LAX04LA213
LAX04LA213

HISTORY OF FLIGHT

On May 15, 2004, at 1704 mountain standard time, an experimental amateur-built Bachman Lancair IV-P, N299SD, impacted terrain in the Grand Canyon near Supai, Arizona. A private individual built the airplane, and it was registered to and operated by the pilot. The private pilot and three passengers sustained fatal injuries. Visual meteorological conditions prevailed, and a flight plan had not been filed for the 14 CFR Part 91 personal flight. The local flight departed the North Las Vegas Airport (VGT), North Las Vegas, Nevada, at 1607.

According to relatives of the victims, the pilot and his family were in Las Vegas because the pilot's son was getting married on the 16th. The pilot's plan was to take his son, his son's fiancé, and the fiancé's best friend for a tour flight over the Grand Canyon the day before his son's wedding.

Communication transcripts obtained from North Las Vegas Air Traffic Control Tower (ATCT) revealed that the pilot requested a visual flight rules (VFR) clearance to the Grand Canyon. The pilot was given a clearance and departed for the Grand Canyon at 1607. The United States Air Force 84th Radar Evaluation Squadron (RADES) radar data depicted a target tracking westbound over the Grand Canyon between 15,500 and 16,000 feet mean sea level (msl) mode C reported altitudes. At 1653, the radar data depicts the target beginning a climb to 16,500 feet and reversing course. The target then began moving eastbound over the canyon between 16,500 and 16,800 feet.

At 1657:21, the pilot contacted the Los Angeles Air Route Traffic Control Center and requested VFR flight following back to North Las Vegas. They instructed the pilot to squawk 1044 on his transponder. At 1658:52, they established radar contact 40 miles northeast of the Peach Springs very high omni-directional radio range navigation facility. The controller asked the pilot to say his altitude, to which the pilot answered 16,500 feet. The controller provided the Grand Canyon altimeter setting of 30.03 inches of mercury, which the pilot repeated at 1659:07. This was the last communication received from the pilot. The last eight mode C returns that provided altitude information indicated the following:

Time Latitude Longitude Altitude Transponder

08.) 1702:16 36:10:42 N 113:00:49 W 16,400 1044
07.) 1702:27 36:10:45 N 113:01:28 W 16,200 1044
06.) 1702:28 36:10:40 N 113:01:34 W 16,100 1044
05.) 1702:37 36:10:48 N 113:02:17 W 16,000 1044
04.) 1702:40 36:10:43 N 113:02:31 W 16,200 1044
03.) 1702:52 36:10:50 N 113:02:55 W 13,800 1044
02.) 1703:04 36:10:52 N 113:02:32 W 11,300 1044
01.) 1703:16 36:10:59 N 113:02:50 W 9,100 1044

Witnesses located within the Grand Canyon National Park told park rangers that they observed the airplane descending at a nose-low pitch attitude, and "spinning or moving in some strange way" before impacting terrain and catching fire. According to one witness, he heard the engine "gear up then slow down repeatedly." Another witness reported hearing the "engine revving at a high rate of speed." Photographs taken just moments following ground impact by one of the witnesses located on the north rim revealed that it exploded upon impact producing a mushroom cloud of smoke.

The accident site was on the south rim of the Grand Canyon at a latitude and longitude of 36 degrees 11 minutes 05 seconds north by 113 degrees 02 minutes 38 seconds west, respectively.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) records revealed that the pilot held a private pilot certificate with single engine land and instrument airplane ratings. He was issued his most recent medical certificate (third-class) on January 12, 2004, with a limitation indicating that he must "wear lenses that correct for distant vision and posses glasses that correct for near vision while exercising the privileges of his airman's certificate." According to the application for the 2004 medical certificate, the pilot accumulated a total of 1,900 flight hours, 20 of which were accumulated within the past 6 months. A copy of the pilot's logbook was provided to the National Transportation Safety Board investigator-in-charge (IIC); however, the last entry was dated November 7, 1991. The last flight review endorsement found in the logbook was from 1990.

