This text was copied out of the NTSB report with no editing. It was done to capture the text as it existed on 8-8-2005. It is possible that this text and links will change (or disappear) on the NTSB.gov site, but it will remain the same here --- Lee Devlin
NTSB Identification: LAX98FA008 .
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14 CFR Part 91: General Aviation
Accident occurred Sunday, October 12, 1997 in PACIFIC GROVE, CA
Probable Cause Approval Date: 1/26/1999
Aircraft: ADRIAN DAVIS LONG-EZ, registration: N555JD
Injuries: 1 Fatal.
The pilot had recently purchased the experimental, amateur-built Long-EZ airplane, which had a fuel system that differed from the designer's plans. The original builder had modified the fuel system by relocating the fuel selector handle from a position between the front pilot's legs to a position behind & above his (or her) left shoulder. There were no markings for the operating positions of the fuel selector handle, which were up (for off), down (for the right tank), and to the right (for the left tank). This deviation from the original design plans did not require FAA approval, nor did it require a placard to indicate such change from the original design. On 10/11/97 at Santa Maria, CA, the pilot received a 1/2-hour flight and ground checkout in the airplane by another Long-EZ pilot. The checkout pilot reported that the pilot needed a seatback cushion to be in position to reach the rudder pedals, and that he had difficulty reaching the fuel selector handle while seated with the cushion added. The pilot then departed on a 1-hour flight to his home base at Monterey with an estimated 12.5 gallons of fuel in the right tank & 6.5 gallons in the left tank. The checkout pilot estimated about 9 gallons of fuel were needed for the flight, and he noted the fuel selector was positioned to the right tank before departure. On 10/12/97 (the next day), a maintenance technician assisted the pilot in preparing for another flight. During preflight, the pilot was not observed to visually check the fuel. The technician noted that when the pilot was seated in the airplane, he had difficulty reaching the fuel selector handle. Also, he gave the pilot a mirror to look over his shoulder to see the unmarked, non-linear, fuel sight gauges, which were located in the rear cockpit. The technician estimated the available fuel and advised the pilot that the left tank indicated less than 1/4 full and that the right tank indicated less than 1/2 full. He said his estimate was based on the assumption that the gauges were accurate and linear. The pilot declined an offer for additional fuel, saying he would only be airborne about 1 hour and did not need fuel. The technician observed that before the engine was started, the fuel selector handle was in a vertical position; however, he did not note whether it was up (off) or down (right tank). As the technician went to the hangar, he heard the engine start & run for a short time, then quit. He saw the pilot turn in the seat toward the fuel selector handle, then the pilot motioned with his hand that things were all right. The technician did not observe whether the pilot had repositioned the fuel selector. The pilot restarted the engine, taxied, took off, and performed three touch-and-go landings in a span of about 26 minutes, followed by a straight-out departure to the west. Ground witnesses saw the airplane in straight and level flight about 350 to 500 feet over a residential area, then they heard a reduction of engine noise. The airplane was seen to pitch slightly nose up; then it banked sharply to the right & descended nose first into the ocean. The major structural components of the airframe were found fragmented on the ocean floor near the engine, but no preimpact part failure was found. The fuel selector valve was found in an intermediate position, about 1/3 open between the engine feed line and the right tank, and about 2-4% open to the left tank. Tests using another engine showed that the engine could be operated at full power with the selector in the as-found position; however, when the cap was removed from the left port (simulating the effect of an empty left tank), fuel pressure dropped to less than 1/2; & within a few seconds, the engine lost power. Conditions were simulated using another Long-EZ to evaluate the maneuver required to switch tanks from the front seat. The simulation revealed that 4 actions were required to change the fuel selector in flight: 1) Remove pilot's hand from the control stick; 2) Loosen shoulder harness; 3) Rotate upper body to the extreme left to reach the fuel selector handle; & 4) Rotate the handle to a non-marked (not logically oriented) position. During the evaluation, investigators noted a natural reaction for the pilot's right foot to depress the right rudder pedal when turning in the seat to reach the fuel selector handle. With the right rudder depressed in flight, the airplane would pitch up slightly & bank to the right.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
the pilot's diversion of attention from the operation of the airplane and his inadvertent application of right rudder that resulted in the loss of airplane control while attempting to manipulate the fuel selector handle. Also, the Board determined that the pilot's inadequate preflight planning and preparation, specifically his failure to refuel the airplane, was causal. The Board determined that the builder's decision to locate the unmarked fuel selector handle in a hard-to-access position, unmarked fuel quantity sight gauges, inadequate transition training by the pilot, and his lack of total experience in this type of airplane were factors in the accident.
