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Sam

Joined: 18 May 2008
Posts: 135

Posted: Fri Jun 26, 2009 3:52 am Post subject: Complex aircraft NTSB report

All,



I found this link on the rotary engine news group.  It's a thorough NTSB report about a complex engine/electrical installation that the builder/pilot was unwilling and unprepared to finish correctly.



 http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20071120X01821&ntsbno=NYC08FA023&akey=1



Sam

[quote] [b]

_________________
Sam Hoskins
www.samhoskins.blogspot.com

nuckolls.bob(at)aeroelect
Guest

Posted: Fri Jun 26, 2009 9:19 am Post subject: Complex aircraft NTSB report

At 06:50 AM 6/26/2009, you wrote:

  	  Quote: 	
		  All,



 I found this link on the rotary engine news group.  It's a thorough NTSB report about a complex engine/electrical installation that the builder/pilot was unwilling and unprepared to finish correctly.



 [url=http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1] http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1[/url] 	


   I've had several private links to this posting.

   Very sad. It's an unfortunate fact of the human

   condition that rational thought processes and

   understanding of simple-ideas can be so terribly

   diminished by hazardous behaviors.



   Let us strive to watch out for each other. 

   Don't be afraid to speak up when we perceive

   that somebody's project is not going forward

   with the best goals and processes we know how

   to do.



   Its far better to risk getting some builder

   pissed off at you than to be thinking "I SHOULD

   have told you so" while reading the NTSB report.



 

        Bob . . .



         ---------------------------------------

        ( . . .  a long habit of not thinking   )

        ( a thing wrong, gives it a superficial )

        ( appearance of being right . . .       )

        (                                       )

        (                  -Thomas Paine 1776-  )

         ---------------------------------------    [quote][b]

frank.hinde(at)hp.com
Guest

Posted: Fri Jun 26, 2009 9:45 am Post subject: Complex aircraft NTSB report

Absolutely..This was so sad and many of us on the Vans  airforce forum kinda saw it coming.

  

 I get slammed almost daily for my choice to use electric  fuel pumps with no mechanical backup from folks who are not engineers and don't  understand my system.

  

 You know what, I would rather recieve a thousand emails of  uninformed dissent for the potential of seeing one nugget of information that is  maybe a flaw in my system.

  

 None of us are so well informed that we can't learn  something.

  

 The accident airplane had a an Eggenfelner subaru  conversion installed I believe.

  

 Cheers

  

 Frank



   From:  owner-aeroelectric-list-server(at)matronics.com  [mailto:owner-aeroelectric-list-server(at)matronics.com] On Behalf Of Robert  L. Nuckolls, III

Sent: Friday, June 26, 2009 10:17 AM

To:  aeroelectric-list(at)matronics.com

Subject: Re: AeroElectric-List:  Complex aircraft NTSB report

 

At 06:50 AM 6/26/2009, you wrote:

  	  Quote: 	
		  All,



I found this link on    the rotary engine news group.  It's a thorough NTSB report about a    complex engine/electrical installation that the builder/pilot was unwilling    and unprepared to finish correctly.



http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20071120X01821&ntsbno=NYC08FA023&akey=1  	


  I've had several private links to this  posting.

  Very sad. It's an unfortunate fact of the human

   condition that rational thought processes and

  understanding of  simple-ideas can be so terribly

  diminished by hazardous  behaviors.



    [quote][b]

bcollinsmn

Joined: 17 Aug 2008
Posts: 23
Location: St. Paul, MN.

Posted: Fri Jun 26, 2009 12:00 pm Post subject: Re: Complex aircraft NTSB report

I wrote about this yesterday on Letters From Flyover Country. Please keep in mind also that this was the NTSB factual report. It is not the probable cause report, although I think we can figure out what's coming.



As I was reading the report, I was reminded of two articles. One was the Kitplanes article (folks who know me know which one I'm talking about), where the author wrote that people should just get their plane in the air. Period. And the other was a thread on VAF a couple of weeks ago basically goading those people who are deviating from planes and taking forever, to just hurry up and get in the air.



What we have here appears to be a concession of safety for the fastest way into the air.



This is a good reminder that a slow builder, a careful builder, a builder whose first goal is not to get in the air as soon as possible,  is not someone to criticize or ridicule, it's someone to emulate.

_________________
Bob Collins
St. Paul, Minn.
RV-7A - Running wires
http://rvbuildershotline.com
Day job: http://minnesota.publicradio.org/collections/special/columns/news_cut/

echristley(at)nc.rr.com
Guest

Posted: Fri Jun 26, 2009 12:18 pm Post subject: Complex aircraft NTSB report

Robert L. Nuckolls, III wrote:

 	  Quote: 	
		   At 06:50 AM 6/26/2009, you wrote:

> All,

>

> I found this link on the rotary engine news group.  It's a thorough 

> NTSB report about a complex engine/electrical installation that the 

> builder/pilot was unwilling and unprepared to finish correctly.

>

> http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1 

> <http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1> 

   I've had several private links to this posting.