AIRCRAFT INFORMATION

The pressurized airplane kit (serial number LIV-370) was sold to the builder on December 7, 1998, and was issued an experimental airworthiness certificate on January 1, 2000, by a Designated Airworthiness Representative (DAR). The amateur-built airplane completed its required 40 hours of flight testing, intended to establish operating limitations, on March 18, 2000 (the airplanes's operating limitations issued during certification indicated that no person may operate an aircraft that has an experimental certificate outside of an area assigned by the Administrator until it is shown that-- (1) The aircraft is controllable throughout its normal range of speeds and throughout all the maneuvers to be executed; and (2) The aircraft has no hazardous operating characteristics or design features).

The airplane was equipped with a 350-horsepower Teledyne Continental Motors TSIO-550-E1B reciprocating engine (serial number 803059), and a composite Whirlwind three-blade propeller. Lancair sold the airplane as a kit (not a fast-build), and the airplane was mostly carbon fiber and fiberglass. According to the airframe maintenance logbook, the airplane was equipped with a Garmin GNC300XL global positioning system, an S-Tec autopilot, a Goodrich stormscope, distance measuring equipment, a Ryan terrain collision avoidance system, a Trimble radio altimeter, and a King KX-165 navigation/communication system.

The following information was obtained from the airplane's maintenance logbooks, correspondence between the pilot/owner and repair facilities, and repair invoices.

The airplane was sold to the pilot in June 2001, and registered to him on October 15, 2001. Prior to the purchase of the airplane, the pilot had Weeldreyer Aviation of Manhattan Beach, California, conduct an aircraft insurance inspection on June 8, 2001. Weeldreyer Aviation utilized their own inspection form for the Lancair IV, and noted some discrepancies on the checklist. On June 15, 2001, the pilot signed an agreement with Weeldreyer Aviation agreeing that they would "perform an inspection and flight testing for the assembled airplane and give flight instruction in the assembled airplane as needed."

In a letter dated July 20, 2001, the pilot/owner indicated that the "items that needed attention" during the June 8, 2001, inspection "have been repaired or are in the process of being repaired." The letter continued by indicating that the pilot had flown the airplane and intended on flying it again on July 21 and 22, 2001, for the purpose of identifying "any other problems which might exist." He added that there was a "problem with maintaining pressurization as the door latch disengaged."

In a letter dated July 26, 2001, the pilot/owner indicated again that the cabin door continued to have problems, and the airplane was unable to maintain pressurization. The pilot then listed additional maintenance squawks that needed attention, some of which are listed below:

- Landing gear did not seem to properly retract.
- Speed brakes did not completely retract on several occasions.
- Vacuum pump suction pressure gage never registered in the "green" range.
- Right flap had insufficient clearance on one of the connecting rods.
- The left elevator's trim tab piano hinge wire was sliding out.
- Fuel line on passenger side in cockpit needed more clearance.
- Windshield on left side appeared to be scratched or cracked.
- Attitude indicator seemed to not be functioning properly, but was "more operational" with the autopilot on.

Sometime following the aforementioned letters, the pilot took the airplane to have an interior installed in the airplane and have the exterior painted. In a letter dated September 4, 2001, the pilot/owner indicated that the right wing fuel tank vent was plugged. He also remarked that the facility that was painting the airplane had some questions about "mass balance specifications for the rudder, flaps, elevators, and ailerons." He continued by indicating that the interior installation facility "managed to damage the inflatable door seal."

