Saturday, August 19, 2017

Rans S-6ES Coyote II, N5196W: Fatal accident occurred February 19, 2015 in Rincon, Puerto Rico -and- Accident occurred March 05, 2006 near Cartersville Airport (KVPC), Bartow County, Georgia



The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; San Juan, Puerto Rico
Rotech Research; Vernon, British Columbia, Canada

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

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

http://registry.faa.gov/N5196W

NTSB Identification: ERA15LA133
14 CFR Part 91: General Aviation
Accident occurred Thursday, February 19, 2015 in Rincon, PR
Aircraft: JOHNSON JOEL H RANS S-6ES COYOTE II, registration: N5196W
Injuries: 1 Fatal, 1 Minor.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

HISTORY OF FLIGHT

On February 19, 2015, about 1835 Atlantic standard time, an experimental, amateur-built Rans S-6ES Coyote II, N5196W, ditched in the waters of the Mona Passage after a partial loss of engine power near Rincon, Puerto Rico. The private pilot sustained minor injuries, and the passenger was fatally injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight operated under the provisions of 14 Code of Federal Regulations Part 91, which departed Eugenio Maria de Hostos Airport (TJMZ), Mayaguez, Puerto Rico, about 1815.

According to the pilot, he arrived at TJMZ on the day of the accident about 1600 to purchase the airplane. After a short test flight of about 15 to 20 minutes, he paid the owner for the airplane. He then received a telephone call from his brother-in-law and invited him to come out to the airport for a short flight to show him the airplane he had just purchased. The pilot left the airport about 1802, purchased premium automobile gasoline for the airplane at a local gas station, and refueled the airplane. After the refueling process was complete, about 1815, he and his brother-in-law (the passenger) boarded the airplane and taxied out for takeoff. The pilot verified that the gasoline valve was on and conducted a magneto check. After takeoff, they climbed to about 1,000 ft above sea level.

About 20 minutes into the flight, the pilot noticed that the engine was not producing enough power to sustain flight. The engine never lost power completely, but it would not produce full power, so he began to troubleshoot while he flew a course that would place the airplane parallel to the shoreline over shallow water near Rincon. He saw that there were people and sharp rocks along the shoreline, so he decided not to land on the beach but to ditch the airplane in the water. He maneuvered the airplane until it was 4 to 6 ft above the water, set the wing flaps to 20°, stalled the airplane, and touched down on the surface of the water. Upon touchdown, the airplane decelerated and sank but did not nose over. The pilot released his seatbelt and, about 5 seconds later, was able to egress and swim to the surface.

When the pilot reached the surface, he did not see his passenger. He swam back down to the wreckage, released the passenger's seatbelt and swam him up to the surface, but the passenger was not breathing. By this time, a person on a boogie board had reached them. They placed the passenger on the boogie board and paddled him to the beach. Cardio pulmonary resuscitation was performed but was unsuccessful.

PERSONNEL INFORMATION

The pilot held a Federal Aviation Administration (FAA) private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on September 8, 2014. He reported that he had accrued about 609 total flight hours.

AIRCRAFT INFORMATION

The airplane was a kit-built, two-seat, high-wing, airplane. The cockpit was constructed of welded 4130 steel tubing, and the rear fuselage was constructed of bolted aluminum tubing. The wings and tail surfaces were covered in presewn Dacron envelopes. The airplane was equipped with tricycle-type landing gear.

The airplane was assembled from a kit by the original owner and issued an FAA special airworthiness certificate on April 18, 1994. At the time of issuance, the airplane was powered by a Volkswagen air-cooled engine, driving a composite, ground-adjustable IVO propeller. Shortly thereafter, the Volkswagen engine was replaced with a Rotax 582 engine that had been manufactured in November 1990.

On March 5, 2006, in Cartersville, Georgia, the airplane was involved in an accident (NTSB Case No. ATL06LA048) during an instructional flight. The NTSB determined that the probable cause of the accident was: "The loss of engine power during cruise flight for undetermined reasons, which resulted in a forced landing, on ground collision with a ditch, and nose over."

On March 7, 2006, the airplane was sold by the original owner, and over the next 2 years, the airplane was owned by a succession of individuals in the continental US. On March 8, 2008, the engine was replaced with another Rotax 582 engine. Later that year, the airplane was shipped to Puerto Rico.