   Very sad. It's an unfortunate fact of the human

   condition that rational thought processes and

   understanding of simple-ideas can be so terribly

   diminished by hazardous behaviors.

Let's not let simple ideas get lost in our sympathy for the pilot in 

this accident.  Most of this report is superfluous fluff with little 

bearing on what could have caused the accident.  In fact, there is no 

statement of what caused the accident that could be blamed on the lack 

of a rational thought processes on the part of the builder.

Most of the report was dedicated to pointing out how the high-end EFIS 

was not calibrated.  At no point was the lack of calibration cited as a 

contributing factor to the accident.  The man was flying day VFR.  The 

instrument was superfluous for the mission.  The fact that the pilot was 

not familiar with the instrument's operation was superfluous to the 

report.  The fact that the instrument was in the plane at all was 

superfluous to the report.  How could anything displayed on an 

uncalibrated EFIS translate into a plane taking a 35 to 60 degree 

nosedive during a day VFR flight?

Most of the remainder of the report was equally superfluous.  The first 

flight occurred on July 12.  The accident occurred on November 2.  The 

fact that clecoes held the cowling on for the first flight was 

superfluous to the accident report.  It might have been germane if an 

accident had occurred with the clecoes still in use, but that was not 

the case. 

The fact that the propeller was under manual control vs some sort of 

electronics is superfluous.  Are there not many examples of airplanes 

flying just fine with manual control?  And I hear that there are a few 

flying with no pitch control at all.  There is some information that the 

pilot was having issues with coordinating the engine power with the 

propeller pitch controls.  But that does not translate to taking a 35 to 

60 degree nose dive into terra firma.  I can't even translate it to a 

situation where the pilot would not be able to maintain altitude.  It 

might translate to an inability to maintain smooth level flight, but 

there is a wide gulf between smooth level flight and a dirt bath.

The report pointed out that the rudder trim was attached with duct 

tape.  The key word is "attached".  How did a *rudder* trim that was 

*attached* contribute to a 60 degree nosedive?  How does an *attached* 

rudder trim even make it difficult to maintain altitude?  An aileron 

trim tab rod had been broken and poorly repaired.  Was the weak 

attachment cause of an accident, or more superfluous data?

The report makes hay of the pilots lack of high performance training.  

He was flying the plane for nearly 4 months before the accident.  I 

would imagine that high performance training would cover issues like 

severe P factors and overspeeding the airplane.  Is "maintaining 

altitude" taught exclusively in high performance trainging now?  If not, 

why is the lack of such training an issue?  The report details the 

pilots rush to get to Oshkosh, and the pilots willingness to falsify 

records in order to meet legal requirements.  How did any of that 

contribute to an accident that occurred months later?

There were some wires not connected.  So?  Did any of them contribute to 

the inability to maintain altitude?  I have several wires in my project 

that are slated for future upgrades.  It's much easier to run them now 

than when everything is closed up.  They are not connected to anything.  

If something really bad happens to me, those wires will have nothing to 

do with it, but will "unconnected cables" be cited in the report anyway?

I suggest reading the report again...but cross out all the superfluous 

lines that obviously have nothing at all to do with the accident.  Cross 

out the parts that point out "He didn't follow the rules.  He was a 

BAAAAD man."  It'll be a much shorter report.  The pilot of N289DT may 

very well be a prime candidate for a Darwin Award, but we can't know 

that from reading this report.  All I can tell is that the investigator 

was much more concerned with pointing out how the pilot was not 

following procedure than about what occurred.

-- 

http://www.ernest.isa-geek.org

nuckolls.bob(at)aeroelect
Guest

Posted: Fri Jun 26, 2009 1:59 pm Post subject: Complex aircraft NTSB report

At 03:16 PM 6/26/2009, you wrote:


<echristley(at)nc.rr.com>



Let's not let simple ideas get lost in our sympathy for the pilot in 

this accident.  Most of this report is superfluous fluff with little 

bearing on what could have caused the accident.  In fact, there is no 

statement of what caused the accident that could be blamed on the 

lack of a rational thought processes on the part of the builder.



Most of the report was dedicated to pointing out how the high-end 

EFIS was not calibrated.  At no point was the lack of calibration 

cited as a contributing factor to the accident.  The man was flying 

day VFR.  The instrument was superfluous for the mission.  The fact 

that the pilot was not familiar with the instrument's operation was 

superfluous to the report.  The fact that the instrument was in the 

plane at all was superfluous to the report.  How could anything 

displayed on an uncalibrated EFIS translate into a plane taking a 35 

to 60 degree nosedive during a day VFR flight?



    To be sure, the first documents generated by

    any well crafted investigation are "factual reports".

    I've done many and was soundly admonished by

    my boss for inserting anything that smacked of

    analysis, supposition or opinion. In fact, we

    always dictated field notes, had them typed,

    and then judiciously edited them to offer only

    factual information. The tapes were then

    destroyed after the field investigator compared

    his tapes with the finished document.



Most of the remainder of the report was equally superfluous . . .



