NTSB Identification: nyc07fa196
HISTORY OF FLIGHT
On August 19, 2007, about 1212 eastern daylight time, a Liberty Aerospace XL-2, N550XL, was substantially damaged when it impacted terrain during an aborted landing at Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida. The student pilot, the sole occupant, sustained serious injuries. The flight was operated by Ormond Beach Aviation under the provisions of 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was filed for the local instructional flight.
The accident occurred during the student pilot's second flight, and his first solo flight of the day. Earlier in the day, the student pilot's certificated flight instructor (CFI) requested that the pilot conduct a "surprise" dual flight from OMN to Flagler County Airport, approximately 11 miles to the north, and back. The CFI stated that the pilot "handled [the flight] very well." Upon their return to OMN, the CFI had the student pilot conduct several circuits of the traffic pattern to practice takeoffs and landings, after which they landed and refueled the airplane. The CFI then released the student pilot for a solo flight to continue practicing takeoffs and landings at OMN.
The CFI stated that he released the student pilot, watched him take off, turn crosswind and then downwind. The CFI lost sight of the airplane on the base leg, but he saw the airplane take off again. At that point, the CFI left the fueling area for personal business. The CFI estimated that it was approximately 6 minutes between the time the student pilot first taxied out for his solo flight, and when the CFI left the fueling area.
The recordings of the communications between the airplane and the OMN air traffic control tower (ATCT) indicated that approximately 8 minutes after he requested clearance to taxi out for his solo traffic pattern work, the student pilot requested "to taxi back to the ramp" because he had "a bit of a problem with low oil pressure" and that he needed to "check it out" prior to conducting the flight. The controller asked the student pilot "did [name unclear] break another one?" The student pilot responded "negative, [I] think its getting a bit low on oil, need to [take] a bit of a look."
According to a written transcript of a January 15, 2008, telephone conversation between the student pilot and his legal representatives, the student pilot taxied to "the hanger" (sic) where he "gave it a little top up." The transcript indicated that the student pilot, without the knowledge or assistance of anyone else, including any flight school personnel, added "maybe a quart" of oil to the engine, secured the oil filler cap, and taxied out again for takeoff. During the same conversation, the student pilot was specifically asked whether he examined the airplane to see if there was an oil leak. He responded that he did check, and that he did not detect any indications of an oil leak.
The ATCT ground control recording indicated that approximately 19 minutes elapsed between the student pilot's request to return to the ramp for the oil pressure problem, and his request for the subsequent taxi-out. When the student pilot contacted ground control for the second taxi-out, he informed the controller that he had automatic terminal information service (ATIS) "Papa." The controller informed the student pilot that ATIS information "Quebec" was current, and that "the winds had changed." The controller then informed the student pilot that the revised winds were from 090 degrees at 8 knots, with gusts to 14 knots. The student pilot acknowledged the updated information, and taxied to runway 8 for departure.
The ATCT local control recording indicated that the student pilot was cleared for takeoff, instructed to "make left traffic," and to advise the controller when he was "midfield" on the left downwind for runway 8. Approximately four minutes later, the student pilot reported that he was midfield left downwind, and that he wanted to conduct a full stop landing, with a taxi-back for another takeoff. The controller cleared the flight to land. The controller did not provide any wind information during any of these communications.
Approximately three minutes after receiving his clearance to land, the student pilot announced that he was executing a go-around. The controller then questioned the student pilot as to whether he intended to remain in the traffic pattern. The student pilot responded in the affirmative, and again requested a full stop landing, with a taxi-back for another takeoff. This time, the controller instructed the student pilot to fly a right-hand traffic pattern. Two minutes later, the controller instructed the student pilot to extend his downwind leg for departing traffic, and informed the student pilot that the controller would notify the student pilot when he should turn his base leg. One minute after the controller's request to extend the downwind leg, the controller instructed the student pilot to begin his base leg. One minute after that, a Cessna Citation 550 was cleared for takeoff. Thirty seconds later, the student pilot was cleared to land, and was advised to exercise caution due to wake turbulence from the departing Cessna Citation business jet airplane.
According to the local controller, just prior to the accident, the student pilot initiated a go-around for undetermined reasons. Both the ground and local controllers stated that the airplane began a climbing left turn, followed by a left roll and left-wing-first, nose-down impact with the ground. The ground controller reported that the airplane "caught fire within seconds of impact."
The ATCT recordings indicate that approximately 2 - 1/2 minutes after the landing clearance was issued, an unidentified individual in the ATCT telephoned the flight school to inform them of an accident with one of their airplanes. Approximately one minute after that, an unidentified individual in the ATCT remarked that it "looks like the pilot got out."