Index for Oct1997 | Index of months
LAX98FA008
HISTORY OF FLIGHT
On October 12, 1997, shortly after 1728 Pacific daylight time, an experimental
Adrian Davis Long EZ, N555JD, crashed into the Pacific Ocean near Pacific Grove,
California. The airplane was destroyed and the pilot, the sole occupant,
received fatal injuries. The accident occurred during a local, personal flight,
visual meteorological conditions and no flight plan was filed.
An aircraft maintenance technician who assisted the pilot in removing the
airplane from a hangar before the accident flight stated that he observed the
pilot perform a preflight check that took about 20 minutes. He stated that the
pilot borrowed a fuel sump cup and drained a fuel sample to check for
contaminants. He did not observe whether the pilot visually verified the
quantity of fuel aboard the airplane. He did not see the pilot check the engine
oil level.
The technician stated that he and the pilot talked about the inaccessibility of
the cockpit fuel selector valve handle and its resistance to being turned. The
handle was located behind the pilot's left shoulder. They attempted to extend
the reach of the handle, using a pair of vice grip pliers. But this did not
solve the problem as the pilot could not reach the handle. The pilot said he
would use the autopilot inflight, if necessary, to hold the airplane level while
he turned the fuel selector valve.
According to the maintenance technician, the pilot declined an offer of fuel
service. The pilot told him that he would only be flying for about 1 hour. The
pilot then got in the airplane and proceeded with his preflight duties,
including checking the operation of the control surfaces According to the
technician, he observed the fuel selector handle in a vertical position. (see
Aircraft Information section for a discussion of fuel selector handle ). The
technician said that he went into the hangar to put away his tools, and he heard
the engine start; however, it soon quit. He walked out of the hangar and
observed the pilot turned in his seat to the left, toward the fuel selector
location. The technician said he believes that the pilot changed the fuel
selector and restarted the engine.
A review of the Monterey Peninsula Airport Air Traffic Control Tower (ATCT)
tapes revealed that the pilot contacted ground control at 1702 and obtained a
taxi-for-takeoff clearance from the hangar. At 1709, the pilot contacted the
local controller, reported ready for takeoff on runway 28, and requested to stay
in the traffic pattern for some touch-and-go landings. He was subsequently
cleared for takeoff at 1712, and performed three touch-and-go landings before
departing the traffic pattern about 1727. At this time the controller asked the
pilot to recycle his transponder code, and the pilot did so. The ATC tapes
revealed no recorded distress calls from the pilot, and the pilot did not
indicate any aircraft or engine malfunctions.
A certified audio cassette re-recording of the transmissions between the
accident airplane and the Monterey ATCT local control position was sent to the
Safety Board's audio laboratory for analysis. The radio transmissions were
examined on an audio spectrum analyzer in an attempt to identify any background
sound signatures that could be associated with either the engine or the
propeller. Analysis of nine transmissions between 1714 and 1728:06 showed engine
speed harmonics between 2,100 and 2,200 revolutions per minute (rpm). At the
last radio transmission attributed by the Federal Aviation Administration (FAA)
to the accident aircraft (at 1728:06), the measured frequency was to 2,200 rpm.
A copy of the laboratory report is attached.