   <snip>



I suggest reading the report again...but cross out all the 

superfluous lines that obviously have nothing at all to do with the 

accident.  Cross out the parts that point out "He didn't follow the 

rules.  He was a BAAAAD man."  It'll be a much shorter report.  The 

pilot of N289DT may very well be a prime candidate for a Darwin 

Award, but we can't know that from reading this report.  All I can 

tell is that the investigator was much more concerned with pointing 

out how the pilot was not following procedure than about what occurred.



    Points well taken. Everything that is factual

    should be in there and evaluated for significance

    by others who are detached from the natural emotions

    that arise from investigation. Digging through

    bent aluminum and archiving of written records

    is a task that should never be mixed with attempts

    to assign significance and deduce cause/effect.



    The NTSB Blue Ribbon Report will be produced

    later and screened for significance by less-invested

    minds. The report suggests some risky attitudes

    on the part of the builder but the exact cause

    of engine failure is pure physics. We can only

    grieve for his attitudes but learning can happen

    only if we understand the physics.



        Bob . . .



         ---------------------------------------

        ( . . .  a long habit of not thinking   )

        ( a thing wrong, gives it a superficial )

        ( appearance of being right . . .       )

        (                                       )

        (                  -Thomas Paine 1776-  )

         ---------------------------------------

mprather(at)spro.net
Guest

Posted: Fri Jun 26, 2009 2:11 pm Post subject: Complex aircraft NTSB report

As another poster pointed out, this report is "Factual", not "Probably

Cause".    I imagine that the investigator made an effort to find out as

much as he could about the airplane and pilot and this report is the

culmination of this search.  I believe that's a reasonably common method

for investigating crashes.

Another way to interpret the report is that it is documenting the fact

that there were many things that could have caused the pilot to get

distracted from the cardinal "Aviate, Navigate, then Communicate."  If I

were investigating an airplane crash I would be interested in listing all

discrepancies from "normal" practice as any such deviations could cause

the crash.  This report does not find or imply blame for the crash.

Matt-

 	  Quote: 	

 <echristley(at)nc.rr.com>

 Robert L. Nuckolls, III wrote:

> At 06:50 AM 6/26/2009, you wrote:

>> All,

>>

>> I found this link on the rotary engine news group.  It's a thorough

>> NTSB report about a complex engine/electrical installation that the

>> builder/pilot was unwilling and unprepared to finish correctly.

>>

>> http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1

>> <http://www.ntsb.gov/ntsb/brief2.asp?ev_id 071120X01821&ntsbno=NYC08FA023&akey=1>

>   I've had several private links to this posting.

>   Very sad. It's an unfortunate fact of the human

>   condition that rational thought processes and

>   understanding of simple-ideas can be so terribly

>   diminished by hazardous behaviors.

>

 Let's not let simple ideas get lost in our sympathy for the pilot in

 this accident.  Most of this report is superfluous fluff with little

 bearing on what could have caused the accident.  In fact, there is no

 statement of what caused the accident that could be blamed on the lack

 of a rational thought processes on the part of the builder.

 Most of the report was dedicated to pointing out how the high-end EFIS

 was not calibrated.  At no point was the lack of calibration cited as a

 contributing factor to the accident.  The man was flying day VFR.  The

 instrument was superfluous for the mission.  The fact that the pilot was

 not familiar with the instrument's operation was superfluous to the

 report.  The fact that the instrument was in the plane at all was

 superfluous to the report.  How could anything displayed on an

 uncalibrated EFIS translate into a plane taking a 35 to 60 degree

 nosedive during a day VFR flight?

 Most of the remainder of the report was equally superfluous.  The first

 flight occurred on July 12.  The accident occurred on November 2.  The

 fact that clecoes held the cowling on for the first flight was

 superfluous to the accident report.  It might have been germane if an

 accident had occurred with the clecoes still in use, but that was not

 the case.

 The fact that the propeller was under manual control vs some sort of

 electronics is superfluous.  Are there not many examples of airplanes

 flying just fine with manual control?  And I hear that there are a few

 flying with no pitch control at all.  There is some information that the

 pilot was having issues with coordinating the engine power with the

 propeller pitch controls.  But that does not translate to taking a 35 to

 60 degree nose dive into terra firma.  I can't even translate it to a

 situation where the pilot would not be able to maintain altitude.  It

 might translate to an inability to maintain smooth level flight, but

 there is a wide gulf between smooth level flight and a dirt bath.

 The report pointed out that the rudder trim was attached with duct

 tape.  The key word is "attached".  How did a *rudder* trim that was

 *attached* contribute to a 60 degree nosedive?  How does an *attached*

 rudder trim even make it difficult to maintain altitude?  An aileron

 trim tab rod had been broken and poorly repaired.  Was the weak

 attachment cause of an accident, or more superfluous data?

 The report makes hay of the pilots lack of high performance training.

 He was flying the plane for nearly 4 months before the accident.  I

 would imagine that high performance training would cover issues like

 severe P factors and overspeeding the airplane.  Is "maintaining

 altitude" taught exclusively in high performance trainging now?  If not,

 why is the lack of such training an issue?  The report details the

 pilots rush to get to Oshkosh, and the pilots willingness to falsify

 records in order to meet legal requirements.  How did any of that

 contribute to an accident that occurred months later?