On April 20, 2009, a liquid-cooled, 64-horsepower, Rotax 582 Mod 99 engine, with dual carburetors and dual ignition, driving a three-blade, Warp Drive, ground-adjustable propeller was installed. Over the next 5 years, the airplane was once again owned by a succession of owners, until March 5, 2014, when it was sold to the previous owner, who operated it for about 11 months and sold it to the pilot on the day of the accident.

The airplane's most recent condition inspection was completed on November 26, 2014. At the time of the inspection, the airplane had accrued 881.5 total hours of operation, and the engine had accrued 191.5 total hours of operation.

METEOROLOGICAL INFORMATION

At 1750, the reported weather at Rafael Hernandez Airport (TJBQ), Aguadilla, Puerto Rico, located 11 nautical miles northeast of the accident site, included: wind 310° at 9 knots, 7 miles visibility in light rain, scattered clouds at 1,000 ft, broken clouds at 2,100 ft, overcast clouds at 5,000 ft, temperature 23°C, dew point 22C, and an altimeter setting of 29.99 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

On February 21, 2015, the wreckage of the airplane was recovered from about 20 ft of water about 200 ft off the beach near Rincon and transported to the Port of Mayaguez.

Examination of the airplane and engine revealed that the firewall and engine mounts were bent and broken, and the engine had been removed during the recovery. Both carburetors were displaced from their mounting positions, the coolant lines had been cut, and all spark plugs had sustained impact damage. The propeller was still attached to the engine gearbox, and all three propeller blades remained attached to the propeller hub. Surface corrosion could be seen on all exposed aluminum parts of the airplane, which was consistent with the airplane's submergence in sea water.

Engine

Examination of the intake system revealed that the air filters were the proper type but had suffered damage from impact or recovery of the wreckage from the ocean, and the element pleats were packed with dirt and sand.

Examination of the exhaust system revealed that a large section of the exhaust system was missing. Only the exhaust "Y" pipe, the first portion of exhaust system which connected both cylinders to a single section of exhaust pipe and held the two exhaust gas metering probes, was still attached to the engine.

Examination of the spark plugs and dual capacity discharge ignition system revealed that the spark plugs were impact damaged, had non-conforming removable resistor caps, and had rust-colored water droplets on them, which was indicative of sea water being present in the combustion chambers. The ignition modules were of the proper type and in good physical condition. The ignition wires also of the proper type and had incurred impact damage.

Examination of the coolant system revealed that the overflow bottle was missing; all the coolant hoses were breached; the water pump was intact; and the coolant radiator was still attached to the firewall but was heavily damaged. There was no evidence of coolant remaining in the system.

Examination of the injection oil lubrication system revealed that it had been disconnected and was no longer operational. This required the pilot to premix the fuel with oil at a 50:1 ratio before pouring it into the airplane's fuel tanks.

Examination of the rotary lubrication system revealed that the system and the oil tank were contaminated with sea water, and the perpendicular shaft and rotary valve plate were corroded due to submersion.

An attempt to rotate the crankshaft by turning the propeller shaft by hand to establish thumb compression and drivetrain continuity was unsuccessful. The propeller shaft would not rotate indicating that something internally was preventing this action. The propeller was removed, and the engine was placed on a work bench for further inspection and disassembly.

Examination of the reduction gearbox revealed that lubrication gear oil was still contained within the gearbox, and the gear-set and bearings appeared to be in good condition.

Examination of the combustion chamber revealed that the cylinder heads were in good physical condition. Examination of the power takeoff side (PTO) cylinder and the magneto side (MAG) cylinder revealed that the cylinder heads were in good physical condition. Both displayed a reddish coating of iron oxide (rust) on the barrel surface. No seizure marks or mechanical anomalies could be seen on either the PTO or MAG cylinders. Due to the stuck position of the crankshaft, the MAG piston could not be removed from its connecting rod, and the crankcase could not be spilt open. Inspection of the crankshaft and connecting rods was done though the connecting rod holes in the crank case. Corrosion from submergence in sea water was found on the connecting rods and crankshaft, and this was determined to be the reason the crankshaft could not be rotated. Other than the surface corrosion from the salt water submersion, no anomalies were found with the crankshaft, connecting rods, or bearings.

