Sunday, May 20, 2018

Van's RV-8A, N838RV: Fatal accident occurred March 12, 2016 in Clermont, Lake County, Florida

Analysis

The private pilot was in cruise flight in the experimental, amateur-built airplane. The pilot transmitted a mayday call via radio, stating that he had "lost an engine." Witnesses saw the airplane before impact and stated that the airplane was not making any sound. One witness saw the airplane enter a sharp turn before entering a nose-low descent. The airplane then impacted an open field; the sharp turn followed by the nose-low descent is consistent with an aerodynamic stall.

Examination of the experimental, kit-built engine revealed that the crankshaft had fractured forward of the No. 2 connecting rod journal. Further testing of the crankshaft revealed that the fracture was the result of fatigue cracking. There were no chemical variations or foreign material present in the metallurgical testing. The crankshaft only had 20 hours total time in service, suggesting that initiation of the cracking and the subsequent failure of the crankshaft was almost immediate. As there were no apparent metallurgical mechanical deficiencies with the crankshaft, the fatigue failure was likely the result of unusual stresses; however, there was insufficient information about the engine operation in the final 17 minutes of flight to determine the reason for the failure.

Although the pilot's toxicology results tested positive for Zolpidem, a prescription medication for the treatment of insomnia, the values were below the normal therapeutic range and there was no evidence that impairment contributed to the accident. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's exceedance of the airplane's critical angle of attack while maneuvering for a forced landing; which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the fatigue failure of the crankshaft for reasons that could not be determined based on the available information. 

Findings

Aircraft
Recip engine power section - Failure (Factor)
Airspeed - Not attained/maintained (Cause)
Angle of attack - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Enroute
Loss of engine power (total)

Emergency descent
Off-field or emergency landing
Loss of control in flight

Enroute
Powerplant sys/comp malf/fail (Defining event)

Landing-flare/touchdown
Collision with terr/obj (non-CFIT)

Dane Sheahen and Buddy, his bulldog.

Dane lived in Fort Sheridan and had a second home in Spruce Creek, a fly-in community a few miles south of Daytona in northeast Florida. Friends describe him as a longtime recreational pilot based at Waukegan Airport who was a member of Lake County’s Stick and Rudder Club for many years. They also said he took no chances. “Flying was his passion,” Karen Schmid of Lake Forest told Daily North Shore. “He was a pilot who crossed his Ts and dotted his Is. He had a new engine installed in his plane in January 2016 right before he flew it to Florida with Buddy, his bulldog and frequent flying companion. He was very safe.”


James "Jim" Maurice Kos
 November 25, 1958 - March 12, 2016

In 2009 Jim started his career in the aviation industry and began classes at Canadian Valley Technology Center to obtain his airframe and powerplant (A&P) mechanic certification. After obtaining his certification in 2011 he later obtained his inspection authorization (AI) certification in 2013.




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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Orlando, Florida
Superior; Coppell, Texas
Barrett Precision Engines; Tulsa, Oklahoma

Aviation Accident Final 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/N838RV



Aviation Accident Factual Report - National Transportation Safety Board

Location: Clermont, FL
Accident Number: ERA16FA127
Date & Time: 03/12/2016, 0847 EST
Registration: N838RV
Aircraft: SHEAHEN DANE E RV-8
Aircraft Damage: Substantial
Defining Event: Powerplant sys/comp malf/fail
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On March 12, 2016, about 0847 eastern standard time, an experimental amateur-built Vans RV-8A, N838RV, was substantially damaged after it impacted the ground following a total loss of engine power near Clermont, Florida. The private pilot and passenger were fatally injured. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which originated from Spruce Creek Airport (7FL6), Port Orange, Florida, about 0825, and was destined for Winter Haven's Gilbert Airport (GIF), Winter Haven, Florida.

Two witnesses near the accident site reported seeing an airplane that matched the description of the accident airplane. They stated they did not hear any sound from the airplane as it flew overhead. One witness stated that the airplane made a "sharp" left turn and that the nose dropped before the airplane descended out of sight. The wreckage was subsequently located in an open field adjacent to a residential area.

According to radar track data, the airplane was flying on a southerly heading about 2,100 ft mean sea level (msl) about 3 miles from the accident site. The pilot of a nearby airplane reported that, around the time of the accident, he heard the pilot of an RV airplane transmit a mayday radio call saying that he had "lost an engine." 

Pilot Information

Certificate: Private
Age: 63, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 07/06/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 07/31/2015
Flight Time: 880 hours (Total, all aircraft), 20 hours (Total, this make and model) 

The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. According to Federal Aviation Administration (FAA) records, the pilot was issued a repairman experimental aircraft builder certificate on August 25, 2003, for the accident airplane. His most recent third-class FAA medical certificate was issued on July 8, 2014; on the application for that certificate, he reported 880 total hours of flight experience with 12 hours in the previous 6 months. The pilot's flight experience at the time of the accident could not be determined.

The passenger was a student pilot and held an airframe and powerplant mechanic certificate. His most recent FAA third-class medical certificate was issued on September 23, 2015. At that time, he reported 25 total hours of flight experience.



