Wednesday, May 2, 2018

Rutan VariEze, N80681: Fatal accident occurred May 28, 2016 in Santa Paula, Ventura County, California

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

Analysis 

The airline transport pilot and a passenger departed on a local area flight; shortly after takeoff, the engine experienced a total loss of power. To the northwest of the accident site was an open field and a road; both were available to use for landing but presented challenges. The field had been recently plowed and there was auto traffic on the road. It was likely that the pilot was attempting to land on the road but struck power lines during the descent. The airplane came to rest in a lemon orchard and was subsequently consumed by a postcrash fire.

Visual examination of the engine revealed thermal damage. The engine crankcase was disassembled; the main bearings on the left crankcase half were dark in color and exhibited pitting. The camshaft drive gear cluster displayed nine broken teeth, most of which were found in the oil sump.

Metallurgical examination revealed that three of the camshaft drive gear teeth failed in fatigue, which subsequently resulted in the overstress failure of the other six teeth. The fatigue initiated at sharp corners formed during hand-grinding of the forward faces of the teeth while dressing the edges and removing burrs from the teeth during manufacture.

Airplane logbook entries revealed that the engine was assembled by a third party and installed new on the airframe about 13 years before the accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be: 
A total loss of engine power due to fatigue failure of the camshaft drive gear teeth. 

Findings

Aircraft
Engine (reciprocating) - Fatigue/wear/corrosion (Cause)

Environmental issues
Wire - Contributed to outcome

Factual Information

History of Flight

Maneuvering
Loss of engine power (total) (Defining event)

Emergency descent
Collision with terr/obj (non-CFIT)


Matthew Robert Boutell
 July 15, 1994 - May 28, 2016
Camarillo, California 
Matthew Robert Boutell, 21, was a kind and gentle person with a diplomatic sense of humor. He inspired the best in everybody and that spirit will remain in our hearts forever. After graduating in 2013 with Honors from Triton Academy in Camarillo, Matt found employment at Implantech in Ventura where he was valued and loved by the employees.
~

Edgar Friederichs, 61, was piloting a Rutan VariEze when it crashed on May 28, 2016.  Bob Hirsch, 62, a pilot who has a hangar next to the one Friederichs used at Santa Paula Airport, said the two had known each other since meeting at a picnic when they were boys. "He was probably as well rounded in aviation as anyone could be," Hirsch said.  Hirsch stayed in touch with Friederichs throughout the years. "We lived parallel lives in many ways," Hirsch said, as he recalled working at Santa Monica Airport as a young man fueling aircraft, a job Friederichs also held there. Friederichs went on to become a licensed aircraft mechanic and later an aeronautical engineer, Hirsch said.  Among the many projects Friederichs worked on, was the development of the MD-80 for McDonnell Douglas, a passenger jet that Hirsch flew when he worked as a commercial pilot. Hirsch is retired from American Airlines. Hirsch eventually bought a hangar at Santa Paula Airport and later rented it to Friederichs. Friederichs ended up buying the hangar from Hirsch, he said, while Hirsch bought an adjacent hangar. "Edgar didn't have to prove anything when it came to aircraft," Hirsch said. "He just knew it."  He said Friederichs quickly developed a reputation at Santa Paula Airport "for his deep knowledge of aircraft and flying."

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 
Continental Motors Inc.; Mobile, Alabama 

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/N80681



Aviation Accident Factual Report - National Transportation Safety Board

Location: Santa Paula, CA
Accident Number: WPR16FA118
Date & Time: 05/28/2016, 1515 PDT
Registration: N80681
Aircraft: MOORE JOSEPH O VARIEZE
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (total)
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On May 28, 2016, about 1515 Pacific daylight time, an experimental amateur-built VariEze airplane, N80681, impacted power lines and terrain following a total loss of engine power near Santa Paula, California. The airline transport pilot and passenger were fatally injured. The airplane was destroyed in the postcrash fire. The airplane was privately owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the local area flight which departed Santa Paula Airport (SZP), Santa Paula, California, about 1510.