Examination of the PTO piston through the exhaust port revealed severe corrosion and salt deposits. The piston was stuck in the top dead center position; it could not be rotated to reveal the condition of the piston rings or cylinder bore; and it displayed a reddish colored coating of iron oxide (rust). There were no signs of vertical scoring, metal transfer, or excessive heat signatures seen on the exhaust side of the PTO piston. There were no indications of piston seizure, detonation, or mechanical anomalies.

Examination of the MAG piston through the exhaust port also revealed severe corrosion and salt deposits. The piston was stuck in the bottom dead center position and could not be rotated to reveal the condition of the side of the piston. The cylinder bore, top of the piston, and piston rings were exposed and could be examined for anomalies. Severe corrosion and salt deposits could be seen on all the metal surfaces, and the piston rings were stuck in their respective ring groove lands. As with the PTO piston, the MAG piston also had a reddish coating of iron oxide (rust) on its surface, and no indication of a piston seizure, detonation, or mechanical anomalies was discovered.

Fuel System

The fuel system included a primer plunger, an electric fuel pump, a pneumatic engine driven fuel pump, a fuel filter, and two carburetors. Breaches in the fuel system were found in the lines between the pneumatic fuel pump and the carburetors and between the fuel tank and the electric fuel pump. No preimpact anomalies were found with the fuel lines.

Both fuel tanks displayed internal dark stains and damage from impact or recovery of the airplane from the ocean.

No anomalies were found with the electric fuel pump, the primer plunger, or the pneumatic fuel pump.
The fuel filter was located between the electric fuel pump and the primer plunger. The fuel filter was examined for obstruction and blockage, and it was found full of sand and debris that appeared to be obstructing the mesh filter screen. The fuel filter had a transparent housing for easy inspection, and it was located on the left side of the fuselage next to where the pilot's left leg would be positioned. The fuel filter's location allowed for easy access for daily inspection.

The engine was equipped with dual Bing 54, side-draft carburetors with no external manual mixture control. The carburetors were examined for condition, conformity, and proper components. Since the carburetors were found displaced from the engine due to impact, the carburetor position angle relative to the crankshaft could not be determined.

The PTO carburetor float bowl was removed to examine the internal condition and jet size. Severe contamination and corrosion was found inside the carburetor float bowl because of submersion of the engine in salt water. The main jet was removed and found to be completely blocked with corrosion and salt deposits. The sieve screen was found crushed around the main jet tower. This was indicative of poor installation as the sieve screen should be allowed to freely move up and down. The top of the carburetor was removed to inspect the jet needle, but the piston was stuck in its bore due to severe corrosion. Other than the crushed sieve screen, corrosion, and water contamination, no anomalies were found with the PTO carburetor.

The MAG carburetor float bowl was removed to examine the internal condition and jet size. Severe contamination and corrosion was found inside the carburetor float bowl because of submersion of the engine in salt water. The main jet was removed and found to be completely blocked with corrosion and salt deposits. The sieve screen in this carburetor was also found crushed around the main jet tower. The top of the carburetor was removed to inspect the jet needle, but the piston was stuck in its bore due to severe corrosion. Other than the crushed sieve screen, corrosion, and water contamination, no anomalies were found with the MAG carburetor.

MEDICAL AND PATHOLOGICAL INFORMATION

The Puerto Rico Institute of Forensic Sciences performed an autopsy on the passenger. The passenger's cause of death was asphyxiation by drowning. Toxicological testing of the passenger was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens from the passenger were negative for carbon monoxide. Loratadine, a non-sedating tricyclic antihistamine, was detected in blood. Ranitidine, an antihistamine used in the treatment of gastric acid secretion, was detected in blood and urine.

TESTS AND RESEARCH

The Rans S-6ES Build Manual, under the "Fuel System" subsection of the "Inspection of Engine Systems" section called for a check for "fuel filter clogs."

The Rotax Operators Manual stated, "check engine suspension frequently as well as the drive components, fuel lines, wiring, and fuel and air filters." Under "Daily Checks," it stated, "inspect all fuel hose connections, filters, primer bulbs and taps for security, leakage, chafing and kinks."

The Rotax Installation Manual also stated, "check engine suspension frequently as well as the drive components, fuel lines, wiring, and fuel and air filters." It stated, "fuel contamination is a major cause of engine failures. The best place to avoid contamination is at the source. Once fuel is in your container, a very hazardous potential exists. Use a clean safety approved storage container. Filter all fuel entering and leaving this container." (It is unknown what method, if any, the previous owners used to filter fuel before filling the airplane's fuel tanks).

