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ACCID/091210/03-12

MINISTRY OF WORKS AND TRANSPORT

DIRECTORATE OF AIRCRAFT ACCIDENT INVESTIGATION ACCIDENT REPORT – EXECUTIVE SUMMARY

Aircraft Registration ZU-FCY Date of Accident 12 September 2010 Time of

Accident 0724Z

Type of Aircraft LANCAIR LEGACY 2000 Type of Operation Private

Pilot- In - Command Licence Type Private Age 60 Licence Valid Yes Pilot- In - Command Flying Experience

Total Flying Hours 1 400.0 Hours on Type 60.0

Last point of departure Omaruru Aerodrome, Namibia Next point of intended landing Eros Aerodrome, Namibia (FYWE)

Location of the accident site with reference to eas ily defined geographical points (GPS readings if possible)

Open field 19 nm West of the town of Okahandja (GPS position; South 22º 00’96 East 016º 34’45) Meteorological Information Surface wind; Easterly/12 knots, Visibility: >10km Number of people on board 1 + 1 No. of people injured 0 No. of people killed 0

Synopsis

On 12 September 2010, a pilot, accompanied by a passenger departed from Omaruru aerodrome on a private visual flight rules (VFR) flight in a Lancair Legacy 2000 aircraft with the registration ZU-FCY. There intended destination being Eros aerodrome, near Windhoek where they have planned to land and uplift fuel in order to continue with their journey back to South Africa. The pilot stated, while approximately 11 minutes from landing at Eros aerodrome he experienced a sudden loss of engine power. He attempted to restart the engine, but was unsuccessful in doing so. He then made the decision to execute a forced landing on a dirt road he had identified from the air as a suitable area. He executed a right turn in order to line up with the road but as the aircraft descent he observed power lines ahead of him, which require immediate evasive action and he executed a left turn in order to avoid colliding with the wires. He then realigned the aircraft with the road and aimed to touchdown after the cattle gate. At approximately 50 feet above ground level (AGL) he selected the landing gear down as well as full flaps. He was unable to reach the road and using all the elevator control available he mush the aircraft into the bush type of terrain. During the forced landing the landing gear broke off with the aircraft came to rest in an upright position approximately 50 meters from the first point of touchdown. Nobody was injured in the accident but the aircraft was substantially damage. The pilot was a holder of a valid private pilot license. His aviation medical certificate was valid without any restrictions. The last Annual Inspection that was certified on the aircraft prior to the accident was carried out on 30 September 2009 at 28.8 airframe hours. The aircraft had flown a further 36.1 hours since the last inspection was certified.

Probable Cause

Unsuccessful forced landing following an engine malfunction in-flight.

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AIRCRAFT ACCIDENT REPORT

Name of Owner/Operator : J.M. Onderstall

Manufacturer : Lancair International

Model : Lancair Legacy 2000

Nationality : South African

Registration Mark : ZU-FCY

Place : 19 nm West of Okahandja

Date : 12 September 2010000T0055553 March 2008

Time :

All times given in this report are Co-ordinated Universal Time (UTC).

Disclaimer:

The report is given without prejudice to the rights of the Directorate of Aircraft Accident

Investigations, which are reserved.

Purpose of the Investigation:

In terms of ICAO Annex 13, this report was compiled in the interest of the promotion of

aviation safety and the reduction of risk of aviation accident or incidents and not to establish

legal liability.

This report contains fact relating to aircraft accidents or incidents which have been

determined at the time of issue. The report may therefore be revised should new and

substantive facts be made available to the investigator(s).

1. FACTUAL INFORMATION

1.1 History of Flight:

1.1.1 On 12 September 2010, a pilot, accompanied by a passenger departed from Omaruru

aerodrome on a private visual flight rules (VFR) flight in a Lancair Legacy 2000 aircraft

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with the registration ZU-FCY. There intended destination being Eros aerodrome, near

Windhoek where they have planned to land and uplift fuel in order to continue with

their journey back to South Africa.

1.1.2 The pilot stated while flying at flight level (FL) 55, approximately 11 minutes from

landing at Eros aerodrome the engine experienced a sudden loss of engine power.

He attempted an engine restart, by selecting the fuel pump on high and then to the low

but was unsuccessful in getting the engine to restart. He then made the decision to

execute a forced landing on a dirt road he had identified from the air as a suitable

area.

1.1.3 He executed a right turn in order to line up with the road but as the aircraft descent he

observed power lines ahead of him, which require immediate evasive action and he

executed a left turn in order to avoid colliding with the wires. He again realigned the

aircraft with the road and aimed to touchdown past the cattle gate. At approximately

50 feet above ground level (AGL) he selected the landing gear down as well as full

flaps. He was unable to reach the road and using all the elevator control available he

mush the aircraft into bush type of terrain. During the forced landing the landing gear

broke off and the aircraft came to rest in an upright position approximately 50 meters

from the first point of touchdown. Nobody was injured in the accident but the aircraft

was substantially damage.