 There were some wires not connected.  So?  Did any of them contribute to

 the inability to maintain altitude?  I have several wires in my project

 that are slated for future upgrades.  It's much easier to run them now

 than when everything is closed up.  They are not connected to anything.

 If something really bad happens to me, those wires will have nothing to

 do with it, but will "unconnected cables" be cited in the report anyway?

 I suggest reading the report again...but cross out all the superfluous

 lines that obviously have nothing at all to do with the accident.  Cross

 out the parts that point out "He didn't follow the rules.  He was a

 BAAAAD man."  It'll be a much shorter report.  The pilot of N289DT may

 very well be a prime candidate for a Darwin Award, but we can't know

 that from reading this report.  All I can tell is that the investigator

 was much more concerned with pointing out how the pilot was not

 following procedure than about what occurred.

 --

 http://www.ernest.isa-geek.org

rob(at)hyperion-ef.com
Guest

Posted: Fri Jun 26, 2009 2:26 pm Post subject: Complex aircraft NTSB report

Wow, it’s as if you and I read two different accounts of this unfortunate accident.  I came away with the distinct impression that the builder/pilot was both careless and impatient, and utterly indifferent to the FAA regulations governing pilots and amateur built airplanes.  

   

Here we have a novice pilot (221.4 hours logged) flying a complex, high performance aircraft without logging the required training.  I’ll agree with you that it is possible that the pilot had sufficient experience by the time of the crash that he should have been able to find an instructor that would provide the necessary logbook endorsement to fly the airplane, but the fact remains there was no such endorsement, so no flights up to and including the accident flight were legal.  

   

There were many indications in the NTSB report of violations and just plain bad judgment.  Let’s look at them in the same order that they are mentioned in the report.   

   

The blade retention nuts were also found tightened approximately 1/4 inch tighter than the index marks scribed on the hub. This however, did not appear to affect the pitch rotation friction.  

A minor error but indicative (when taken with many other similar factors) of careless assembly and an urge to get the airplane finished on a tight schedule.  

   

Examination of the propeller controller revealed that it was not the propeller controller that was manufactured by the propeller manufacturer.  

Another minor discrepancy that is also indicative of that urge to get flying.  Sure, he could just fly as if it was a fixed pitch prop and avoid the workload associated with manually adjusting pitch, but the report seems to suggest that was not the case.  

   

It gets worse.  

   

…examination of the flight control system revealed that, the outboard ends of the ailerons had been filled with foam and then fiberglass had been used to seal in the foam. A trim tab for the rudder was discovered to be attached with duct tape. The lock nuts which were used on the rod ends for the pitch control system could be spun by hand and were not tightened against the rod ends, and were found on the threaded portion of the rods approximately 1/4 inch away from what would be their normal seated positions. The right trim tab rod on the elevator was connected to its rod end by two threads and was shorter than the trim tab rod for the left trim tab. It displayed evidence that the end of the trim tab rod at one time had broken off, and then had been re-inserted into the rod end, as the rest of the threaded portion was not present.  

I can’t see how to interpret that paragraph other than the builder had what I would charitably call “a relaxed attitude” toward quality workmanship.  This isn’t sloppy upholstery or paint here, this is flight safety related.  

   

Multiple wires showed no evidence of having being connected prior to impact. Examination of the cableing (sic) connected to the electrical system's contactor relays, revealed that a cable was not secured to its corresponding terminal on the contact  

or relay.  

More of that “relaxed attitude.”  

   

Examination of the pilot's logbook revealed no evidence of the training required by the FAA for operation of an airplane with an engine of more than 200 horsepower.  

The accident flight was in violation of the FARs and so were all previous flights.  

   

Examination of the airplane's maintenance logbook revealed that on July 10, 2007, the FAA issued a special airworthiness certificate allowing operation of the airplane.

 

 Seven days later, on July 17, 2007, the pilot certified in the maintenance logbook that the prescribed 40 hours of test flying required by the FAA had been completed however, no record of separate entries for each of the test flights was discovered. The pilot also certified on that date that the airplane was controllable throughout its normal range of speeds and maneuvers, and that it had no hazardous characteristics or design flaws and that it was safe for operation. The pilot additionally certified that he had demonstrated by flight test, the operating data for the airplane and the weight and balance data.  

Anyone who believes that the 40 hour test program was actually completed in seven days probably also has seen Bigfoot and the Loch Ness Monster, and believes in both Santa Claus and the Easter Bunny.  Pardon my skepticism, but I don’t think he did it, and I also think he admitted as much when he was quoted (later in the report) saying “That's not what the logbooks say" at OSH when one other builder stated to the pilot that "There's no way you could have completed your fly off yet."  Later in the NTSB report it says that  “On July 13, 2007 the pilot emailed an RV builders group that he … had 39 hours and 20 minutes left to fly off…” making it even less believable that the remaining time was actually flown in 4 more days.  