An invoice, dated October 16, 2001, indicated that the rudder and elevator trim wires had a bad crimp and wires had pulled out, but were repaired. An invoice dated October 19, 2001, indicated that the airplane exterior was painted. Another invoice dated December 7, 2001, indicated that Mansberger Aircraft, Minden, Nevada (which was the same facility that painted the airplane), conducted the following repairs:

- Fabricated and installed a rear baggage closeout panel.
- Repaired and adjusted cabin door latching mechanism.
- Repaired and refinish cracks in wing root fillets.
- Remove and reinstall left wingtip for landing light troubleshooting.
- Prep and carbon fiber lay-up around lower door latch cutouts, re-trim and fit latches, repaint door jam.

Review of the airframe logbook revealed that on February 21, 2001, at a tachometer time of 49.0 hours, the airplane underwent an "annual inspection."

Between February 8, 2002, and May 15, 2002, Aviation Classics, Reno, Nevada, conducted the following work on the accident airplane:

- Troubleshoot horizontal situation indicator (HSI). Found bad wires, reconnected broken wires to autopilot servos and found cables cut by interior installation. Repaired wires.
- Disassembled interior and repaired broken wires; rerouted and chafe-protected and cleared control rods; spliced and rerouted speed brake and gyro cables.
- Cables not sealed at pressure feed-throughs. Cleaned cables, rerouted and sealed with Pro-seal. Reinstalled interior.
- Repaired copilot stick wires and installed roll pin. Repaired pilot's side. Pilot's stick travel restricted by armrest. Cut cleared and called for interior repair (outside labor).

An estimate from Mansberger Aviation dated July 1, 2002, indicated that the lower cowling needed repairing and repainting. According to Mansberger Aviation personnel, this repair was required as a result of another maintenance facility dropping the airplane from lift jacks. Acquaintances of the pilot/owner indicated that the composite propeller had also sustained damage in that event, but it had been repaired. Another estimate from Mansberger Aviation dated July 1, 2002, listed repairs for:

- Cracking in the original builder's fill work in areas of wing root fillet fuselage junctions and door.
- Repair areas where fill and primer are delaminating from poorly prepped carbon fiber in same areas and cowlings.
- Repairs to be made by grinding out cracks and debonds in fill work, recontouring new fill work, followed by applying 4 oz. Layer of fiberglass cloth over all areas susceptible to expansion from pressurization.
- Repaint as required.

A fax to the pilot, dated November 3, 2002, from a person listed as one of Lancair International's technical representatives for the builder assist program listed the Hobbs meter time for the airplane as 157.2 hours and a tachometer time as 123.9 hours. This fax also listed 53 discrepancies ranging in severity. Some of discrepancies listed are as follows:

- Panel wiring entwined with autopilot.
- Fuel leak in right tip at vent line.
- Right aileron inboard hardware hitting wing skin.
- Right elevator hitting right rudder skin.
- Rudder chafes vertical at top and bottom left side.
- Inboard left elevator hits inspection panel at full down.
- Hydraulic leaks in cockpit.
- Fuel leaks in cockpit.
- Pitch servo mount missing and loose hardware.
- Elevator pushrod chafed by pitch servo.
- Left aileron actuator loose.
- Flap travels are not equal.
- Fuel leaks in both wings.
- Aircraft needs new weight and balance.
- Aircraft limitations missing.
- Fuel leak at mechanical pump under shroud.
- Rudder pedal interference with avionics solenoid on co-pilots side.

The fax continued by indicating that the wings would need to be removed to repair the fuel leaks. It also listed the control travel specifications and compared that with their actual manufacturer recommended travel limits (all of which were off by some degree). According to acquaintances of the pilot, the pilot contracted with this person to repair the door window, which failed in cruise flight while at 22,000 feet mean sea level (msl).