Twenty witnesses to the accident were interviewed. Some of the witnesses
observed the airplane descend into the ocean near Point Pinos approximately 150
yards off shore, where the water is 30 feet deep. Depending on where they were
when the crash occurred; four of the witnesses indicated that the airplane was
originally heading west; five of them observed the airplane in a steep bank,
with four of those five reporting the bank was to the right (north). Twelve
witnesses saw the airplane in a steep nose-down descent, and 6 of them saw the
airplane hit the water. Witnesses estimated the airplane at 350 to 500 feet over
the residential area while heading toward the shoreline. Eight of the witnesses
said that they heard a "pop" or "backfire," along with a reduction in the engine
noise level just before the airplane descended into the water.
PILOT INFORMATION
The pilot's logbook was not recovered. During the investigation, the pilot's FAA
airman and medical records were obtained from the Airman and Medical Records
Certification Branch, FAA, in Oklahoma City, Oklahoma. On his most recent
medical application of record, dated June 13, 1996, he reported a total flight
time of 2,750 hours. He held a private pilot certificate, with airplane ratings
for single and multiengine land, single-engine sea and gliders. He also held an
instrument airplane rating and a Lear Jet type rating.
Another Long EZ pilot (hereinafter referred to as the "checkout" pilot), gave
the pilot about 1/2 hour of ground and flight checkout in the accident airplane
in Santa Maria, California on the day before the accident, before the pilot's
departure for Monterey. He said that they performed two touch-and-go landings
and some slow flight maneuvers, and that they discussed the aircraft systems,
including the fuel selector location. He said that he had made arrangements with
the pilot to relocate the fuel selector handle while the pilot, a musical
performer, was away on tour. He also said that a pillow was placed on the back
of the pilot's seat to assist him in reaching the rudder pedals.
The checkout pilot stated that about a month before the accident, he had flown
in the front seat with the pilot on a demonstration flight in the accident
airplane. He said the pilot had also flown in the backseat on two other Long EZ
demonstration flights.
A certified true copy of the pilot's FAA medical record files were obtained and
reviewed by Safety Board investigators. According to the pilot's FAA medical
records, the physician who examined the pilot on June 13, 1996, issued a
third-class medical certificate to the pilot at the conclusion of the
examination. His FAA medical records further showed that on November 6, 1996,
the FAA Civil Aeromedical Certification Division sent the pilot a letter by
certified mail, return receipt requested, acknowledging receipt of his June 13,
1996, medical application and stating, in part:
We had previously received an interim report from H. C. Whitcomb, Jr., M.D.,
pertinent to your alcohol problem. Dr. Whitcomb reported that "in general
averages two to four drinks of either wine or beer/week when he's traveling." He
further stated that there has been no abuse, (see footnote 1) ...in our letter
of October 18, 1995, we specified that your "continued airman medical
certification remains contingent upon your total abstinence for use of alcohol."
The letter informs the pilot that based on the above information, he did not
meet the medical standards prescribed in Part 67 of the Federal Aviation
Regulations, and a determination was made that he was not qualified for any
class of medical certificate at that time. The letter further states: "If you do
not wish to voluntarily return your certificate, your file may be sent to our
regional office for appropriate action." According to U. S. Postal Service
markings on the envelope, the letter was returned unclaimed to the FAA on
December 2, 1996.
Examination of the FAA medical file disclosed that following the return of the
unclaimed November 6, 1996, letter there was no followup action by the FAA until
March 25, 1997, when the agency sent the pilot a second letter by certified
mail, return request requested, again notifying him that he was medically
disqualified. The return receipt for the certified letter was examined by Safety
Board investigators; however, the signature of the person who had signed for the
mail was illegible.
AIRCRAFT INFORMATION
The accident airplane was an experimental amateur built canard (1) type
aircraft. The data plate indicated a manufacture date of June 1987. The airplane
was designed by Rutan Aircraft Factory and was built from the Rutan plans by
Adrian D. Davis, Jr. Review of FAA Aircraft Registry records for the airplane
revealed that the original builder applied for an airworthiness certificate in
the amateur-built, experimental category on May 5, 1987. The airworthiness
certificate was issued by an FAA Airworthiness Inspector from the Houston,
Texas, Flight Standards District Office on June 12, 1987. On the application,
the inspector checked the box stating "I have found the aircraft described meets
the requirements for the certificate requested." A letter of operating
limitations was also issued on that date and included the statement: "This
aircraft shall contain the placards, listings and instrument markings required
by FAR 91.3 (Subsequently redesignated 14 CFR 91.9).