1.1.4 Prior to touchdown the pilot transmitted a Mayday call on the Eros tower frequency

118.7 MHz, indicating his position at the time.

1.1.5 According to available records there was still ample fuel onboard the aircraft at the

time of the accident. Available records indicated that 112 litres of Avgas was uplifted

at Eros aerodrome on 10 September 2010, when the aircraft was refuelled en route to

Omaruru aerodrome.

1.1.6 The accident occurred during daylight conditions at a geographical position that was

determined to be South 22º 00’96 East 016º 34’45 at an elevation of 4 362 feet above

mean sea level (AMSL).

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1.2 Injuries to Persons:

Injuries Pilot Crew Pass. Other

Fatal - - - -

Serious - - - -

Minor - - - -

None 1 - 1 -

1.3 Damage to Aircraft:

1.3.1 The aircraft, which consisted of a composite airframe structure, was substantially

damage during the impact sequence.

Figure 1. A view of the aircraft as it came to rest next to the dirt road.

1.4 Other Damage:

1.4.1 Minor damage was caused to the vegetation in the immediate surroundings.

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1.5 Personnel Information:

Nationality South Africa

Licence No 0270235997 Gender Male Age 60

Licence valid Yes Type Endorsed Yes

Ratings Night Rating, Test Pilot Rating Class 2

Medical Expiry Date 31 October 2010

Restrictions To have reading spectacles in the aircraft.

Previous Accidents None

Flying Experience:

Total Hours 1 400.00

Total Past 90 Days 25.00

Total on Type Past 90 Days 16.42

Total on Type 60.00

1.6 Aircraft Information:

Airframe:

Type Lancair Legacy 2000

Serial No. L2K-305

Manufacture Lancair International

Year of Manufacture 2009

Total Airframe Hours (At time of Accident) 64.90

Last Annual Inspection (Hours & Date) 28.08 30 September 2009

Hours since Last Annual Inspection 36.82

Authority to Fly (Issue Date) 20 October 2009

C of R (Issue Date) Present owner 25 February 2009

Operating Categories Normal

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Engine:

Type Teledyne Continental IO-550N

Serial No. 820561-R

Hours since New 64:00

Hours since Overhaul T.B.O. not yet reached

Propeller:

Type Hartzell HC-J3YF-1RF/F 73910-3

Serial No. JN111B

Hours since New 64:00

Hours since Overhaul T.B.O. not yet reached

1.7 Meteorological Information:

1.7.1 The following weather information was obtained from the pilot’s questionnaire.

Wind direction Easterly Wind speed ± 12 kt Visibility Good

Temperature unknown Cloud cover None Cloud base None

Dew point unknown

1.8 Aids to Navigation:

1.8.1 The aircraft was equipped with standard navigation equipment, which was serviceable

at the time of accident.

1.9 Communications:

1.9.1 The pilot broadcast a Mayday call on the Eros tower frequency 118.7 MHz.

1.9.2 There was no reported communication problem between the pilot and the air traffic

controller who handle the flight.

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1.10 Aerodrome Information:

1.10.1 The accident did not occur at or near an aerodrome.

1.10 Flight Recorders:

1.11.1 The aircraft was not equipped with a Flight Data Recorders (FDR) and Cockpit Voice

Recorders (CVR), nor was it required by the regulation to be fitted to this type of

aircraft.

1.12 Wreckage and Impact Information:

1.12.1 The aircraft came to rest in an upright position approximately 50 m past the first point

of touchdown. All three landing gear assemblies broke off after touchdown, with the

lower fuselage surface sustaining damage as the aircraft skidded on its belly before it

came to rest. All three propeller blades were bend backwards, with wing leading edge

damage being evident on the right wing, resulting in the fuel tank being ruptured with

fuel leaking from the tank. The left wing fuel tank remained intact and still contained a

substantial amount of fuel.

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Figure 2: Various photos of the accident terrain and damage sustained by the aircraft.

Figure 3 : Various photos indicating the damage to the right wing leading edge as well as the propeller.

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Figure 4: Fuel leaking from the right wing tank following impact damage.

1.13 Medical and Pathological Information:

1.13.1 Not applicable.

1.14 Fire:

1.14.1 There was no pre- or post-impact fire.

1.15 Survival Aspects:

1.15.1 The pilot and the passengers were properly secure by making use of the aircraft

equipped safety harness and did not sustain any injuries during the impact sequence

which was associated with low kinetic forces within the level of human tolerance.

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Figure 5 . A view of the cockpit which remained intact following the impact sequence.

1.16 Tests and Research:

1.16.1A substantial amount of fuel was still present in the aircraft during the on-site

investigation. Fuel samples were taken from both fuel tanks and the fuel were found to

be of the correct grade and free of contamination.

