VNY weather reporting station reported wind from 090 at 5 knots, visibility 10 statute miles, clear skies, temperature 21° C, dew point 04° C, and an altimeter setting of 29.97.

AIRPORT INFORMATION

VNY is located 3 miles northwest of Van Nuys, California, at an elevation of 802 ft. The airport has two hard-surfaced runways, 16R and 34L magnetic, and 16L and 34R magnetic. Runway 16R/34L is 8,001 ft long and 150 ft wide.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest at one corner of two intersecting streets. Telephone and power lines crossed all four corners of the intersection, and diagonally crossed two corners of the intersection. None of the wires appeared to be damaged, and no striations were observed on the airplane. The airplane was oriented to the southeast. The first identified point of contact was an impact crater in the street asphalt. The engine cowling and white paint transfer marks, which were almost parallel to the final orientation of the wings and were the approximate length of the wings, were found adjacent to the impact crater. The main wreckage was about 34 ft east of the impact crater; the area between the impact crater and main wreckage was covered with a sticky, dark-colored fluid. The cockpit area was destroyed, and the seats were fully exposed; the seats belts were not latched. The throttle and mixture controls were full in. 

Both wings remained attached to the fuselage; the right wing leading edge was split open the entire length, and the inboard two-thirds of the left-wing was split. The paint on both leading edges was chipped. The fuel caps for both wings and the header tank were in position and secure. Both wing tanks and the header tank on the fuselage had been breached; there was no fuel remaining in the fuel tanks, however, there was a narrow stream of what smelled like gasoline and engine oil in the gutter. 

The tail section was fractured and separated circumferentially just forward of the vertical stabilizer and horizontal stabilizer. The rudder remained attached at all hinges, and the elevators remained attached at all hinges.

MEDICAL AND PATHOLOGICAL INFORMATION

The County of Los Angeles Department of Medical Examiner-Coroner, Los Angeles, California, conducted an autopsy on the pilot. The cause of death was reported as "multiple blunt traumatic injuries."

The Federal Aviation Administration's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot; 0.388 (ug/ml, ug/g) of doxylamine was detected in the pilot's blood. Doxylamine is a sedating antihistamine available in a number of over-the-counter cold and allergy products. It is also the active ingredient in a few over-the-counter sleep aids. The usual therapeutic window is considered between 0.050 and 0.150 ug/ml. However, doxylamine undergoes significant postmortem redistribution; postmortem levels in central blood may be three times higher than peripheral blood. Tolerance to the effects of doxylamine is less likely to develop than for some of the other sedating antihistamines; therefore, the use of this drug causes some degree of psychomotor slowing.

TESTS AND RESEARCH

Airframe Examination

The cabin area was heavily fragmented; however, the instrument panel remained relatively whole and was still connected to the firewall. Flight control continuity was established from the cabin flight controls to their respective flight control surfaces. 

The fuel system was traced from the wing fuel tanks to the center forward cabin where it was fracture-separated and fragmented. The remaining parts of the fuel system were heavily fragmented. The fuel selector plate and two arms that appeared to be a part of the fuel selector were found loose within the cabin area. One fuel selector body was found; it contained one open end with what appeared to be a one-way check valve and one fractured rod end. 

Engine Examination

There was no evidence of catastrophic malfunction or preimpact fire. The crankcase's nose section sustained heavy impact damage. Due to the damage to the crankcase, the crankshaft would not rotate by hand. Holes were drilled into the case; the inside of the case was examined with a borescope, and there was no evidence of internal mechanical malfunction. 

The induction system sustained heavy crush damage. The fuel injection servo sustained heavy crush damage and was fragmented; however, the throttle and mixture controls were still secured to their respective control arms. The fuel pump was found displaced from its mounting pad; it was disassembled, and there was no evidence of flow obstruction or internal mechanical malfunction. The fuel flow divider remained secured at its mounting pad with the fuel lines secured at their respective fittings. The left magneto was rotated by hand, and it produced sparks at all four posts; the right magneto was an electronic ignition system and could not be tested. The ignition harness was destroyed; the spark plugs were removed, and they exhibited wear patterns consistent with normal operation. 

ADDITIONAL INFORMATION

Pilot's Friend Statement

A friend of the pilot reported that the pilot would often text him when he arrived at the airport about 1230. On the day of the accident, he received a text from the pilot about 1249. He said that he seemed like he was in a hurry that day because he was supposed to have returned to SDL the day before. He later found out that the pilot and his wife had argued about it.

The friend stated that the pilot conducted most of his own maintenance. He also mentioned that the pilot had recently become conscious about where he purchased fuel. Based on the VNY tower controller's direction for the pilot to stay below 2,000 ft if flying Burbank after takeoff, he believes the pilot was flying to Whiteman Airport (WHP), which is 5 nautical miles away from VNY and is notorious for having cheaper fuel than VNY. In order to fly from VNY to WHP, one must contact Burbank air traffic control. 

E-mail Traffic

Between the time the pilot arrived at the airport and the time of the takeoff (between 1249 and 1311), the pilot's work e-mail documented nine messages, three of which were sent by the pilot. In the messages sent just prior to takeoff, the pilot mentioned that he was very confused about the discussion.











































NTSB Identification: WPR15FA081
14 CFR Part 91: General Aviation
Accident occurred Friday, January 09, 2015 in Van Nuys, CA
Aircraft: GIBBS LANCAIR 320, registration: N7ZL
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. 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.

On January 9, 2015, about 1300 Pacific standard time, a Lancair 320, N7ZL, impacted terrain shortly after takeoff from Van Nuys Airport (VNY), Van Nuys, California. The commercial pilot (sole occupant) was fatally injured, and the airplane sustained substantial damage throughout. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight and no flight plan was filed. The flight was destined for Scottsdale Airport (SDL), Scottsdale, Arizona. 

Witnesses reported that shortly after takeoff they heard the airplane's engine start to sputter and quit. They observed the airplane make a right turn; it started to shake before it nosed over and descended into an intersection below. The airplane impacted the ground hard and bounced backward about 15 feet, coming to rest upright. The airplane has been recovered to a secure location for further examination.

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