Two witnesses observed the airplane flying overhead about 200-300 ft above ground level (agl), and they heard the engine sputtering. The airplane descended from their view as it passed behind a hill. When the airplane came back into their view, it was in a steep 45° left turn. The airplane struck power lines, and then impacted the ground; the power lines were about 75-ft tall. Witnesses reported hearing an explosion, and then seeing fire erupt from the accident site.

An ear witness to the accident reported that after the airplane took off, the pilot radioed him that his engine had quit. There were no further communications between the pilot and the ear witness.

Pilot Information

Certificate: Airline Transport
Age: 61, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 07/18/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 06/21/2014
Flight Time:  (Estimated) 3500 hours (Total, all aircraft), 0 hours (Total, this make and model) 

The pilot, age 61, held an airline transport pilot certificate with ratings for airplane single- and multi-engine land. He also held a flight instructor certificate for airplane single- and multi- engine, instrument airplane, and a mechanic certificate for airframe and powerplant. The pilot was issued a Federal Aviation Administration (FAA) second-class medical certificate on July 18, 2015, with the limitation that he must wear corrective lenses. On that date, he reported 3,500 hours of total flight experience, with 30 hours accrued in the previous six months.

Review of the pilot's personal logbook indicated that he had 2,525.8 total hours of flight experience, with 3.6 hours in the previous six months. 



Aircraft and Owner/Operator Information

Aircraft Manufacturer: MOORE JOSEPH O
Registration: N80681
Model/Series: VARIEZE NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 1424
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 05/01/2016, Condition
Certified Max Gross Wt.: 
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: CONT MOTOR
ELT:
Engine Model/Series: O-200X
Registered Owner: On file
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None 

The airplane, serial number 1424, was manufactured in 1980, and equipped with a Continental Motors, Inc., O-200-X (experimental), 100-hosepower reciprocating engine. Review of the airplane's maintenance logbook indicated that a condition inspection was completed on May 1, 2016, with no airframe total time noted. Previous entries indicated a total airframe time of 2,576.0 hours and a total engine time of 324.3 hours as of September 30, 2015. 

Additional aircraft records revealed that that a zero-time engine was installed new in the airplane on March 18, 2003. The engine was assembled from new parts obtained from Continental Motors Inc. (Teledyne Continental Motors) in August of 2002. In December of 2002, a new crankshaft from A.E.R.O., Inc. was shipped to the builder. After the rebuild was completed, the engine was installed in the airplane in May 2003. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSZP, 259 ft msl
Observation Time: 1455 PDT
Distance from Accident Site: 4 Nautical Miles
Direction from Accident Site: 63°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 18°C / 12°C
Lowest Ceiling: Overcast / 1400 ft agl
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 10 knots/ 18 knots, 220°
Visibility (RVR):
Altimeter Setting: 29.89 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SANTA PAULA, CA (SZP)
Type of Flight Plan Filed: None
Destination: SANTA PAULA, CA (SZP)
Type of Clearance: None
Departure Time: 1510 PDT
Type of Airspace: Unknown 

Airport Information

Airport: SANTA PAULA (SZP)
Runway Surface Type: N/A
Airport Elevation: 248 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  34.322778, -119.149167 

The accident area was in a rural part of Santa Paula. To the northwest of the accident site was a road and an open field. The field was unplanted and open but had furrowed rows. Adjacent to the road was the lemon orchard where the airplane came to rest. The initial impact point was identified as powerlines about 162 ft south of the main wreckage. A debris path extended from the powerlines on a magnetic heading of 325°. The airplane came to rest on a magnetic heading of 140° and was consumed by a postcrash fire. All major components of the airplane were accounted for at the accident site, and control continuity was established to each of the flight control surfaces. 

Visual examination of the engine revealed varying degrees of thermal damage. The engine was equipped with a Light Speed Engineering, LLC, electronic ignition system. The mounting pads for the magnetos, mechanical fuel pump, electric starter, and vacuum pump were covered by blank plates. The ignition harness was thermally damaged. The throttle cable arm remained secured at the throttle plate shaft. The throttle cable arm and the carburetor mixture arm could not be tested for proper operation due to the thermal damage.

Internal timing of the engine was compromised due to mechanical damage to the crankshaft cluster gear and the camshaft gear. The top spark plugs were removed. The spark plugs from cylinder Nos. 1, 2, and 4 were oil contaminated; cylinder No. 3 was dry and exhibited normal combustion signatures. 