PERSONNEL INFORMATION
The student pilot was a United Kingdom citizen who was in the United States for flight training purposes. He was obtaining his training from Ormond Beach Aviation ("the flight school") in accordance with 14 CFR Part 61. He held a combination third-class medical/student pilot certificate that was issued on August 8, 2007. The student pilot's flight school records indicated that, excluding the accident flight, he had accumulated 27.4 total hours of flight experience. The student pilot had accumulated 2.0 hours of solo flight experience, and conducted his first three solo flights the day prior to the accident.
Excluding the accident flight, the student pilot had conducted a total of 27 flights, with 6 different flight instructors, within the 35 days preceding the accident. The student pilot flew 25 flights in the 12 days preceding the accident. The student pilot did not fly on two of the twelve days, and three days before the accident, he completed flying seven days in succession. The student pilot flew six flights the day prior to the accident.
AIRCRAFT INFORMATION
The Liberty Aerospace XL-2 was a two-place, fixed tricycle gear, low-wing monoplane. The airplane was equipped with a Teledyne Continental Motors (TCM) IOF-240-B5B full authority digital engine control (FADEC) engine, and a two-blade, fixed pitch, wood and composite propeller. The airplane was type certificated in accordance with 14CFR Part 23 in February 2004.
The accident airplane was equipped with a VM1000FX engine management system. The airplane manufacturer stated that the system "is designed to monitor engine sensors and FADEC data streams to display engine performance" on a flat panel display in the cockpit. The system components include a data processing unit (DPU), engine transducers, a FADEC data interface, and the flat panel display. The transducers are mounted "firewall forward" so that they "do not bring any hazardous fluids into the cockpit." The transducers feed information to the DPU, which processes the information for display by the flat panel, referred to as the VM1000 indicator.
Maintenance records indicate that the fuselage-mounted fuel tank cracked and leaked, and was repaired, and subsequently replaced, in August 2007. Maintenance record entries for August 12 and 13, 2007, documented problems with, and repairs to, the oil pressure functions of the VM1000 indicating system. The August 13 entry was the final entry in the maintenance records.
METEOROLOGICAL INFORMATION
The 1153 recorded weather observation for Daytona Beach International Airport (DAB), Daytona Beach, Florida, Daytona Beach, located 8 miles south of OMN, reported winds from 070 degrees at 12 knots. The 1245 recorded weather observation for OMN reported winds from 080 degrees at 10 knots with gusts to 17 knots, visibility 10 statute miles, scattered clouds at 2,500 and 3,400 feet, temperature 32 degrees Celsius (C), dew point 27 degrees C, and an altimeter setting of 30.14 inches of mercury.
COMMUNICATIONS
The OMN ATCT was a non-federal facility. Review of the ATCT recordings indicated that the only exchange of wind information between the student pilot and the ground controller was when the ground controller notified the student pilot that the winds had changed in the period between the pilot's taxi-in for the oil pressure problem and his subsequent taxi-out. The local controller did not provide any wind information to the student pilot, or to any other aircraft, at any time during the 14 minute period that the student pilot was airborne. During that time, the student pilot made two circuits of the traffic pattern, and the second circuit terminated with the accident.
The recording of the local controller continued for approximately 10 minutes after the accident. Except for an unidentified individual who was heard on the local control recording contacting the flight school just after the accident, the ground and local control recordings did not contain any communications regarding accident notification activities.
WRECKAGE AND IMPACT INFORMATION
The airplane came to rest on a southerly heading, approximately 1,000 feet southeast of the ATCT. The initial ground impact point, located approximately 50 feet south of the main wreckage, contained portions of a red lens. The accident site was located approximately 600 feet north of runway 8, and 250 feet east of runway 17. The wreckage was tightly contained, and the surrounding grass was burned away or scorched to a radius of approximately 20 feet.
The fuselage, the inboard portion of the right wing, and the right horizontal stabilizer sustained significant fire damage. Examination of the remaining components did not reveal any pre-impact failures or malfunctions. The flap actuator measurement corresponded to the full flap extension of 30 degrees. The elevator trim tab actuator measurement corresponded to a trim tab position between neutral and full airplane nose up.
The propeller was highly fragmented. The engine remained partially attached to the main wreckage. The engine data interface (EDI) unit compact flash (CF) card was destroyed by fire. The engine was recovered and shipped to the TCM factory in Mobile, Alabama, for further examination.
