Monday, September 13, 2021

Cessna 177RG Cardinal RG, N2085Q: Fatal accident occurred September 12, 2021 near Lake Havasu City Airport (KHII), Mohave County, Arizona

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. 

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Scottsdale, Arizona
Lycoming Engines; Williamsport, Pennsylvania 
Textron - Cessna; Wichita, Kansas

Location: Lake Havasu City, AZ
Accident Number: WPR21FA340
Date & Time: September 12, 2021, 16:09 Local
Registration: N2085Q
Aircraft: Cessna 177RG 
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal

On September 12, 2021, about 1609 mountain standard time, a Cessna 177RG, N2085Q, was substantially damaged when it was involved in an accident near Lake Havasu Airport, Lake Havasu, Arizona. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The pilot was planning on making a long cross-country to Reno, Nevada in the next several days and the purpose of the accident trip was for him to get fuel at Lake Havasu for the flight to Reno. The airplane was based in at Eagle Airpark in Bullhead City, Arizona and the pilot performed maintenance there earlier in the day including replacing the bushings on the nosewheel because he was experiencing a vibration on takeoff and landing. After finishing the maintenance, he departed about 1530 and landed at Lake Havasu about 1545. The pilot then purchased 24.8 gallons of fuel at the self-serve fuel tank which presumably topped-off the fuel tanks to full fuel onboard as he had intended.

Investigators reviewed video recordings, audio recordings, and flight track data covering the area of the accident during the time surrounding the accident using Federal Aviation Administration (FAA) provided Automatic Dependent Surveillance-Broadcast (ADS-B) data. The airplane taxied to runway 14 and after performing a run-up, departed about 1608. Witnesses report that they observed the airplane
takeoff down the runway at a slow groundspeed and noted that the engine sounded rough as though it was making partial power. The airplane did not ascend as expected and veered to the right of the centerline reaching 100-150 feet agl. The ADB data shows the airplane accelerating down the runway up to a derived airspeed of 65 kts. 

The airplane then pitched up to a nose-high attitude and made an aggressive left bank consistent with pilot attempting to make 180-degree turn back to the runway. Witnesses observed the airplane’s wingspan turn nearly perpendicular to the horizon and then stall with the left wing dropping toward terrain.

At an undetermined time during the takeoff, the pilot made a transmission on the airport common frequency where he stated, “Lake Havasu traffic Cardinal 2085Q making a uh…” The next transmission was less than a second and all that could be heard is a high-pitch tone akin to a stall-warning horn.

The accident site was located in the desert terrain about 830 ft from the end of runway 14 at an elevation of 790 feel msl. In character, the terrain was composed of dry, soft dirt with sparse brush. The wreckage was found distributed over a 200 ft distance on a median magnetic bearing of about 60°. The main wreckage consisted of a majority of the airframe and engine, which had been consumed by fire with the exception of the right wing. The first identified points of contact consisted of disrupted dirt on the flat desert terrain making up the far east-southeast end of the debris field. The markings started as an indentation dirt with shards of red lens fragments imbedded within the soil consistent with the left-wing tip impacting first. The crater was continuous toward the main wreckage with the end of the crater having blue/green lens fragments imbedded. A larger center indentation was found in between the red lens fragments and the green/blue lens fragments and had a large arc-shaped disruption of dirt consistent with a rotating propeller blade.

As part of the post-accident examination, a majority of the engine and its respective components were completely disassembled. In pertinent part, the Nos. 1 and 4 top compression piston-rings were fragmented. On all the piston skirts there was evidence of corrosion and wear with light scuffs/grooves oriented from the base to the crowns. There was additionally evidence of blow-by with heat signatures on the piston skirts on all cylinders, but the least damage was on the No. 3 cylinder.

Separation of the crankcase halves revealed that there was severe spalling on the faces of all the intake lifters and the No. 3 exhaust lifter; there was also evidence of galling noted. On the remaining lifters there was evidence of wear with a circular pattern and pitting.  The camshaft revealed signatures of excessive wear on the cam lobes including rounding of the lobes, pitting and material deformation observed on the lobes. 

The lifter on the No. 4 exhaust valve had a tear in the base of the body, consistent with contact with the hydraulic socket; the pushrods did not show evidence of being bent. The bearings showed light wear and the crankshaft had light rotational scoring.