Aircraft and Owner/Operator Information

Aircraft Manufacturer: SHEAHEN DANE E
Registration: N838RV
Model/Series: RV-8 A
Aircraft Category: Airplane
Year of Manufacture: 2002
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 80797
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection:
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Superior
ELT: Installed, not activated
Engine Model/Series: XP-400
Registered Owner: On file
Rated Power: 215 hp
Operator: On file
Operating Certificate(s) Held: None 

The two-seat, low-wing, fixed tricycle-gear airplane was assembled from a kit and issued an FAA experimental airworthiness certificate in 2002. It was powered by a Superior XP-400, 215-horsepower, experimental kit engine, equipped with a Whirl Wind two-blade constant-speed propeller.

The first entry in the engine logbook was on January 15, 2016, describing the installation of the new engine at 522.5 tachometer hours. The entry noted that the engine was run for 3 hours following assembly before installation. The last entry in the logbook was on January 31, at 531.6 tachometer hours; the oil had been changed and there were no contaminants found in the filter.

An Advanced Flight Systems Inc., AF-5800 electronic flight instrument system was installed in the airplane. The device was capable of displaying aircraft altitude, heading, moving maps, and engine information depending on options and installation. The unit recorded about 50 discrete data parameters to internal non-volatile memory. The device recorded data from flights between February 12 and March 12, totaling about 11 hours of flight time. About 18 minutes of the accident flight was recorded; the last data point was about 17 miles northeast of the accident site.

Given the logbook entries and the AF-5800 data, the estimated total engine time since installation was about 20 hours. A written record of flight time between January 31 and February 12 was not located. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: ORL, 112 ft msl
Observation Time: 1353 UTC
Distance from Accident Site: 19 Nautical Miles
Direction from Accident Site: 92°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 22°C / 19°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 9 knots, 130°
Visibility (RVR):
Altimeter Setting: 30.18 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Port Orange, FL (7FL6)
Type of Flight Plan Filed: None
Destination: WINTER HAVEN, FL (GIF)
Type of Clearance: None
Departure Time: 0825 EDT
Type of Airspace: Class G 

At 0853, the weather reported at Executive Airport (ORL), Orlando, Florida, located 19 miles east of the accident site, included clear skies and wind from 130° at 9 knots, 10 statute miles visibility, temperature 22°C, dew point 19°C, and an altimeter setting of 30.18 inches of mercury. 




Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 28.557222, -81.718889 (est) 

The airplane came to rest in an open field about 307 ft msl. The field was about 2,400 ft long and about 200 ft wide; oriented east to west. There were powerlines on the eastern edge of the field and a road on the western edge. The wreckage was examined at the accident site and all major components were accounted for at the scene. The wreckage path was 30 ft long from an initial ground scar to the main wreckage and was oriented in a westerly direction. The wreckage came to rest upright on a magnetic heading about 110°.

The right wing was intact and attached at the fuselage; the aileron and flap remained attached to the wing. The left wing spar was fractured at the fuselage, the left flap connecting rod was fractured, and the left aileron was separated from the wing. The left wingtip was separated from the airplane and located at the first observed ground scar. The rudder and vertical stabilizer were attached and undamaged. Both the left and right elevators displayed crinkling from the outboard portions inward. Flight control continuity was established from the ailerons, elevator, and rudder surfaces to the cockpit controls. The cockpit was heavily damaged and folded open; the canopy was separated and lay over the right horizontal stabilizer.

One of the two composite propeller blades was fractured and found partially buried in the ground; the other blade remained intact and was undamaged. Both fuel tanks were breached and no residual fuel was observed; the fuel selector was positioned to the left main fuel tank. The engine-driven fuel pump sustained minimal damage and operated normally during a functional test. The fuel nozzle injectors were removed; they showed normal operational signatures and no obstructions. The fuel injection lines were intact and free from obstructions. Metal debris was present in the oil sump finger screen and the oil sump.

The propeller governor, fuel servo, and engine-driven fuel pump were removed and the engine was placed on a stand for testing. The mixture control lever and throttle metering unit moved freely.

The oil pump could not be rotated by hand; the oil pump was removed from the accessory case and exhibited impact to the driveshaft. The drive and gear exhibited normal operation signatures. The oil pump cavity was free of any scuffing or scoring and exhibited normal operating signatures. The oil filter was cut off; the paper element contained metal debris. The engine could not be rotated by hand. The camshaft exhibited normal operating signatures and the crankshaft was fractured.

The fractured crankshaft was forwarded to the NTSB Materials Laboratory, Washington, D.C., for examination. Visual examinations of the fractured surface revealed extensive beach markings and a finely-textured surface indicative of fatigue progression from the vicinity of the connecting rod journal.

Further examination revealed that the crankshaft fractured at the forward radius of the No. 2 connecting rod journal, opposite the top-dead-center position of the piston. Scanning electron microscopy (SEM) further revealed markings consistent with fatigue progression from a subsurface location. SEM examinations also revealed extensive mechanical damage consistent with crack closure and crack face recontact that obliterated the fine details of the fracture.