The airplane was equipped with an electric force bias trim system for both the
pitch and roll axis, and an electrically actuated speed brake that deploys from
the fuselage belly. The switches for the electric trim and the speed brake were
located on the side stick controller. The airplane was equipped with a single
axis roll autopilot, but the autopilot was not recovered.
According to the checkout pilot, and confirmed by the seller, the canard had the
Ronz No. 1145ms airfoil.
According to the operator's manual, the Long EZ was designed either for a rear
mounted Continental O-200 (100 horsepower (hp)) or a Lycoming O-235 (115 hp)
engine. The engine installed on the accident airplane was a Lycoming O-320-E3D,
producing 150 hp and consumes 8.5 to 10 gallons of fuel per hour depending on
the power setting. This engine installation also required the installation of 50
pounds of ballast in the nose. An electrical starter was also installed on the
engine.
The airplane's designer provided a written statement to the Safety Board in
response to an inquiry regarding the compatibility of the airframe with the
Lycoming O-320 engine. He stated that "the only engines approved by the factory
for installation" are the Continental models O-200 or O-240, or the Lycoming
O-235. The designer reported that he is aware that some Long EZ's have been
modified with engines of up to 200 horsepower and operate at weights 50 percent
above the prototype limit, and that "this level of experience with growth
versions does indicate that there are substantial margins in the design.
According to the pilot who sold the airplane to the accident pilot and the
checkout pilot, disclosed that no ballast was installed in the nose. However,
two batteries, totaling 40.8 pounds, were relocated in the nose section, one
directly in front of the foremost bulkhead and the other just behind it.
FAA records indicate that the seller who sold the airplane to the accident pilot
purchased the airplane from the builder on March 5, 1994. On April 13, 1996, the
seller changed the registration number from N5LE to N228VS. According to the
seller, the airplane was sold to the accident pilot on September 27, 1997. The
airplane was then (by the checkout pilot) flown from Santa Ynez to Santa Maria,
California, to be repainted in connection with the sale to the pilot. During the
repainting of the aircraft, the registration number of was changed by the pilot
to N555JD.
At Santa Maria, the airplane was sanded, primed, and painted. Telephone
interviews with personnel at the paint shop revealed that the old paint was not
stripped off. No control surfaces were removed at any time. The only items
removed during the painting were the two wing-mounted cargo pods, which were
painted in a multicolored scheme and reinstalled. As applied, the paint weighed
about 4 pounds per 100 square foot, according to paint shop personnel.
During the investigation, copies of a empty airplane weight and balance
document, dated May 18, 1996, were located at Craftsmans Corner, Santa Paula,
California. It listed an airplane empty weight of 1,061 pounds and center of
gravity (CG) at 110.0 inches. In an interview, the manager of Scaled Composites,
Inc., (Rutan Aircraft) estimated that, based on the total wetted area of the
airplane, the paint applied at Santa Maria would have added 30 pounds to the
empty weight for a total of 1,091 pounds with a CG at 110.0 inches.
Based the weight and balance document and estimates of the airplane's probable
fuel load at the accident flight's departure from Monterey, gross weight and CG
conditions were calculated and are appended to this report. Those calculations
show that at the beginning of the accident flight, the airplane would have had a
gross weight of approximately 1,310 pounds, with a CG at 103.65 inches. At the
time of the accident, the airplane would have had a gross weight of
approximately 1,280 pounds, with a CG at 103.63 inches. According to Scaled
Composites Inc., the design gross weight limit is 1,425 pounds and the CG range
is from the forward limit of 98 inches to the rear limit of 103 inches.