   

Not only did he not fly the test flights but he faked the weight and balance at least once (either in the log or in reporting to the FAA)…  

   

Review of the FAA airworthiness records also revealed that the weight and balance data supplied to the FAA differed from the weight and balance information in the airplane's maintenance logbook. These differences included differing centers of gravity and a difference in empty weight.  

And to support my contention that he was rushing things a bit the report says…  

   

According to friends and other builders, the pilot was impatient with the time it was taking to do everything, and he was pushing to get the airplane assembled and flying in time for the Experimental Aircraft Association (EAA) convention at Wittman Regional Airport, (OSH) Oshkosh, Wisconsin. This resulted in the pilot doing such things as requesting the instrument panel builder to send the panel "as quickly as possible," and traveling to the engine builder's facility to pick up the engine instead of waiting for shipment.  

There’s nothing wrong with using “will call” instead of waiting for a shipment but this is not the only instance of being in too much of a hurry to get the project finished.  

   

On July 14, 2007, the pilot and the engine builder departed 4G1 for X50.  

The last time I checked Florida was not “within an area around 4G1, and I doubt that the engine builder was a required crew member, further indicative of the pilot’s disregard for the FARs.  With only four days since the issuance of the special airworthiness certificate (call that 96 hours on the clock) is it virtually impossible that the flight was legal.  

   

Had the Phase 1 tests been completed as required the pilot should not have needed this exchange…  

   

On November 1, 2007, the day before the accident, the pilot once again emailed his friend asking: 

 

 "What speeds do you carry on base and final when at max load? I am taking the family on our first trip and I am being paranoid but this is the first time I have taken more than 1 passenger. So just doing due diligence."  

Due diligence, indeed!   have not seen any indication in the NTSB report of any due diligence.  

   

   

Best regards,  

   

Rob Housman  

Irvine, CA   

Europa XS Tri-Gear  

A070  

Airframe complete  

   

--

Bob Collins

Joined: 11 Mar 2006
Posts: 470
Location: St. Paul, Minnesota

Posted: Fri Jun 26, 2009 2:48 pm Post subject: Complex aircraft NTSB report

As I build my RV, I also tend to want to have the rod end  bearing jam nuts torqued down. Oh, and if a threaded rod breaks, I'll probably  replace it rather than just stick it in with the broken part  absent.

  

 The problem with many of us who knew Dan is that he was a  good guy. A really nice guy.

  

 I certainly would want to look again at the DAR who signed  off and I feel bad for the friends mentioned in the report who clearly tried to  tell him a few things and I'm guessing they're kicking themselves for not being  a little more direct.

  

 One tragedy WAS averted here. I believe Dan had planned to  put his family in this plane later that day and fly to  Boston.

  

 Let's be careful as we discuss this not to get too  insulting toward Dan while learning from his death. It's a very difficult  close-to-home story for those of us in the RV  community.

   [quote][b]

_________________
Bob Collins
St. Paul, Minn.
Letters from Flyover Country
http://rvnewsletter.blogspot.com/

Kellym

Joined: 10 Jan 2006
Posts: 1705
Location: Sun Lakes AZ

Posted: Fri Jun 26, 2009 8:12 pm Post subject: Complex aircraft NTSB report

Agreed, very troubling for the RV-10 community that suffered this and 2 

weather related fatals in the same year. I don't see any facts in the 

report relating to the electronic ignition for the Subaru engine, and 

its power source, but it certainly makes one wonder if the crash was 

initiated by loss of electrons to fire plugs and produce power, followed 

by power off attempt at landing that unfortunately was not successful. 

The mention of numerous unterminated wires does lead to head scratching.

KM

RV 10 #40866



Bob Collins wrote:

 	  Quote: 	
		   As I build my RV, I also tend to want to have the rod end bearing jam 

 nuts torqued down. Oh, and if a threaded rod breaks, I'll probably 

 replace it rather than just stick it in with the broken part absent.

  

 The problem with many of us who knew Dan is that he was a good guy. A 

 really nice guy.

  

 I certainly would want to look again at the DAR who signed off and I 

 feel bad for the friends mentioned in the report who clearly tried to 

 tell him a few things and I'm guessing they're kicking themselves for 

 not being a little more direct.

  

 One tragedy WAS averted here. I believe Dan had planned to put his 

 family in this plane later that day and fly to Boston.

  

 Let's be careful as we discuss this not to get too insulting toward Dan 

 while learning from his death. It's a very difficult close-to-home story 

 for those of us in the RV community.

 

 *

 

 

 *

_________________
Kelly McMullen
A&P/IA, EAA Tech Counselor # 5286
KCHD

r.r.hall(at)cox.net
Guest

Posted: Sat Jun 27, 2009 4:53 am Post subject: Complex aircraft NTSB report

Well I am just spitballing here but If I had to put forth a theory it would be that the propellor and power problem are what finally did him in. If he had to manually adjust the propellor pitch every time he changed power I think he could have easily either gotten distracted by it and stopped flying the airplane or messed up the settings and lost thrust even though the engine was running. Just my 2 cents. I would have found that plane very hard to fly in that condition. Can't trust the instruments so look outside, reduce power then change prop pitch, shut off alarm, look outside again, oops to low add power reset prop pitch, shut off alarm, etc. I think it would have been easy for him to get distracted or mess up the power or prop setting.