Energy dispersive x-ray spectra and maps of the origin location did not indicate an inclusion or chemical variations in the area. Metallographic cross sections did not reveal any inclusions of foreign material. 



Medical And Pathological Information

The Office of the Medical Examiner, Leesburg, Florida, performed an autopsy of the pilot. The cause of death was listed as multiple blunt force injuries.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, conducted toxicological testing of specimens from the pilot. The testing was negative for ethanol and drugs of abuse. Acetaminophen, clopidogrel, metoprolol, rosuvastatin, ticlopidine, and zolpidem were detected in urine and blood.

Acetaminophen is an over-the-counter analgesic. Clopidogrel is an antiplatelet medication used to prevent heart attacks and strokes. Metoprolol is a beta-blocking agent used to treat high blood pressure and reduce the risk of recurrent heart attacks. Rosuvastatin is used to treat high cholesterol and related conditions. Salicylate is a metabolite of aspirin. Ticlopidine is a prescription platelet aggregation inhibitor. None of these medications are considered to be impairing. Zolpidem is a prescription medication used in the treatment of insomnia. This medication may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Due to adverse side effects, the FAA recommends waiting at least 24 hours after use before flying.



NTSB Identification: ERA16FA127
14 CFR Part 91: General Aviation
Accident occurred Saturday, March 12, 2016 in Clermont, FL
Aircraft: SHEAHEN DANE E RV-8, registration: N838RV
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 March 12, 2016, about 0847 eastern standard time, an experimental amateur-built Sheahen RV-8A, N838RV, operated by a private individual, was substantially damaged after it impacted the ground near Clermont, Florida. The private pilot and the pilot-rated rear-seat passenger were fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight that originated from Spruce Creek Airport (7FL6), Port Orange, Florida, at about 0825. The local personal flight, destined for Winter Haven's Gilbert Airport (GIF), Winter Haven, Florida, was conducted under the provisions of 14 Code of Federal Regulations Part 91. 

Multiple witnesses in the area of the accident site reported seeing an airplane that was consistent with the accident airplane inflight with a rough running engine sound. One witness stated that the engine was not making any noise as the airplane made a 180 degree turn over a field, and descended out of sight in a nose-low attitude. The airplane was located in an open field adjacent to a residential area.

According to preliminary radar data, the airplane was flying in a southwesterly direction, at approximately 2,220 feet mean sea level, when it began a climbing left turn, and reached an altitude of about 2,600 feet (msl). The last few targets showed a rapidly decreasing airspeed. A nearby flight of three airplanes reported hearing the pilot of an "RV airplane" make a mayday distress radio call, reporting that he had "lost his engine" around the time of the accident.

The wreckage was examined at the accident site and all major components were accounted for at the scene. The wreckage came to rest in an open field about 307 feet elevation. The wreckage path was 30 feet long, from an initial ground scar to the main wreckage, which came to rest upright on a magnetic heading of about 110 degrees. The right wing, aileron and flap were intact and attached to the main spar at the fuselage. The left wing spar was fractured at the fuselage, the left flap connecting rod was fractured, and the left aileron was separated from the left wing. The left wing tip was separated from the airplane and located at the first observed ground scar. The rudder and vertical stabilizer was attached and undamaged. Both the left and right elevators displayed crinkling from the outboard portions inward. Flight control continuity was established from the ailerons, elevator, and rudder surfaces to the cockpit controls. The cockpit was heavily damaged and folded open, the canopy was separated and laying over the right horizontal stabilizer.

One of the two composite propeller blades was fractured and found partially buried in the ground; the other blade remained intact and was undamaged. The fuel tank was fragmented and no residual fuel was observed, the fuel selector was positioned to the left main fuel tank. Initial examination of the engine revealed metal debris in the oil sump finger screen. The engine was retained for further examination to be performed at a later date.

The two-seat, low-wing, fixed tricycle-gear airplane, was assembled from a kit and issued a Federal Aviation Administration (FAA) experimental airworthiness certificate in 2002. It was powered by a Superior XP-400, 215-horsepower, experimental kit engine, equipped with a Whirl Wind two-blade, constant-speed propeller.

The pilot held a private pilot certificate, with ratings for airplane single-engine land, and instrument airplane. According to FAA records, the pilot was issued a repairman experimental aircraft builder certificate on August 25, 2003, for the accident airplane. He was issued a third-class medical certificate on January 19, 2011, and he reported 880 total hours of flight experience on that date.

Weather at Orlando Municipal Airport (ORL), about 19 miles east of the accident site, reported at the time of the accident included clear skies, 10 statute miles of visibility and winds from 130 degrees at 9 knots.

1 comment:

Anonymous said...

This engine appears to be a stroked out Lycoming 0360 “clone” that was now an 0400. The crankshaft a total failure at 3 hours or so. Looking at the photos in the metalergical analysis shows where the defect was. I was considering one of these engines as an upgrade, rather than converting to a 6 cylinder 0540 from my existing 0360 in my experimental aircraft. I also noted the lack of counterweights on the stroker crank. I thought that a counterweighted crank was to be used in a stroked engine.