The pilot’s spouse stated that the pilot did a majority of his own maintenance and that he regularly flew the airplane since they purchased it in 2013. A review of the logbook revealed that the airplane had a total time of 3,487.3 hours and the engine had 1,219.4 hours since it was remanufactured at Lycoming.

The logbooks showed that the camshaft and lifters were replaced with new parts in December 2004, equating to 682 hours prior to the accident. The logbook indicated that the No. 1 cylinder was replaced with an overhauled assembly in March 2020, equating to 75.1 hours prior to the accident. The last recorded oil change was at the last annual inspection recorded as being completed on July 16, 2021, 25.7 hours prior the accident.

The pilot had sent samples of the engine oil for Spectrometer analysis on multiple occasions, the most recent of which was September 09, 2021 at an engine time of 1,216.7 hours equating to 3 days prior to the accident or 2.7 flight hours. The sample had not been run before the accident occurred; in pertinent part, it showed elevated levels of Aluminum, Chromium, Iron, Silicon and Nickel.

On the report prior to the most recent, taken in September 2019, the laboratory commented that there was elevated levels of metal. The report stated that if work had not been done recently on the engine, the amount of aluminum, chrome, and iron would indicate piston, ring, and steel wear. The analysis further stated that there was “even enough chrome to show a ring problem.”

Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N2085Q
Model/Series: 177RG
Aircraft Category: Airplane
Amateur Built:
Operator: On file
Operating Certificate(s) Held: None
Operator Designator Code:

Meteorological Information and Flight Plan

Conditions at Accident Site: VMC
Condition of Light: Day
Observation Facility, Elevation: KEED,914 ft msl
Observation Time: 15:56 Local
Distance from Accident Site: 17 Nautical Miles
Temperature/Dew Point: 44°C /4°C
Lowest Cloud Condition: Clear 
Wind Speed/Gusts, Direction: 14 knots / , 190°
Lowest Ceiling: None 
Visibility: 10 miles
Altimeter Setting: 29.77 inches Hg 
Type of Flight Plan Filed: None
Departure Point: Lake Havasu City, AZ
Destination: Bullhead City, AZ (A09)

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries:
Aircraft Fire: On-ground
Ground Injuries: 
Aircraft Explosion: None
Total Injuries: 1 Fatal 
Latitude, Longitude: 34.557952,-114.34983

Those who may have information that might be relevant to the National Transportation Safety Board (NTSB) investigation may contact them by email, and any friends and family who want to contact investigators about the accident should email You can also call the NTSB Response Operations Center at 844-373-9922 or 202-314-6290.

Gary L. Van Dyke

A pilot is dead this week after his single-engine aircraft crashed while taking off from Lake Havasu Municipal Airport on Sunday.

Federal Aviation Administration records show that the plane was registered to Gary L. Van Dyke, of Alvin, Texas. Van Dyke is identified on LinkedIn as a former corporate regional manager, and retired almost two years ago. A social media post Monday from Van Dyke’s sister, Lora Van Dyke, appeared to confirm that Van Dyke was the sole victim in Sunday’s crash.

According to flight-recording website, the Cessna 177RG aircraft departed from the Needles area at 3:34 p.m. Sunday, and landed at Havasu Municipal Airport at 3:45 p.m. The crash was reported shortly after 4 p.m., when the plane went down over the desert area south of the airport, about 75 yards from Wheelan Drive.

Lake Havasu City officials said on Sunday that the plane was fully engulfed in flames when emergency first responders arrived. Firefighters were able to extinguish the fire within minutes, but the aircraft was entirely destroyed and its occupant was deceased.

Federal officials were notified of the crash on Sunday, and have been dispatched to the scene.


  1. "Havasu police and the Community Emergency Response Team is on scene in a gated area south of the airport and north of Agave Business Park, about 75 yards from Whelan Drive." is adjacent to departure end of Rwy 14.
    ADS: " Speed: 54 kt Altitude: 1,000 ft, Vert. Rate: 192 ft/min, Track:175.8° Pos.:34.561°, -114.353°

    1. KHII's runway is 8000' long. AdsbExchange track recording includes a taxi data point at 19:04:32 that suggests the pilot did use full length for takeoff.

      Unfortunate that the takeoff was not rejected on observing low performance. Lots of runway length was available to get stopped.

    2. Weather recorded at 16:15 local time was wind SE 3, clear skies, temp 109 F, dewpoint 45 F, RH 11%, altimeter 29.76.

    3. "...the takeoff was not rejected on observing low performance."