Bottom line is if it ain't working right fix it before you fly.  

---- Kelly McMullen <kellym(at)aviating.com> wrote: 

 	  Quote: 	

 Agreed, very troubling for the RV-10 community that suffered this and 2 

 weather related fatals in the same year. I don't see any facts in the 

 report relating to the electronic ignition for the Subaru engine, and 

 its power source, but it certainly makes one wonder if the crash was 

 initiated by loss of electrons to fire plugs and produce power, followed 

 by power off attempt at landing that unfortunately was not successful. 

 The mention of numerous unterminated wires does lead to head scratching.

 KM

 RV 10 #40866

 Bob Collins wrote:

 > As I build my RV, I also tend to want to have the rod end bearing jam 

 > nuts torqued down. Oh, and if a threaded rod breaks, I'll probably 

 > replace it rather than just stick it in with the broken part absent.

 >  

 > The problem with many of us who knew Dan is that he was a good guy. A 

 > really nice guy.

 >  

 > I certainly would want to look again at the DAR who signed off and I 

 > feel bad for the friends mentioned in the report who clearly tried to 

 > tell him a few things and I'm guessing they're kicking themselves for 

 > not being a little more direct.

 >  

 > One tragedy WAS averted here. I believe Dan had planned to put his 

 > family in this plane later that day and fly to Boston.

 >  

 > Let's be careful as we discuss this not to get too insulting toward Dan 

 > while learning from his death. It's a very difficult close-to-home story 

 > for those of us in the RV community.

 > 

 > *

 > 

 > 

 > *

Speedy11(at)aol.com
Guest

Posted: Sat Jun 27, 2009 5:34 am Post subject: Complex aircraft NTSB report

I believe Ernest is correct.

 The report does indicate a pattern of behavior that may  have contributed to the accident.

 Stan Sutterfield

  

  	  Quote: 	
		  I    suggest reading the report again...but cross out all the superfluous 

lines    that obviously have nothing at all to do with the accident.  Cross    

out the parts that point out "He didn't follow the rules.  He was a    

BAAAAD man."  It'll be a much shorter report.  The pilot of    N289DT may 

very well be a prime candidate for a Darwin Award, but we can't    know 

that from reading this report.  All I can tell is that the    investigator 

was much more concerned with pointing out how the pilot was    not 

following procedure than about what occurred. 	


 

  

 Make your summer sizzle with fast and easy recipes for the grill.

  [quote][b]

jaybannist(at)cs.com
Guest

Posted: Sat Jun 27, 2009 6:17 am Post subject: Complex aircraft NTSB report

It is absolutely not advisable, but on the ground, one can push one's luck and "pencil whip" a lot of stuff and probably get away with it.  When you are airborne and things go wrong, you can't just pull out a pencil and eraser and make problems go away. Pencil whipping is a close cousin of illogical rationalization. Both are counterproductive in that they tend to only hurt the person that does it.  Pencil whipping and illogical rationalization are pure fantasy.  Airborne problems are reality.  Better to stay in the realm of reality all the time, on the ground and in the air.  

 

 Off the soapbox - Jay Bannister

 Do not archive

   Email message sent from CompuServe - visit us today at http://www.cs.com 

  [quote][b]

nuckolls.bob(at)aeroelect
Guest

Posted: Sat Jun 27, 2009 7:48 am Post subject: Complex aircraft NTSB report

At 07:51 AM 6/27/2009, you wrote:




Well I am just spitballing here but If I had to put forth a theory it 

would be that the propellor and power problem are what finally did 

him in. If he had to manually adjust the propellor pitch every time 

he changed power I think he could have easily either gotten 

distracted by it and stopped flying the airplane or messed up the 

settings and lost thrust even though the engine was running. Just my 

2 cents. I would have found that plane very hard to fly in that 

condition. Can't trust the instruments so look outside, reduce power 

then change prop pitch, shut off alarm, look outside again, oops to 

low add power reset prop pitch, shut off alarm, etc. I think it would 

have been easy for him to get distracted or mess up the power or prop setting.



Bottom line is if it ain't working right fix it before you fly.



   There have been numerous electrically driven prop

   pitch adjustment mechanisms that were not automatic.

   The earliest I recall was on a 50's vintage Bonanza.

   These are treated for all practical purposes as a

   fixed pitch prop that can be changed in flight. Keep

   in mind that the engine will keep the craft airborne

   at ANY prop pitch setting. The value in being able to

   adjust it is obvious for optimizing climb vs. cruise

   performance . . . but departures from optimum settings

   do not automatically present hazards beyond that

   of distracting a pilot that doesn't understand how

   it works.