1.16.2 The aircraft wreckage was recovered from the accident site and transported to Eros

aerodrome for safe keeping and further investigation.

1.16.3 Engine Teardown Inspection:

The engine was removed from the wreckage and was taken to an approved engine

maintenance facility where a teardown inspection was performed. The purpose of the

investigation was to determine whether the engine failed due to a mechanical

malfunction. The following observations were made:

Engine Model Teledyne Continental IO-550N

Engine Serial No. 820561-R

Fuel flow divider

Part # 646433-3A2

Serial # C07FA136R

The diaphragm and filter assembly was undamaged.

The unit was opened during the teardown inspection and still

contained a substantial amount of fuel. The unit was

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checked for any dirty that might have been contained inside,

but were found to be clean. The filter screen inside the unit

was undamaged.

Fuel Control Unit

Part # 653353-3A2,

Serial # AO7FA134R

The unit was undamaged and all the linkages were still

attached. The throttle valve moved freely and was

undamaged. A small amount of fuel was still present in

the fuel line when the unit was removed.

Spark plugs

Champion RHM32E

The spark plugs, which were undamaged, were removed and

tested, and no anomalies were noted. They displayed a

greyish colour that was consistent with normal engine

operation.

HT Leads The High Tension Leads were found to be in an overall good

condition and undamaged.

Fuel Pump

Part # 655921-1A1,

Serial # 807FA161R

The unit was undamaged. It was bench tested in accordance

with the Continental Engine Continuous Flow Fuel Injection

System manual at 700 and 2700rpm. It met all the

requirements as stipulated in the manual.

Magneto’s (Alpha)

Part # BL-500556-1,

Serial # DO7FA140R,

DO7FA138R

Both magneto’s were found undamaged and in an overall

good condition. They were still secured to the engine and the

High Tension leads were attached. (Unable to check the

timing). Both units were subjected to a bench test procedure

and functioned satisfactorily.

Oil Filter

The filter was still attached to the engine.

The oil displayed a dark brown colour.

No metal particles were observed in the filter unit.

Gear drive train The gear train was undamaged and intact.

Fuel nozzles

Part # 5239

All the fuel nozzles were removed from the cylinders.

They were found to be free of any obstructions.

Cylinders The cylinders appeared to be in good overall condition and

were within dimensional limitations.

Pistons & Rings

The pistons were in a good condition with no evidence of

carbon build-up or visible wear/scouring.

None of the rings were broken.

Main bearings &

Big-end bearings

All the bearings were in a good overall condition and

displayed sufficient evidence of lubrication.

Connecting rods All six connecting rods were found to be in a good overall

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condition/undamaged.

Camshaft

Part # 654084,

Serial # Z07EA140

The camshaft was found to be in a good overall condition

including the gear drive assembly.

Crankshaft The crankshaft was found to be in an overall good condition.

Oil pick-up tube and

sump assembly

The sump assembly on the engine suffered minor impact

damage in the area of the drain plug. The pick-up screen

was free of debris and found to be undamaged.

Approximately 10 litres of oil were drained from the engine,

which displayed a dark brown colour.

Oil pump The oil pump was found undamaged and in a good condition.

Oil Cooler The Oil cooler was found undamaged and in a good

condition.

1.16.4 Additional observation during engine teardown inspection.

It was noted that the engine rpm pick-up, which was located on the right-hand

magneto (obtaining its impulses from the magnetic field generated by the rotating

magneto) was found to be loose in its housing. Glue needs to be applied to the pick-

up unit before it gets inserted into its housing in order to ensure it remains secure. The

unit was found to be only partially secluded in the housing (no sign of any glue

being applied to the pick-up) and the possibility that the position of the pick-up might

have resulted that the actual engine rpm was not being transferred to the

instrumentation could not be ruled out. (See next page for a photo of the magneto and

the pick-up).

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Figure 6. A view of the right magneto with the rpm pick-up partially secluded.

Conclusion:

With the available evidence gathered during the teardown inspection, no mechanical

evidence could be found to substantiate the statement made by the pilot

with reference to the engine failing in-flight. The engine was found to be in an overall

good condition.

1.16.5 Avionics Data Card:

The aircraft primary flight display (PFD) consisted of a MGL Avionics Odyssey

electronic flight instrument system (EFIS), which contained a removable data card.

The unit was found undamaged and the data card was removed and made available to

an approved avionics maintenance facility to assist with the download of data, which

required special software. The system was however not set-up to record any data of

any of the flights since installation in the aircraft, which include the accident flight.

1.17 Organizational and Management Information:

1.17.1 The aircraft was on a private flight from Omaruru aerodrome to Eros aerodrome in

Namibia.