That list was revised on February 8, 2003, to include a number of other discrepancies (78 in total). The list then included what items were repaired and how, and what items were deferred. According to the repair list, the flight control travels were corrected to within 2 degrees of that specified. The following maintenance entry found in the airframe logbook did not have a date associated with it, but indicated a tachometer time (and airframe total time) of 123.9 hours (same as previous two discrepancy lists), and was made by the same person who produced the lists. That entry listed the following repairs:

- Replaced hardware for speed brake attach.
- Rewired right side of fuselage behind instrument panel.
- Repaired multiple hydraulic and fuel leaks.
- Adjusted all control surface travels to match specs.
- Sanded rudder and elevator surfaces to eliminate interference.
- Replaced right aileron pushrod.
- Replaced elevator pushrod.
- Secured pitch servo with correct hardware.
- Installed vent holes in all control surfaces.
- Removed right aileron for repair of actuator attach bracket, reinstalled following repair.
- Removed wings for repair of fuel leaks. Repaired fuel leaks and installed new drain in forward "D" sections of both wings.
- Reweighed aircraft.
- Relieved radio rack where interfering with aileron crossover.
- Replaced cabin door window and adjusted latch mechanism.

The next (and last) entry in the logbook, dated February 8, 2003, at an airframe total time of 123.9 hours, indicated that the airplane had been inspected in accordance with a condition inspection and determined to be airworthy (a different person than the one that repaired the aforementioned discrepancies endorsed the condition inspection). It should be noted that the operating limitations for the airplane dictated that "no person shall operate this aircraft unless within the preceding 12 calendar months it has had a condition inspection performed in accordance with Appendix D of FAR Part 43, and found to be in a condition for safe operation" (it should be noted that the operation limitations actually stated "in accordance with Appendix D of FAR Part 32"; however, according to the DAR this was a typing error).

An invoice from Mansberger Aviation, dated August 18, 2003, indicated that the repairs listed in the estimate dated July 1, 2002, were conducted. The invoice specifies that in addition to the original estimated repairs, a fractured horizontal stabilizer tip and wing skin were repaired.

A message provided to the Safety Board IIC by a relative of the pilot indicated that she found the following section of a note while looking at the pilot's laptop following the accident:

"Lancair problems: Wed. 04/14/04
Crack in windshield
Missing screws
DOOR
Altitude Indicator
Autopilot
Right Gear"

The Safety Board IIC contacted the DAR that issued the experimental airworthiness certificate to ask whether he had retained any building records on the airplane. The DAR indicated that he had not (it should be noted that the DAR was not required to retain building records for airplanes that he approved for an experimental airworthiness certificate). According to the DAR, the builder died of a heart attack shortly after finishing the airplane.

The accident airplane had the ability to carry 90 gallons of aviation gasoline. Its empty gross weight equated to 2,404 pounds, and its maximum gross weight was 3,300 pounds. According to the weight and balance information provided to the owner in February 8, 2003, with full fuel and four persons on board (with an average weight of 170 pounds each), the airplane would exceed its maximum gross weight by 324 pounds. It is uncertain how much fuel was on board prior to departure and the exact weight of the passengers.

METEOROLOGICAL INFORMATION

At 1754, the weather observation facility at the Grand Canyon National Park Airport (GNC - located 41 nautical miles east of the accident site) reported the wind from 210 degrees at 11 knots; visibility 10 statute miles, clear sky; temperature 23 degrees Celsius; dew point -08 degrees Celsius; and an altimeter setting of 30.02 inches of mercury.

At 1854, the GNC weather observation facility reported the wind from 230 degrees at 16 knots with gusts to 20 knots; visibility 10 statute miles, clear sky; temperature 22 degrees Celsius; dew point -10 degrees Celsius; and an altimeter setting of 30.00 inches of mercury.

There were no pilot reports or Airmen's Meteorological Information (AIRMETS) for turbulence in the area of the accident site.

WRECKAGE AND IMPACT INFORMATION

An FAA inspector from the Las Vegas Flight Standards District Office, along with a designated airworthiness representative (DAR) familiar with Lancair IV-P airplanes, examined the wreckage at the accident site. Photographs taken at the accident site by the FAA inspector revealed that the airplane was severely fragmented, and fire had damaged much of the wreckage. According to the FAA inspector, he was unable to positively identify all of the flight control surfaces due to the impact and fire damage. The inspector and the DAR were able to positively identify one of the ailerons and oxygen bottle, which were not significantly fire damaged, and the engine, propeller, main wing spar, and landing gear, which were fire damaged. The landing gear were in the retracted position.