The Rotax Maintenance Manual also stated, "check engine suspension frequently as well as the drive components, fuel lines, wiring, and fuel and air filters." The maintenance schedule required that the fuel filter be checked every 25, 50, and 75 hours of operation and be replaced every 100 hours of operation. Section 11.8, "Check and Replacement of Fuel Filter" stated, "the flow through the filter may be restricted due to long term buildup of dirt. A more serious type of blockage, which can occur quite rapidly is caused by a reaction between detergents in certain two-stroke oils and water in the fuel. Both types of blockage may be difficult to detect visually. If blockage is suspected, renew fuel filter or filter element. Subsequently avoid water contamination of fuel." Examination of the airplane and engine maintenance records did not find any entries related to the fuel filter.

Based on the engine serial number, the engine was manufactured on April 17, 2008. The Rotax Maintenance Manual (Section 10.2 - Maintenance Schedule) stated that general overhaul of the engine should be carried out every 5 years, or every 300 hours, whichever comes first. Maintenance records did not indicate that the engine had been overhauled since its installation in 2009.

Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia

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

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

NTSB Identification: ATL06LA048
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Sunday, March 05, 2006 in Cartersville, GA
Probable Cause Approval Date: 07/31/2006
Aircraft: Joel H Johnson Rans S-6ES Coyote II, registration: N5196W
Injuries: 1 Minor, 1 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The certified flight instructor (CFI) and student pilot were practicing takeoff training, pattern work, and approach to landing instruction. The CFI stated that after making a "touch and go", the engine began to "sputter" and was losing power. The airplane was 300 to 400 feet above the ground and about two thirds down runway-01.The CFI took control of the airplane and leveled it out in hopes that the engine would regain power. The engine stopped and the CFI made a forced landing in a field adjacent to the airport. The airplane collided with a ditch on touchdown and nosed over. The registered owner of the airplane stated, "The engine assembly was removed from the airframe and examined. The top spark plugs were removed. The electrodes were normal as depicted in the Rotax Maintenance Manual, and the proper gap was set. The oil and fuel lines were not breached. A visual fuel sample was taken and no contaminants were noted. The fuel system was intact and full of fuel. The in-line fuel filters were free of contaminants. The carburetors were inspected and no contaminants were noted. The electrical system was examined. A functional check of the electrical coils and lighting coils was completed. No anomalies were noted. Manually turning the engine checked the gearbox. The rotary valves were functional and compression appeared normal with rotation of the engine by hand. The engine head was removed and no damage was noted to the pistons, sleeves or rings. No determination was made pertaining to the loss of engine power."

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The loss of engine power during cruise flight for undetermined reasons, which resulted in an forced landing, on ground collision with a ditch, and nose over.

On March 5, 2006, at 1645 eastern standard time, an experimental Rans S-6ES Coyote II, N5196W, registered to and operated by a private owner, as a 14 CFR Part 91 instructional flight, lost engine power, made a forced landing, and nosed over inverted two miles north of Cartersville Airport, Cartersville, Georgia. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was substantially damaged. The commercial pilot/ flight instructor (CFI) reported minor injuries, and the student pilot was not injured. The flight was originating from Cartersville Airport at the time of the accident. 

The CFI and student pilot were practicing take off training, pattern work, and approach to landing instruction. The CFI stated that after making a "touch and go", the engine began to "sputter" and was losing power. The airplane was 300 to 400 feet above the ground and about two thirds down runway-01.The CFI took control of the airplane and leveled it out in hopes that the engine would regain power. The engine stopped and the CFI made a forced landing in a field adjacent to the airport. The airplane collided with a ditch on touch down and nosed over inverted. 

The registered owner of the airplane stated, "The engine assembly was removed from the airframe and examined. The top spark plugs were removed. The electrodes were normal as depicted in the Rotax Maintenance Manual, and the proper gap was set. The oil and fuel lines were not breached. A visual fuel sample was taken and no contaminants were noted. The fuel system was intact and full of fuel. The three in line fuel filters were free of contaminants. The carburetors were inspected and no contaminants were noted. The electrical system was examined. A functional check of the electrical coils and lighting coils was completed. No anomalies were noted. Manually turning the engine checked the gearbox. The rotary valves were functional and compression appeared normal with rotation of the engine by hand. The engine head was removed and no damage was noted to the pistons, sleeves or rings. No determination was made pertaining to the loss of engine power."

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