In a telephone interview on June 15, 1998, an engineering representative from
Scaled Composites, Inc., reported that the airplane was designed with a
published aft limit of 104 inches, and the prototype was extensively tested and
flown at this limit. Subsequently, in the interests of conservative margins, the
designer changed the published limit to 103 inches. According to the designer
during flight tests, the prototype was flown at 106 inches and flew all test
points satisfactorily, and no adverse handling characteristics were noted.
The representative from Scaled Composites, Inc., also reported that the company
flew the same profile as that believed to have been flown during the accident
flight (start, taxi, run-up, takeoff, three touch-and-goes, and a pattern
departure) in a Lycoming O-320-equipped Long-EZ and measured the fuel consumed
at 3.6 gallons. After running one tank dry, a time interval of 6 to 8 seconds
was measured between changing the fuel selector and the resuming of engine
power. The representative stated that although the fuel tanks of the airplane
were extensively damaged, during the wreckage reconstruction he observed that
the fuel tanks were built to plan specifications. The representative of Scaled
Composites, Inc. said the system does not appear to have an unusable quantity.
Two sumps, each having about a quart capacity, are located in the tanks. The
tank is designed so that the fuel will feed into the sumps in all flight
attitudes. The representative said the only known condition that would tend to
favor an unporting is in a prolonged descent with just a few gallons of fuel in
the tank.
According to the designer of the airplane and the drawings issued to the
builder, the fuel selector is to be located just aft of the nose wheel position
window between the pilot's legs. The accident airplane's fuel selector handle
was positioned by the builder on the bulkhead behind the pilot's left shoulder.
The selector valve was installed inside the engine firewall 45 inches aft of the
selector handle. The handle and valve were joined by steel and aluminum tubing,
connected by a universal joint.
According to the designer and the seller, this type of airplane has two
26-gallon fuel tanks in the wing roots that contain usable fuel. The fuel
quantity is determined by viewing non-linear sight leave gauges located in the
rear cockpit at the wing roots. The sight gauges show an amount of actual fuel
supporting a red float. Postaccident examination of the airplane disclosed that
the sight gauges were not marked or calibrated for quantity.
The maintenance technician who helped the pilot move the airplane out of the
hangar before the accident flight mentioned that the fuel sight gauges were only
visible to the rear cockpit occupant. The pilot then asked the technician about
the quantity of fuel shown. The technician told the pilot that he had "less than
half in the right tank and less than a quarter in the left tank." The technician
said that he estimated the fuel quantity based on the assumption that the gauge
presentation was linear. The technician provided a shop inspection mirror to the
pilot so that he could look over his shoulder at the fuel sight gauges. The
mirror was recovered in the wreckage.
According to other pilots who were familiar with the airplane and/or had flown
it, to change the fuel selector a pilot had to: 1) Remove his hand from the
right side control stick if he was hand flying the aircraft; 2) Release the
shoulder harness; 3) Turn his upper body 90 degrees to the left to reach the
handle; and 4) Turn the handle to another position. Two pilots shared their
experiences of having inadvertently run a fuel tank dry with nearly catastrophic
consequences because of the selector and sight gauge locations.
The fuel selector handle location was discussed with the seller and other pilots
who had flown the accident airplane. The seller reported that he had asked the
builder why he had located it behind the pilot's left shoulder. The builder
responded that he did not want fuel in the cockpit area. The seller said that
when he changed tanks inflight he would engage the autopilot, allowing his right
hand to reach behind his left shoulder to the selector handle. The seller said
that at the time of the accident, the handle was "firm to turn with good
detents." He also said that the checkout pilot had removed the selector valve
for cleaning and lubricating some time ago. The checkout pilot said that the
seller attempted to work on the valve in early 1996, but that he (the checkout
pilot) ended up finishing the repair in April 1996. He also said that he had
removed the two rivets that were drilled through the brass valve shaft and the
he had replaced one of the two torque tubes.
The checkout pilot was asked about the selector. He said that he had simulated
changing tanks using the selector on one occasion on the ground and that he was
not pleased with the location. Because of the difficulties of using the
selector, he said that he had never used the selector in flight.