      Sorry, where does it say there was low performance and that the pilot elected not to reject the takeoff?

    4. Low performance shows in the ADS-B data. Looking at the ground speed and altitude in the Adsbexchange track recording, you can easily see the low forward speed and lack of altitude increase in spite of traversing the 8000 feet of runway:

    5. I disagree with the conclusion that he did not use the full length for takeoff. The ADS-B point at 19:04:32 has a GPS position well past the point where he would have turned onto taxiway A5 for an intersection takeoff. After that point there is a data gap of about 3.5 minutes until the next recorded point at 19:07:57 which was on the runway. adsbexchange drew a dashed line between the two points showing there is discontinuous data, but the pilot most likely taxied all the way to A6 and did a full length takeoff. ADS-B reception on ground level is spotty at best as buildings and other obstacles can more easily block the signal from getting to ADS-B ground receivers.

      However, I do agree the ground speed data does seem to indicate poor aircraft performance on takeoff, even accounting for wind.

    6. When posting "I disagree with the conclusion that he did not use the full length for takeoff." were you responding to the original comment above that was posted Tuesday, September 14, 2021 at 8:04:00 AM EDT, or something seen elsewhere?

      The original Tuesday, Sept 14 @ 8:04 comment stated:
      "KHII's runway is 8000' long. AdsbExchange track recording includes a taxi data point at 19:04:32 that suggests the pilot did use full length for takeoff."

      The original comment made the conclusion that the full length was used and included the same data point. Nothing to disagree about.

  2. Gary was a friend of mine. What a great loss. He was very active in Angel Flight. I took the photo you show at the top of the page. It was for a shoot for Cessna Owner Organization and his plane was the cover plane. Very experienced pilot. He'd only recently moved to AZ from TX. Blue Skies, my friend. You have a lot of us in tears today.

    1. I'm sorry for your loss. I hope this isn't inappropriate, but that is a great photo. How did you capture it?

    2. I'm sorry for your loss. It's a great looking photograph, you have real talent.

    3. Thanks. Air-to-Air from a Cessna 170. It was certainly a day to remember.

    4. Sorry to hear that Jack. I said a little prayer. Hope it helps you get past this.

    5. He made that issue's cover page look great!

  3. I was afraid he might be relying on Cessna's C177 book numbers, which were fraudulent and the subject of an engineering disaster that NASA had to get involved in, but it doesn't look like it with that long of a runway. I think the fraudulent data centered on the fixed-gear version, also, so it may not be relevant anyway.

  4. Head scratcher. The 170 series is the most docile of all planes, retract or not. I suspect some incapacitation on takeoff, or a wildlife strike through the window that would be hard to see afterwards when the plane was roasted and everything in it. The weather condition were certainly full VFR and even with some gusts manageable. I went into that airport a few months ago and see nothing unusual. Nice long runway and no issues.

  5. Based on info at the time of the crash, density altitude was 5440.8 feet. Full power and full rich could have been an issue. Although my engines are very different, I fly a Beech Duke, departing at temperatures above 100 pose problems with keeping the CHTs below red line. The inclination is to enrichen the mixtures ( hot temps and high elevation ) which in turn degrades climb performance. One engine hic up ( lose a cylinder, vapor lock ) and down I go.
    I’m not speculating. Just offering up one set of scenarios that I’ve experienced that involve circumstances this gentleman may have had to deal with.
    My sincerest condolences to his family and friends.

    1. @Leo - Would be interested to understand what WX conditions, field elevation and calculation you used that gave you a density altitude result of 5440.8 feet? That number is off by about 1000 feet, as detailed below:

      KHII AWOS recordings closest to 23:10Z are 22:55Z with T= 109.40F, DP= 46.40F, Altimeter= 29.76 and 23:15Z with T=109.40F, DP= 44.60F, Altimeter= 29.76 (From full day archive at link below)

      Drop that data into the pilotfriend calculator along with KHII's 783 foot field elevation from Airnav and you get 4,399 feet.

      If you don't trust that calculator, use the National Weather Service calc tools. Two calc tools apply, the first is used to convert Altimeter setting to station pressure:
      For Altimeter= 29.76 inches Hg and 782.8' field elevation, station pressure comes out to 28.93 inches Hg.