   If we indulge in useful speculation I'll suggest

   that items in the factual report are particularly

   significant. Namely the probability that wires

   that SHOULD have been managing power around the

   recently moved batteries were not properly

   terminated. Given that the engine was electrically

   dependent, the idea that wires were coming loose

   at the battery is not pleasant to contemplate.



   Once the engine is dead, the pilot is faced with

   a whole new task that exceedingly few are well

   trained to achieve . . . walk away from the

   impending arrival with the earth. Pilot's attitudes

   and other errors not withstanding, the manner in

   which the last few seconds of this story unfolded

   tells the tale.



   I'm told that the terrain was relatively flat

   farm land and that major damage to the airframe

   occurred when it contacted a raised roadbed

   at right angles. All these things suggest a

   host of poor actions on the part of a neophyte

   pilot who was tasked with making good decisions

   under the worst of circumstances.



   As dark-n-stormy night stories go, this one is

   rich with factual data. At the same time, it's

   particularly sad because the root cause that

   started this unhappy chain of events probably

   did not involve an error of design or failure

   of a component. It seems likely that attention

   to ordinary details of good craftsmanship and

   pilotage set the stage for this play. It's

   no different than finding the engine suddenly

   silent because one neglected to take on

   predictable and necessary fuel before flight.



        Bob . . .



         ---------------------------------------

        ( . . .  a long habit of not thinking   )

        ( a thing wrong, gives it a superficial )

        ( appearance of being right . . .       )

        (                                       )

        (                  -Thomas Paine 1776-  )

         ---------------------------------------

echristley(at)nc.rr.com
Guest

Posted: Sat Jun 27, 2009 8:09 am Post subject: Complex aircraft NTSB report

jaybannist(at)cs.com wrote:

 	  Quote: 	
		   It is absolutely not advisable, but on the ground, one can push one's 

 luck and "pencil whip" a lot of stuff and probably get away with it.  

 When you are airborne and things go wrong, you can't just pull out a 

 pencil and eraser and make problems go away. Pencil whipping is a 

 close cousin of illogical rationalization. Both are counterproductive 

 in that they tend to only hurt the person that does it.   Pencil 

 whipping and illogical rationalization are pure fantasy.  Airborne 

 problems are reality.  Better to stay in the realm of reality all the 

 time, on the ground and in the air. 



 Off the soapbox - Jay Bannister

 Do not archive

 Email message sent from CompuServe - visit us today at http://www.cs.com

In no case, and at no point does the wind, engine, wings or control 
	


surfaces have any idea or concern about what your pencil is doing.



Flying with loose lock nuts on the rod ends or control rods is STEWPID.  

Stupid in the "Heh, Bubba, watch this!" vein of stupid.  But unless one 

is found disconnected, it was simply stupid, not fatal.



-- 



http://www.ernest.isa-geek.org

r.r.hall(at)cox.net
Guest

Posted: Sat Jun 27, 2009 9:11 am Post subject: Complex aircraft NTSB report

---- "Robert L. Nuckolls wrote: 

 	  Quote: 	
		   

 

 

>    There have been numerous electrically driven prop

    pitch adjustment mechanisms that were not automatic.

    The earliest I recall was on a 50's vintage Bonanza.

    These are treated for all practical purposes as a

    fixed pitch prop that can be changed in flight. Keep

    in mind that the engine will keep the craft airborne

    at ANY prop pitch setting. The value in being able to

    adjust it is obvious for optimizing climb vs. cruise

    performance . . . but departures from optimum settings

    do not automatically present hazards beyond that

    of distracting a pilot that doesn't understand how

    it works.

 

    If we indulge in useful speculation I'll suggest

    that items in the factual report are particularly

    significant. Namely the probability that wires

    that SHOULD have been managing power around the

    recently moved batteries were not properly

    terminated. Given that the engine was electrically

    dependent, the idea that wires were coming loose

    at the battery is not pleasant to contemplate.

 

Another good possibility Bob. If as the story says, he crimped the battery terminals with a pair of pliers the connections could very well have come loose. My point was that he had a constant speed prop apparently and was trying to adjust it with each change in power setting which, along with everything else, could have overloaded him especially if he was having intermitent electrical problems from a loose battery wire.
	


I have to agree with poor craftsmanship and a seeming passion for working around problems instead of fixing them seems the culprit. A strong lesson we should all take to heart. Another lesson here is that if you have a friend, acquaintance or  fellow pilot with a problem help them to get it fixed and don't let them think it is okay to fly with these kinds of issues. The days of duct tape and bailing wire fixes are long gone.



Rodney

nuckolls.bob(at)aeroelect
Guest

Posted: Sat Jun 27, 2009 3:46 pm Post subject: Complex aircraft NTSB report

 	  Quote: 	
		  I have to agree with poor craftsmanship and a seeming passion for 

working around problems instead of fixing them seems the culprit. A 

strong lesson we should all take to heart. Another lesson here is 

that if you have a friend, acquaintance or  fellow pilot with a 

problem help them to get it fixed and don't let them think it is 

okay to fly with these kinds of issues. The days of duct tape and 

bailing wire fixes are long gone.