Postaccident wreckage examination by Safety Board investigators revealed that
the selector handle was not placarded or marked for any operating position.
According to the checkout pilot, the handle in the right position was for the
left tank, the handle in the down position was for the right tank, and the off
position was up.
When investigators attempted to switch fuel tanks in a similar Long EZ, each
time while an investigator turned his body the 90 degrees required to reach the
valve, his natural tendency was to extend his right foot against the right
rudder pedal to support his body as he turned in the seat.
Concerning the yaw flight controls, the representative from Scaled Composite,
Inc. reported that the rudders move and serve as vertical spoilers. Pressing on
the right rudder peddle moves only the right rudder in an outboard direction,
which produces increased drag and a subsequent yawing moment. He stated that the
rudders are very effective because of the long moment arm. With a center of
effort (increased drag) above the longitudinal CG, activation of a rudder will
produce a pitch-up moment along with the yaw. The airplane also has a very
strong spiral mode. He also reported that the lateral roll control with the side
stick controller is very sensitive and that a 1/8 inch movement will cause a
roll initiation.
The airplane's logbooks were not recovered. According to the seller of the
airplane, the airframe and engine had accumulated about 850 total flight hours.
He reported that the last FAA-required, 12-month condition inspection had taken
place on September 20, 1997.
The checkout pilot who flew the airplane from Santa Ynez to Santa Maria for
repainting estimated that before his departure 5 gallons of fuel was on board
with 2 gallons on one side and 3 gallons in the other. He stated that he added
10 gallons of fuel to each tank. The checkout pilot said that he did not update
the Fuelwatch (2) fuel monitoring instrument after refueling because he was not
familiar with the procedure. The flight to Santa Maria lasted 10 minutes it is
estimated to have consumed 2 gallons of fuel. During the pilot's 30-minute
checkout at Santa Maria, the checkout pilot estimated that 4 gallons of fuel
were consumed.
The checkout pilot stated that the pilot flew the airplane from Santa Maria to
Monterey, and that he had departed with about 19 gallons of fuel onboard. There
were 12.5 gallons of fuel in the right tank and 6.5 gallons in the left tank. He
noted that the selector was located on the right tank before to the pilot's
departure from Santa Maria.
The Safety Board and the parties to the investigation estimated that the amount
of fuel required to fly to Monterey from Santa Maria ranged from 6.4 to 9.1
gallons, depending on the power settings used. Estimates for fuel used during
the checkout flight at Santa Maria ranged from 2.5 to 3.6 gallons. The accident
flight was estimated to have consumed 3.0 to 4.3 gallons, for a combined total
consumption of 11.9 to 17.0 gallons of fuel. Fuel records disclosed that the
airplane was not refueled at Monterey Airport.
WRECKAGE AND IMPACT INFORMATION
The wreckage was located the Pacific Ocean in 30-foot water within about 150
yards of the rocky shoreline near Pacific Grove, California. An underwater video
taken by a diver from the National Oceanic and Atmospheric Administration,
Monterey Bay National Marine Sanctuary, revealed broken rock structures where
the airplane wreckage was located on the ocean floor. The broken sections of
rock were free of normal underwater growth.
The recovery was made by members of the Pacific Grove Ocean Rescue Team and
members of the Sheriff's Dive Team. All major structural components of the
airframe were found in a fragmented state on the ocean floor near the engine.
Most of the control system rods and rod ends were recovered. The landing gear
assembly was separated from the fuselage, and the right wheel and brake were
separated from the gear leg. The nose gear was found in the retracted position.
The engine was found separated from the airframe structure but remained attached
to its mounts. The mounts were crushed in a forward direction. Two induction
tubes were found broken from the engine. The wooden composite-covered propeller
hub was still attached to the engine crankshaft flange. Both propeller blades
were severed about 18 inches outboard of the hub center. Fragmented composite
propeller blade coverings and blade wood were recovered near the engine.
Subsequent layout disclosed that the fragments comprised the leading edges of
both blades.