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1.17.2 The aircraft was in possession of a valid Authority to Fly that was issued on 20

October 2009 and was to expire on 30 September 2010.

1.18 Additional Information:

1.18.1 Over-flight Authorization:

An over-flight and landing authorization for the aircraft ZU-FCY was obtained from the

aviation Regulatory Authority in Namibia before the pilot commenced with the flight

from South Africa to Namibia. He was issued with permit No. CH27/2857/2010, which

was valid for the period 9 to 17 September 2010.

1.19 Useful or Effective Investigation Techniques:

1.19.1 None.

2. ANALYSIS

2.1.1 The pilot of the aircraft was properly certified and qualified under the Civil Aviation

Regulations to conducted the flight. No evidence indicated any pre-existing medical

condition that might have adversely affected the pilot’s performance during the

accident flight. The pilot had broadcast a Mayday call on the Eros tower frequency

after he made the decision to execute a forced landing.

2.1.2 The accident aircraft was properly maintained in accordance with the Civil Aviation

Regulation provisions of a non type certified aircraft (NTCA).

2.1.3 During the bench test of the magnetos, which operated satisfactorily in all aspects it

was noted that the engine rpm pick-up located on the right-hand magneto was not

properly secluded in its housing with glue. The possibility that the pick-up might have

provided erratic or erroneous information on the primary flight display could not be

ruled out. However during a discussion with the pilot following the accident he

indicated that the engine power loss was sudden with no engine cockpit indication out

of the norm that he could picked up an impending failure during the flight. With the

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pilot also being the owner of the aircraft and have flown the aircraft since new he

mentioned that this was the first time he had experienced any technical problem with

the aircraft.

2.1.4 The investigation determined that the engine was;

(i) Mechanically in a good condition with no evidence found that could have

contributed or have caused the engine to loss power.

(ii) Two of the engine fuel system units still contained fuel during the engine

teardown inspection indicating that fuel was delivered to the engine, thereby

ruling out fuel starvation. Ample fuel was still in the aircraft at the time of the

accident and the fuel samples that were taken indicate it to be free of

contamination.

(iii) Approximately 10 litres of oil was drained from the engine during the teardown

inspection. All bearings and associated lubricated surfaces were found to be in

an overall good condition.

(iv) No evidence of overheating was visible to any of the engine components.

(v) Both magnetos functioned satisfactorily during the bench test procedure and

the spark plugs displayed a greyish colour consisted with normal engine

operation.

(vi) It was noted that the engine rpm pick-up located on the right-hand magneto

was not properly secluded in its housing with glue.

(vii) The exhaust system displayed minor impact damage.

2.1.5 The cause the engine power loss resulting in a forced landing in open bush type of

terrain could not be determined with certainty.

3. CONCLUSION

3.1 Findings

3.1.1 The pilot was the holder of a valid private pilot licence and had the aircraft type

endorsed in his logbook.

3.1.2 The aircraft was in possession of a valid Authority to Fly.

3.1.3 The pilot was in possession of a valid over-fly and landing authorisation that was

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issued by the Namibian aviation authorities prior to him commencing with the flight

from South Africa to Namibia.

3.1.4 The last fuel uplift prior to the accident was on 10 September 2010 when 112 litres of

Avgas was uplifted at Eros aerodrome.

3.1.5 There was ample fuel remaining in the aircraft at the time of the accident, with fuel

leaking from the right wing tank, which was ruptured due to impact damage.

3.1.6 Fuel samples that were taken on the scene indicate that the fuel was of the correct

grade and free of contamination.

3.1.7 Following an engine malfunction in-flight the pilot broadcast a Mayday call on the Eros

tower frequency 118.7 MHz.

3.1.8 The engine was removed from the wreckage and was subjected to a teardown

inspection at an approved engine maintenance facility. No evidence of mechanical

malfunction that could have contributed or have caused the engine to fail was

detected.

3.1.9 The engine rpm pick-up, which was located on the right-hand magneto was found to be

only partially secluded in its housing (no sign of any glue being applied to the pick-up

to ensure it remain secure).

3.1.10 The aircraft was found to be within the weight and balance limits at the time of

accident.

3.1.11 Good weather conditioned prevailed at the time of the flight and was not considered to

be a factor in this accident.

3.2 Probable Cause/s:

3.2.1 Unsuccessful forced landing following an engine malfunction in-flight.

3.3 Contributory Factor/s:

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3.3.1 None.

4. SAFETY RECOMMENDATIONS

4.1 None.

5. APPENDICES

5.1 None.

Compiled by:

...........................

Titus Shuungula Date: .........................

Investigator-in-charge

.........................................

Herman T. Hipondoka Date: .........................

Co–Investigator

For Director of Aircraft Accident Investigation

Released by:

......................................

Erkki Nghimtina (MP) Date: .........................

MINISTER: MINISTRY OF WORKS AND TRANSPORT