Rodney


	


    Well put sir. I'll suggest that the mission is core

    to the purposes of all the Lists. They can be the

    repository and offeror of proven recipes for success

    as well as a filter for combining simple-ideas

    into new recipes.



    This isn't just a brother's keeper issue. When

    somebody makes a spectacular and newsworthy exit in

    any (but particularly an OBAM) aircraft, public and

    regulatory perceptions will paint us all with the same

    brush dipped into the words of ignorant and ratings-

    motivated vendors of the morning rags and disseminators

    of the evening news.

        Bob . . .



         ---------------------------------------

        ( . . .  a long habit of not thinking   )

        ( a thing wrong, gives it a superficial )

        ( appearance of being right . . .       )

        (                                       )

        (                  -Thomas Paine 1776-  )

         ---------------------------------------

rgf(at)dcn.davis.ca.us
Guest

Posted: Sat Jun 27, 2009 9:12 pm Post subject: Complex aircraft NTSB report

I finally read the NTSB report.  As usual, these accidents are years in the making.  Not sure what lesson(s) apply to us here….idiots with more money than brains are everywhere, including the highest levels of Wall Street and banking .  

   

This quote by the owner/pilot is classic: “… just doing due diligence."  We sure are good at self-deception.  

   

Ralph  

RV-9A QB SA  

     

From: owner-aeroelectric-list-server(at)matronics.com [mailto:owner-aeroelectric-list-server(at)matronics.com] On Behalf Of Sam Hoskins

 Sent: Friday, June 26, 2009 4:51 AM

 To: Aerolectric List

 Subject: Complex aircraft NTSB report  

  

   

All,

 

 I found this link on the rotary engine news group.  It's a thorough NTSB report about a complex engine/electrical installation that the builder/pilot was unwilling and unprepared to finish correctly.

 

 http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20071120X01821&ntsbno=NYC08FA023&akey=1

 

 Sam  [quote] [b]

bakerocb

Joined: 15 Jan 2006
Posts: 727
Location: FAIRFAX VA

Posted: Sun Jun 28, 2009 6:15 am Post subject: Complex aircraft NTSB report

6/28/2009



The NTSB Report NYC08FA023 contains the following statement:



"14 CFR Part 21.93 requires that any major changes that are made to an

airplane require inspection by the FAA prior to further flight."



This statement does not apply to the amateur built experimental airplane 

being reported upon in this accident report. Instead it applies to aircraft 

with changes in type design.



Actions required when changes are made to an amateur built experimental 

aircraft are described in the Operating Limitations for that specific 

aircraft.



'OC' Says: "The best investment we can make is the effort to gather and 

understand knowledge."

nuckolls.bob(at)aeroelect
Guest

Posted: Sun Jun 28, 2009 7:05 am Post subject: Complex aircraft NTSB report

At 09:07 AM 6/28/2009, you wrote:




6/28/2009



The NTSB Report NYC08FA023 contains the following statement:



"14 CFR Part 21.93 requires that any major changes that are made to an

airplane require inspection by the FAA prior to further flight."



This statement does not apply to the amateur built experimental 

airplane being reported upon in this accident report. Instead it 

applies to aircraft with changes in type design.



Actions required when changes are made to an amateur built 

experimental aircraft are described in the Operating Limitations for 

that specific aircraft.



    Thanks for responding to this Bob. It rang

    some alarm bells when I first read it but

    had not yet taken time to research it.



    I would offer to add the following: Just

    because some legacy or regulatory mandate

    "does not apply" to the OBAM aircraft endeavor

    does not automatically tag it useless or

    unworthy of consideration.



    I have many moons of experience working inside

    the rubber padded room that is bounded by lots

    of rules . . . some of which were crafted and

    later administered by folks who didn't understand

    the discipline in which we work.



    At the same time, MOST of the rules stand

    on foundations crafted of simple-ideas of

    physics, logic and/or historical experience.

    In the case of 21.93, when one takes hammer

    and saw to the airplane, it doesn't hurt and

    may be very helpful to seek the advice of

    any who can offer mentorship.



    Clearly, the subject of this unhappy thread

    did not avail himself of the volumes of

    data and guidance freely offered from hundred

    of sources. It was his choice, decision and

    risk. Fortunately, the other seats were

    un occupied when the risks tagged him on the

    shoulder.



    If the community of OBAM aircraft builders

    can claim any common fraternal goal, it

    should go much deeper than the sharing goggles,

    helmet and white scarf experiences of flying.

    It includes the task of RISK REDUCTION. Our

    machines are beautiful, exciting, and offer

    a potential for great utility. But they

    are exceedingly unforgiving of those

    who do not embrace a necessity of

    responsible conduct supported by skill

    and understanding.



    Fly comfortably my friends . . .



        Bob . . .



         ---------------------------------------

        ( . . .  a long habit of not thinking   )

        ( a thing wrong, gives it a superficial )

        ( appearance of being right . . .       )

        (                                       )

        (                  -Thomas Paine 1776-  )

         ---------------------------------------

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