MEDICAL AND PATHOLOGICAL INFORMATION
According to information provided by his legal representatives, the student pilot sustained third degree burns over approximately 60 percent of his body. The burns were primarily on his head, neck, shoulders, arms and legs. The student pilot also sustained bilateral fractures to his nasal bones. Soon after the accident, the student pilot was placed into a medically-induced coma for several weeks. He was discharged from his US hospital in stable condition on November 8, 2007, and transferred to a hospital in the United Kingdom.
SURVIVAL ASPECTS
The owner of the flight school stated that the airplane was equipped with seat belts and shoulder harnesses. The ATCT ground controller stated that the airplane caught fire "within seconds" of ground impact. Fire damage precluded any determination of the condition or possible usage of the seat belts and shoulder harnesses. According to first responders, the student pilot was able to communicate verbally just after the accident. The student pilot was air-evacuated from the accident location to a hospital in Orlando, Florida.
TEST AND RESEARCH
Engine Examination
On November 7, 2007, the engine was disassembled and examined at TCM's analytical department in Mobile, Alabama. No evidence of any pre-existing mechanical problems or failures was noted during the engine examination.
Airframe Examination
The airframe wreckage was examined at OMN on June 10, 2008. The fuselage was severely fire-damaged, but cloth from approximately one-third of the cockpit/cabin area composite fuselage skin/structure retained its original shape.
Several shaped fragments of cloth were identified, including the lower, forward and aft portions of the left (pilot side) door, and the lower portion of the right (passenger side) door. The left door fragment contained the exterior handle; the handle was in the stowed position. The right door fragment was missing the exterior handle. Both the left and right door fragments contained their respective interior door latch assemblies, and both were missing their respective key-lock assemblies. Both interior door latch assemblies were found intact, with the actuator handles in their respective "Closed" positions. Approximately 90 percent of the windshield was recovered. No soot deposits were found on the interior surfaces of any windshield fragments.
The left main landing gear did not exhibit impact or fire damage. The recovered windshield fragments did not exhibit fire damage or signatures consistent with exposure to an in-flight fire. Both wings contained signatures consistent with a fire that occurred while the wing was stationary, and did not contain any signatures consistent with an in-flight fire. The tailplane contained signatures consistent with a fire that occurred while the tailplane was stationary, and did not contain any signatures consistent with an in-flight fire.
Several exemplar XL-2 airplanes were examined, and the following operations were observed:
When activated and then released, the exterior door latch returned to its stowed position, independent of whether the door was open or closed, or whether the latch pins were engaged or not. The exterior door handle did not move when the interior handle was moved. When the interior door handle was moved to either the "Close" or "Open" position, it remained in that respective position.
FAA XL-2 Airplane Fact Finding Investigation
In April 2008, the FAA Small Airplane Directorate formed a fact-finding investigation (FFI) team to conduct a formal, independent investigation of the safety allegations received from a U.S. flight school ("the complainant") against Liberty Aerospace Incorporated for the Model XL-2 airplane. The investigation was completed in July 2008, and the FFI report was published in September 2008.
According to the report, the FFI team comprised individuals from different organizations within the FAA. The team gathered information for this investigation through conducting visits, interviews, flight evaluations, and various database and document reviews. The team worked with the complainant flight school, Liberty Aircraft, the Civil Aviation Safety Authority (CASA) of Australia, different flight school operators and maintained personnel, and different organizations within the FAA.
According to the report, the complainant stated that:
“It takes approximately 25 hours to solo a student pilot in the Model XL-2 and typically 15 hours in the Cessna Model 150” and “Good airplane, tightly coupled and probably too sensitive in pitch for student pilot.”
According to the report, FAA test pilots stated that:
"...it is a fairly decent challenge to get a good flare in the Model XL-2. For a pilot with little experience, it may be tougher" and "The all-movable stabilator provides a lot of elevator power, and if the pilot is a little fast entering the flare, it is extremely easy to over control and get into a porpoise situation."
According to the report, other flight schools stated that:
"The airplane is sensitive on pitch and challenging for students to get used to, especially on landing" and "The time to solo flight varied between schools from a low of approximately 12 hours to a high of 22 hours with an average of approximately 18 hours."
According to the report, a former Liberty test pilot stated that:
"Great airplanes if pilot understands its characteristics," "Typical landing issue: airplane coming in hot and pilot overflares and bounces airplane" and "Pilots tend to overflare the airplane in landing."
A complete summary of the FFI team’s findings, as cited in their report, is as follows:
-- The FAA Atlanta Certification Office (ACO) and FAA Orlando Manufacturing Inspections District Office (MIDO) have provided appropriate oversight to the certification and post-certification activities of the Model XL-2.
-- The 14 CFR part 23 certification requirements related to the complainant’s safety concerns were reviewed and determined to be in compliance. The FFI team did not find any specific safety concerns that have not been addressed.