The wreckage was collected and transported to Air Transport's facility in Phoenix, Arizona. During wreckage recovery from the canyon, a fly-by of the accident site area was conducted in an attempt to find additional wreckage. None was located.

TESTS AND RESEARCH

On July 16, 2004, the Safety Board IIC, along with the FAA inspector, and an investigator from Teledyne Continental Motors, examined the wreckage at Air Transport's facility. The wreckage was laid out in attempt to determine what components were salvaged from the accident site. The extent of the impact and fire damage made it difficult to determine whether or not all of the flight control surfaces were present. Components from each flight control system were identified; however, their preimpact condition could not be determined. Remnants from both ailerons were present at the wreckage layout, as were the flap tracks and the flap bell cranks, one of which remained attached to a section of burnt remains of flap. Sections of the elevator, rudder, and aileron control systems were identified, but they were mostly steel control rods or cables. A section of rear wing spar was in the debris. An autopilot servo was also located; however, which servo was unknown.

The engine sustained significant impact and fire damage. The propeller hub separated from the engine crankshaft, but remained intact. Two of the three blades remained attached to the propeller hub, while one separated. The engine separated from its mount, and its intake and exhaust components sustained fire and impact damage. The majority of the balanced induction system melted away. The exhaust stack emanating from the right turbocharger was flattened. The right turbocharger remained attached to the engine and remained intact. The left turbocharger was found among the debris and had sustained impact damage and melting of its components. The slope controller was destroyed and could not be tested. The two magnetos separated from their mounts and were destroyed. The fuel manifold remained attached to the engine via its distorted and bent injection lines, but it sustained heat damage. The number 2 and number 4 cylinders were impact and fire damaged to the extent that their respective pistons and intake valves were visible (no anomalies were noted with the number 2 piston and valve; however the number 4 piston was melted and cracked). Close examination of the crankshaft fracture face revealed 45-degree shear lips.

Another section of unidentified, unburned debris resembling a longeron or a secondary spar was retained and shipped to the Safety Board Materials Laboratory in Washington, DC, for further examination.

Material and comparative examination of the previously unidentified component sent to the Materials Laboratory revealed that it was likely a section of the left rear wing spar. Green-gray coating was visible on the interior portions of the C-shaped spar. Adhesive material remained attached to approximately 60 percent of the upper surface of the spar. Pieces of carbon fiber bundles from a carbon fiber fabric with fibers oriented at +/- 45 degrees were attached to the upper surface of the adhesive. According to a Lancair technical representative, the carbon-fiber fabric was consistent with wing skin material. On most of the lower surface of the spar, the adhesive fractured from the lower side. In locations where adhesive remained, the lower fracture surface had features similar to that of the adhesive on the upper surface, with carbon fibers, carbon fiber impressions and peel ply patterns. The remainder of the fracture surface had a relatively uniform color and under optical magnification using a stereo microscope, had patches of rough resin fracture intermixed with smooth voids.

MEDICAL AND PATHOLOGICAL INFORMATION

The Coconino County Medical Examiner's Office conducted an autopsy on the pilot after identifying him through dental records. According to the autopsy report, the pilot died as a result of multiple blunt force injuries. The FAA's Civil Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. The toxicological test contained findings for the following:

13 mg/dL of ethanol detected in the brain
7 mg/dL acetaldehyde detected in the brain
74 mg/dL acetaldehyde detected in kidney

According to the toxicological report, the ethanol found in this case may be from postmortem ethanol formation and not from the ingestion of ethanol.

ADDITIONAL INFORMATION

The wreckage was released to the owner's family.

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