      The density altitude calculator is at:
      Entering 28.93 inches Hg station pressure, T= 109.40F, DP= 46.40F returns a density altitude of 4,410 feet. For the 44.6F dewpoint reading at 23:15Z, density altitude is 4,401 feet.

      Or do the simple form manual calc in centigrade, adjusting the 15 degree ISA sea level temp to 13 for KHII elevation being almost 1000' MSL:
      Density altitude in feet = pressure altitude in feet + (120 x (OAT - ISA temperature))
      Density altitude = 783 + (120 x (43 - 13)) = 4,383 feet

      Full day KHII 9/12/2021 AWOS archive:

    2. Wrong... You use your flight computer that you learned or, (should have learned) in ground school. No electronic devices, web-sites, Etc. Just good ole basic flight planning using the tools that were developed many years ago.
      I'll bet most "New" pilots have no idea how to use, or even seen, a flight computer.

    3. If the E6B flight computer returns 5440.8 feet density altitude for the noted conditions at KHII, you are operating it incorrectly!

      Instructions, if needed:

    4. My mistake entirely and I apologize for the error. DA is indeed 4400 feet. The E6B and strained eyes aren’t always the best combo.

    5. Eye strain can't explain getting 5,440.8 from reading the dial in the E6B flight computer's density altitude window cutout.

      The tick marks on the dial represent 100 foot increments. That extra .8 stuck on to 5,440 doesn't make sense. (Look at the "Density Alt." window, located to the right of the center rivet in the photo linked below).

    6. @Leo - kind of you to admit a minor mistake. Unfortunate that your one-time misread of an E6B is the subject getting people riled up instead of focusing on the tragedy at hand and learning from it.

    7. TIL that you can't read an E6B to tenths of a foot.

  6. Turbocharged engines do not require leaning for high density altitude takeoffs. Normally aspirated Lycoming's as in the Cessna 177 recommend leaning for takeoff only above 5000' DA. So any gain from leaning would be very modest at DA of 5440'.

  7. I used a previously posted number for density altitude. The important issue is that full rich mixture would not have been an issue as some have speculated. A much more important issue would be that the prop was inadvertently left at a cruise setting of perhaps 2300 rpm. It is clear that the airplane performance was way below what it should have been.

    1. Nothing was wrong with your leaning comment. Correcting the other person's erroneous DA number was in support of your "Normally aspirated Lycoming's as in the Cessna 177 recommend leaning for takeoff only above 5000' DA" statement.

    2. I was under the impression this 177RG was not turbonormalized, the aircraft directory shows it having the IO-360-A1B6D power plant. IO = injected, TIO = turbo. This explains my wondering if mixture leaning was a factor. Having the prop in cruise setting? If so, what a tragic oversight.
      Years ago I learned of an RG that upon gear retract a failure ( hydraulic leak ) with no possibility to manually raise or lower. With the gear partially retracted, it suffered substantial performance loss and of course, had a eventful landing.
      Maybe someone in here with RG experience could comment on either. The gear issue is not uncommon, as I’ve learned over the years.
      As for the .8 and use of a E6B, a point of aggravation with a hidden, near hysterical commenter.Truth in advertising, I used my electronic E6B. I own both, use both. I also own a cell phone, but know how to use a rotary dial if needed.

    3. Just because there is no "T" in the engine model number does not mean it is not turbo-charged by the Aircraft Manufacturer, or modified by STC to be turbo-charged. The "T" in the engine model descriptor means it is turbo-charged by the engine manufacturer.

    4. If STC-Turbo'd, he would have said so in the user perspective article. You can read it here:

    5. To answer (I think) the question above, Cardinal RGs have no problem flying with a partially retracted gear. There may be a slight performance loss from the sideways wheels, but not much in the overall scheme of things.

  8. has the purpose of the short stop at the airport terminal bldg been revealed? 85Q landed, taxied direct to the terminal bldg, approx <10 minute stop, possible not a shut down and then departure.

    1. The ground arrival ADS-B furthest detected position before going back out is at the 22:49:39Z data point and maps to a location near the FBO fueling loop. The first detected data point going back out is at 23:03:27Z.

      Suggests a 10 or 11 minute fuel stop. Doesn't appear to place the aircraft at the public terminal building.

      Ground track at FBO:

      Map pinned 22:49:39Z data point at FBO:

    2. N2085Q was operating locally out of A09 on July 16, 18 & 22. Started a long trip from A09 on July 24, returning to A09 August 15. There is favorable 100LL pricing at KHII, 23 miles from A09.