The oil pump was disassembled. The cavity displayed some scratches on the walls. The oil pump gears exhibited pitting of the gear teeth surfaces. The oil filter was disassembled, and the internal paper filter element had turned to ash because of the postcrash fire.

All four cylinders remained intact but sustained thermal damage. The valves were intact with no signs of mechanical damage. The rocker arms were intact and in place. The piston rings and pins showed no visible damage. The Nos. 1, 2, and 4 connecting rods and caps were normal and the rod bearings exhibited normal coloration and wear patterns. The No. 3 connecting rod and cap appeared normal; however, the rod bearings were pitted on the surface material.

The engine was rotated manually; it rotated fully in one direction, but binding was noted during rotation in the opposite direction. The engine crankcase was separated. The engine data plate had sustained thermal damage and was unreadable. The main bearings on the left crankcase half exhibited a dark coloration and some pitting. The main bearings on the right crankcase half, displayed normal coloration and wear patterns. The rear and center main crankshaft bearing journals were dark and discolored. The crankshaft cluster gear and the camshaft gear exhibited mechanical damage. The camshaft appeared normal. 

Medical And Pathological Information

The Ventura County Medical Examiner's Office, Ventura, California, performed a postmortem examination of the pilot. The cause of death was reported as thermal injuries due to an aircraft accident.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. The results were negative for carbon monoxide, volatiles, and tested-for-drugs. A cyanide screen was not performed. The toxicology report yielded positive results for:

21 (mg/dl) Glucose detected in Vitreous

519 (mg/dl) Glucose detected in Urine

5.6 (%) Hemoglobin A1C detected in Blood (Cardiac) 

Tests And Research

The crankshaft with camshaft drive gear cluster, main bearings, and the camshaft with gear were submitted to the National Transportation Safety Board Materials Laboratory in Washington, DC, for further examination. The crankshaft was intact but discolored at several bearing locations. All three main bearing journals and cylinder Nos. 2 and 3 journals were darkened on the same side; consistent with thermal damage from the postcrash fire.

The camshaft drive gear ring of the crankshaft gear cluster displayed 9 consecutive fractured gear teeth. Large pieces of 8 of the teeth were recovered from the oil sump, along with several smaller pieces. A magnified optical examination of the fractured gear teeth surfaces revealed fatigue progression beach marking on the fracture surfaces of teeth Nos. 1, 2 and 3. The remaining teeth fractures were consistent with overstress. Scanning electron microscope imaging verified that the fatigue initiation location was near the base of each tooth, about 0.025 inches outboard of the root diameters for teeth Nos. 1 and 2.



NTSB Identification: WPR16FA118
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 28, 2016 in Santa Paula, CA
Aircraft: MOORE JOSEPH O VARIEZE, registration: N80681
Injuries: 2 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 May 28, 2016, about 1515 Pacific daylight time, an experimental amateur built Moore VariEze airplane, N80681, reported a total loss of engine power and impacted power lines before coming to rest in a lemon orchard in Santa Paula, California. The owner/airline transport pilot and passenger were fatally injured. The airplane was destroyed in the postcrash fire. Visual meteorological conditions prevailed for the local area flight that departed the Santa Paula Airport (SZP), Santa Paula, California, about 1500. 

Two ground witnesses reported observing the airplane flying overhead, and heard the engine sputtering. The airplane was descending, and dropped out of their view as it passed behind a hill. The airplane came back into view in a steep left turn, which both witnesses estimated to be at least 45 degrees. The airplane struck power lines, and then then impacted the ground. Both witnesses reported hearing an explosion, and then seeing fire erupt from the accident site.

An ear witness to the accident reported that after the airplane took off, the pilot radioed him that his engine had quit. There were no further communications between the pilot and the ear witness.

National Transportation Safety Board (NTSB) investigators and a Federal Aviation Administration (FAA) inspector responded to the accident site. Examination of the wreckage site revealed that the airplane had struck power lines about 162 feet from the final resting point of the airplane. The debris path was along a magnetic heading of 325 degrees. The airplane came to rest on a magnetic heading of 140 degrees. The entire airplane was located at the accident site.

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