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Pilot’s improper maintenance leads to fatal crash

By NTSB · January 4, 2018 ·

The private pilot conducted a 20-minute local flight in the Eros 1600, an experimental, amateur-built airplane, after installing a new ignition coil on the two-stroke, two-cylinder engine.

He then returned to the airport in Lebanon, Tennessee, where he landed the airplane, back-taxied on the runway, and initiated a second takeoff.

Witnesses reported that, shortly after takeoff, the plane experienced a total loss of engine power.

The airplane entered a left turn back toward the runway, then subsequently turned “sharply” left and descended to the ground. The pilot died in the crash.

Examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Examination of the engine revealed that the front spark plug was burnt white, consistent with exposure to high temperatures or an excessively lean carburetor calibration. Although both front and aft carburetor adaptors exhibited degradation, the front cylinder adaptor exhibited significantly more damage and cracking compared to that of the aft cylinder.

This likely resulted in additional air being ingested by the front carburetor, which subsequently resulted in a leaner fuel/air mixture in that cylinder.

In addition, the front cylinder piston exhibited a hole about 1 centimeter in diameter, consistent with detonation/preignition.

Records located in the pilot’s hangar indicated that he was servicing the engine with a fuel/oil ratio of 40:1, rather than the manufacturer-recommended ratio of 50:1.

It is likely that the use of an improper fuel/oil ratio resulted in carbon deposits in the front cylinder.

Combined with the effects of the lean fuel/air mixture as a result of the degraded carburetor adaptors, the engine was susceptible to the development of detonation and/or preignition, which subsequently resulted in the development of a hole in the front cylinder piston head.

As a result, the engine experienced a total loss of power, to which the pilot responded by attempting to turn back to the airport at low altitude. During the turn, he allowed the airplane’s airspeed to decay and exceeded its critical angle of attack, which resulted in an aerodynamic stall and collision with terrain.

Probable cause: A failure of the front cylinder piston due to the pilot’s improper maintenance, which resulted in a total loss of engine power after takeoff. Contributing to the accident was the pilot’s decision to return to the runway at low altitude following the loss of engine power, and his failure to maintain adequate airspeed during the turn, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.

NTSB Identification: ERA16FA084

This January 2016 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. Bob Fusco says

    January 6, 2018 at 7:10 am

    Never attempt to turn back, maintain attitude land straight! Lesson 1

  2. gbigs says

    January 5, 2018 at 7:16 am

    Amateur maintained. Impossible turn. Every high risk behavior in aviation.

    • Sarah A says

      January 5, 2018 at 2:02 pm

      I am not sure that you will find many (if any) “Professionals” that have any knowledge of a 2-stroke engine and would even want to deal with a such a small homebuilt given the lack of typical maintenance documentation available. Given that the pilot would have also been the builder he was the best qualified person to do that, he just did not put a lot of effort into apparently. The expanded report shows that there was only 14 hours on the airframe and 2 hours on the engine since it was installed, the yearly Condition Inspection was accomplished at the same time and almost 7 calendar months had passed since the installation. However it also says that the engine had been previously installed on a snowmobile so it would have had more time on it. That bit of history is more telling as to what might have happened, maybe the engine was not converted over to aircraft duty properly or it had pre-existing problems that were not addressed during install. So maybe this was more of a build error than maintenance error. But you had your chance to go off half cocked and poke a stick in the eye of the Experimental Amateur Built category and you took it.

    • BJS says

      January 5, 2018 at 6:35 pm

      Never question the motives or maintenance qualifications of amateur built/maintained aircraft individuals, gbigs, or you’re subject to the wrath of such folks as “Sarie”! My guess is “Sarie” built her own airplane or airs up the tires from time to time. Now “Sarie” can also jump me!!

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