      July 18 must have been a super nice day for a local flight:

  9. Leaning only below 5,000ft DA?
    I learned to fly in Southern Arizona at about 2,600ft field elevation. DA depending on season and time of day significantly higher. The owner of the school and the instructors taught to ALWAYS lean engines in their 172s before taxing, during runup and climb/cruise and after landing again before taxing again. One can see, feel and hear the difference to full rich when doing it.
    All other CFIs I flew with for biannuals, some with tons of experience in all kinds of fixed and rotary turbine aircraft, ALL leaned the engines I flew.
    Same at an airport at sealevel in Southern France - the French instructor just leaned.

    Car engines and a few modern piston aircraft ones automatically use the best mixture, it's just that those old aircraft engines are from a different era.
    Several myths or old wives tales have been laid to rest, e.g. rich of peak vs. lean of peak has been around for while now together with good explanations and numbers of the various temperatures inside the engine - obviously best if separate measurements for each cylinder.
    But many engines are still just old and do not offer the possibility to really fine tune the combustion for each cycle, so a crude leaning has to be acceptable.

    In the end molecules, chemistry and physics are always the same and we have to understand how to tweak things but cannot cheat things...

    Blue skies and tailwinds.

  10. Seems unlikely that the pilot would be unskilled with the mixture control, looking at the 2013 registration date for his 177RG and a 2018 post about travel habits:

    "We can reach either coast in an 8-hour day and we make at least one trip of around 1500 miles one way each year. Two years ago we flew to the Bahamas in the spring and Catalina Island in the fall with stops at Sedona, Meteor Crater, Monument Valley, Lake Powell, and the Grand Canyon."

    The 2018 post:

    He also mentions in the post about starting with a 1956 172. Registration history indicates that he owned that bird from 2004 to 2013. It had a carbureted Conti 0-300.

  11. Replies
    1. No bathroom stop required coming from home base at A09, 23 miles away. Doesn't seem impossible to pull up to KHII Desert Skies self serve in the fuel loop and top in 10-11 minutes. Just a guess based on the mapped location coordinates....

    2. likely normal for credit card selfserve. I second all comments that leaning of simple nonturbo is normal in these circumstances and doubt a local pilot would forget that OR prop to high rpm. Very sad for his family's loss but also because this is the most and perhaps only gorgeous, lowslung, sports-car-looking Cessna ever built and I've been saving up to find one.

    3. "Don’t forget to sample some of the fuel you just pumped."
      last STEP 14 "Most importantly, take a walk around the entire airplane when you’re done. When you think you’re ready to start the engine and taxi away, pause for a moment and look at the airplane. Make sure the fuel caps are on, the hose is put away, and there are no objects on the ramp. Many pilots start rushing around during fueling, especially if it’s hot or there’s a line of airplanes. Resist the urge to do that and take one last look."
      September 2, 2019/by studentpltnews

      STEPS 1 - 14

    4. I am not going to get into what I have learned except to say there is some evidence of ongoing engine problems that likely were treated as an annoyance but could have developed into something really bad.
      One of the many issues I have with that piece of garbage design is that the gascolator is stuffed into a tiny little area near the nose wheel well. This almost guarantees a fire in even a minor impact.
      Worderful to hear from so many people who know more about Lycomings than the Lycoming Factory.

    5. I don't believe that I can fuel my single tank airplane that does not require a ladder in under 15 minutes!!!!!
      Two tanks, position the ladder, move the ladder, put the ladder away-NO WAY

    6. Regarding the comment "except to say there is some evidence of ongoing engine problems" seen a couple of posts before this one:

      Was that a reference to Lycoming "morning sickness" that the pilot experienced and posted about in a forum on 27 March 2021?

      "I fired up but had a case of morning sickness. It cleared but didn’t want to take the chance of it trapping me away from home, or worse, sticking while in flight.

      I’m grounded until I get a chance to ream some exhaust valves."

      His post demonstrates that he was knowledgeable about the valve sticking from deposits issue and was not one to attribute the clearing up to "dirty plugs" or to perform a takeoff after experiencing valve sticking.

      Reaming to remove deposits and resolve sticking is an approved procedure in Lycoming Service instruction 1425. Grounding the aircraft to perform 1425 is not treating the sticking as an annoyance.