-- To date, there were no safety related items discovered in the investigation that warrant conducting a special certification review.
-- The Model XL-2 is a technically advanced airplane and would benefit from the FAA Industry Training Standards (FITS) scenario-based training.
-- The airplane controls are more sensitive than other training airplanes, but the airplane meets 14 CFR part 23, subpart B requirements and is an acceptable airplane for training.
-- Other flight schools operate the Model XL-2 airplane successfully in their pilot training programs. Several international aviation authorities have evaluated and issued type certificates for the Model XL-2, including the European Aviation Safety Agency (EASA).
--The Model XL-2 accident / incident rates are comparable to those of similar airplanes.
In the report, FFI team pilots noted in part, the following:
--"The control responsiveness and crispness is still apparent at minimum controllable airspeeds associated with the landing flare. The crispness and instantaneous response of the airplane could potentially result in an over controlling tendency by the pilot."
--"A pilot attempting to recover from porpoising should immediately initiate a go-around. Proper training and experience are the best recovery techniques for this situation."
--"Instructors should provide student training in the bounced landing and go-around procedures."
ORGANIZATIONAL AND MANAGEMENT INFORMATION
The website for the flight school stated that the school is intended "…specifically for European pilots, wishing to qualify for their JAA [Joint Aviation Authorities]…" certificates or ratings. The school was certificated under 14 CFR Part 141, but also provided training in accordance with 14 CFR Part 61.
According to the flight school's chief flight instructor, the flight school imposed wind limits on its student pilots for solo flights. These limits varied as both a function of which particular training program a student was enrolled in, and of the student's experience and progress. The only written guidance for wind limits (excluding airplane operating limitations) was in the school's General Flying Orders Handbook; this guidance applied only to students enrolled in the 14 CFR Part 141 training program, and who were obtaining JAA certificates or ratings. In all cases, each CFI was responsible for determining the student's wind limits, and each CFI was required to explicitly cite the student's wind limits in each logbook endorsement for solo flight. The limits applied to the steady state wind speeds. The chief flight instructor stated that if gust limits were imposed on a student, these would also be cited in the logbook endorsement.
According to the owner of the flight school, the wind limits for the accident student pilot were 12 knots maximum, and 6 knots crosswind. The owner stated that the flight school "has a policy and standard operating procedure (SOP) for all solo operations that "touch and go's" are not permitted…" He also stated that the student pilot had received dual instruction and practice in takeoffs, landings and go-arounds, and that the student pilot was "explicitly" briefed on the flight school's limitations regarding solo flights.
In a post accident interview, the CFI stated that he did not have any knowledge of the pilot's oil pressure problem, or his resultant return to the ramp. The CFI did not notice that the winds had changed, and did not monitor or recall the pilot to prevent him from conducting the solo flight. According to the CFI, it was not the practice of the flight school or the CFI to recall students when the weather conditions approached or exceeded the flight school's limits. He stated that it was the responsibility of the students to monitor the weather conditions, and to ensure that they operated within the flight school's limits.
ADDITIONAL INFORMATION
Air Traffic Control Tower Personnel Observations.
On September 12, 2007 the Safety Board was provided with written statements from each of the two ATCT controllers on duty at the time of the accident. Neither statement mentioned smoke or any other indications of a pre-impact fire.
Student Pilot's Recollection
The transcript of the student pilot's January 15, 2008, conversation with his legal representatives included a discussion in which the student pilot alleged that during the approach to the accident landing, he noticed a fire in the airplane when he was at an altitude of approximately 500 feet. The student pilot variously described it as "an engine fire," or as coming from behind his head. He stated that he "did emergency shutoff procedures," and then the fire entered the cockpit, and began to burn him. He stated that the conditions prompted him to aim the airplane for the grass on the left side of the runway for a softer landing, and that he exited the airplane while it was airborne "15 or 20" feet above the ground. He further stated that except for the fire, he did not experience any problems with the airplane.
Witness Accounts Substantiating Pilot's Recollection
No witnesses reported seeing the pilot exit the airplane prior to impact.
Airplane Flight Manual Guidance
The XL-2 Airplane Flight Manual (AFM) provided the following guidance for low oil pressure: "An indication of low oil pressure may be a problem with the oil pressure indicating system or the engine oil pressure relief valve. However, it may also be an indication of internal mechanical damage to the engine and a warning of imminent complete engine failure. Monitor oil pressure, oil temperature, and cylinder head temperature indications. If oil temperature remains normal, proceed to the nearest airport for landing."
(This report was modified on June 19, 2009)