The engine was examined externally and internally. Gear and valve train
continuity was established by rotation. Cylinder compression was established.
All cylinders were removed and examined. The accessory housing was removed for
examination of the oil pump gears and crankshaft gear. The carburetor was
removed and opened for a visual examination. Fuel and water were found in the
carburetor bowl. The magnetos had been replaced with an electronic ignition
system. There were no discrepancies found during these examinations.
During the investigation, the wreckage was laid out with the recovered
components placed in their normal positions. All aircraft extremities were
accounted for in the examination. All recovered control system push-pull tubes
and associated bell cranks were examined, with overload signatures evident and
no unusual operating condition noted. No battering or over-travel signatures
were observed to any control limit stop.
MEDICAL AND PATHOLOGICAL INFORMATION
On October 13, 1997, the Monterey County Medical Examiner performed an autopsy
on the pilot. According to the report, the cause of death was multiple blunt
force trauma. During the examination, samples were obtained for toxicological
analysis by the FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma.
Tests were negative for all screened drugs and Ethanol.
TESTS AND RESEARCH INFORMATION
The fuel selector, linkage, universal joint, handle, and handle bearing block
were recovered. The brass selector stem/shaft was found fractured between two
opposing drilled rivet holes that attach the hollow portion of the shaft to the
torque tube/handle linkage. The Safety Board's Materials Laboratory examined the
stem/shaft fracture. Although the stem/shaft was severely weakened by the rivet
addition, there was no evidence of pre-impact failure on the stem. A copy of the
laboratory report is attached.
The brass 3-port Imperial fuel selector valve assembly was examined and found in
an intermediate position, which was one-half open between the engine feed line
and the right tank fuel supply line. The port to the left tank was also observed
to be open about 2 to 4 percent to the engine feed line. The valve was found
frozen in place and could not be moved. The fuel valve was plumbed into an
engine test cell, with the fuel supply connected to the valve's right tank fuel
port. At that point, the left tank port was open to the atmosphere and was
subsequently capped. An exemplar Lycoming O-320 engine was installed in the test
cell, started and run to maximum power. The one-half-open right port position
had negligible effect on the engine power output; however, when the cap was
removed from the left port (simulating the effect of an empty left tank) the
fuel pressure dropped to less than one-half, and within a few seconds the engine
quit because of the fuel/air mixture resulted in a vapor state.
The steel and aluminum rods connecting the handle to the fuel selector valve
were found bent. The rods were straightened to determine the handle position
relative to the valve position. Extensive metallurgical and installation
examinations were performed at the Safety Board Materials Laboratory and with
exemplar aircraft in the field. Copies of the laboratory reports are attached.
The Safety Board examined the recovered wreckage for evidence of a possible bird
strike. There were no leading edge canard or wing sections intact. The canopy
was destroyed, and only fragments of the Plexiglas were recovered. Bird feathers
were found commingled in the recovered wreckage. The curator of the local Museum
of Natural History was asked to view the feathers during the wreckage
examination. A seat cushion determined to be from the accident airplane was
found torn open. According to the cushion material tag, it was filled with goose
feathers; however, the curator also found duck feathers in the cushion. The
cushion feathers matched the ones found commingled with the wreckage.
ADDITIONAL INFORMATION
The wreckage was released to the insurance adjuster representing the pilot on
June 10, 1998. When it was last viewed by investigators the wreckage was located
at Monterey, California.
1 A type of airplane in which the pitch controls that are normally mounted on
the empennage of the airplane are mounted ahead of the main lifting plane. An
airplane on which the pitch controls are mounted forward of the wing rather than
behind the wing.
2 A fuel management system that provides a fuel burn rate and fuel remaining.
FOOTNOTE 1:
1 The letter from Dr. Whitcomn dated March 22, 1996, was also in the pilot's
medical file it stated: "In general, he has done remarkably well. For the last
three weeks, he has been on a fast and has had absolutely no alcohol, but in
general averages two to four drinks of either wine or beer/week when he's
traveling. There has been no abuse. The patient seems very happy and balanced at
this stage of his life."
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