    7. For at least a few of us a ladder is not required to refuel a Cardinal RG. I can walk up and fuel it directly, although I am 6'4". It goes pretty quickly... remember he was topping off for a flight to follow. He only pumped 24.8 gallons. Still, that was a quick turn.

  12. The full Cessna owner magazine article content on N2085Q is at:

    And more of the raw photo shoot images, quite inspiring:

  13. Absolutely, you couldn't top off a low winger that fast much less a Cessna unless someone had the pump running when you pulled up and started fueling for you. RIP Gary :-(

  14. Summer 3pm in the afternoon here in Havasu City is terrible time to take off almost 110F air cooled engines don't like that kind of heat. I think I would have landed head for a nice dinner at a hotel get back in the air at 5am.

    1. The pilot had taken off from his home base A09's 4,800 foot long runway under similar conditions about a half hour prior to the accident.

    2. Regarding A09, because of the AG operation and associated equipment on or near the end of runway 18, takeoffs are typically done from the displaced threshold of runway 18 which leaves 4200' useable. The accident airplane had been hangared at A09 since at least July, before the long flight.
      Looking at the ADSB info it seems likely that information did not have the altitude exactly correct. That makes it likely the airplane never reached 1000' MSL on takeoff.

  15. Regarding the ADSB info altitude was showing 1000' and 18kts ground speed just before exiting runway on landing. Maximum altitude on takeoff was 1000'with four displays starting with approximately 1/3 of runway remaining. Ground speed 65/65/56 and 54. Airplane turned to a track of 175 prior to end of runway. So the airplane may have only climbed a few feet and with less than 5 knots wind the last ground speed was right at stall.

    1. The aircraft could have climbed to almost 100' AGL and still returned that steady 1000' MSL number in ADS-B, as explained below:

      Interpreting the observed lack of increase from the ADS-B transmitted 1000' MSL "on runway" during takeoff has to consider rounding up/down to the nearest 100 foot increment as seen in the Adsbexchange final approach data that stepped down in 100 foot increments during N2085Q's arrival.

      The landing included a 900' data point on runway at 45:41 (zoom in using track link below) that is in between two 1000' data points recorded for 45:40 and 45:51. A value of 949' would round down to 900', while a value of 951' would round up to 1000'. That 900' data point at 45:41 tells us that all of the on runway data points of 1000' are rounded up.

      Similarly, a value between 951 and 1,049 will report as 1000', but a value of 1,051 will move the reported altitude to 1,100'. Whatever gain in altitude occurred during takeoff is hidden by the rounding and the 100 foot change increment. Could have been a few feet or almost 100 feet.

      Zoom this view to see 45:41 data point:

      While commenting on the 1000' reading, it is important to address the reason that 1000' was reported in ADS-B data while on runway at KHII when the field elevation is 783'.

      ADS-B altitude data reported "on runway" always reveals the offset caused from pressure altitude encoders being referenced to 29.92 by design, uncorrected for local altimeter setting.

      The ADS-B data showed 1000 feet while on runway instead of KHII's 783 foot field elevation primarily due to that built-in lack of correction to local altimeter.

  16. The final report will probably include electron microscope imaging of the fracture surfaces at the break in cylinder #4's top ring. The multi-fragmented cylinder #1 top ring had to have been run that way for a period of time.

    A fracture surface examination of the cylinder #4 ring that doesn't find significant re-contacting wear at the break would be consistent with that ring's failure occurring during the accident takeoff.

    The pilot made a POA forum post on 27 March 2021 about "morning sickness". It is possible that he misinterpreted the engine's accident day behavior as a repeat of that condition and continued the takeoff run too far while expecting it to clear up.

    The turn back stall ending is another sad reminder how difficult it is to commit to putting the bird down straight ahead, resisting the turn back attempt.

    1. One of the protocols from the many articles on turn back is to self brief EVERY takeoff. Below x altitude I will not turn. At y altitude I will turn no more than 90 degrees. At z altitude or above I will attempt a turnback, however at any point if things are not going well level the wings and DON'T STALL.

    2. That valve train had been tearing itself apart for a long time. Improper lubrication of cam when installed, long periods of inactivity etc. are all possibilities. Setting the oil pressure near the top of the green arc is alleged to do wonders for valve train lubrication. Also for Lycoming extended periods of low power on ground should be at a minimum of 1100 r/m for proper splash lubrication.