NTSB Factual Report

HISTORY OF FLIGHT

On September 2, 2011, about 1650 Pacific daylight time, a Consolidated Aeronautics, Inc., Lake LA-4-200 Buccaneer, N80033, sustained substantial damage during impact with terrain on takeoff initial climb from Lampson Field Airport, Lakeport, California. The commercial pilot, the sole occupant and the owner of the airplane, received serious injuries. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the personal cross-country flight, which had just originated. A flight plan had not been filed.

A witness, who was employed by an aircraft maintenance facility at the airport, reported that he observed the pilot being dropped off at the airport by another airplane, a Cessna 340, which did not shut down its engines and immediately departed. The pilot performed a preflight inspection of the accident airplane and then taxied to a run-up area and performed an engine run-up. According to the witness, the engine ran smoothly and sounded like it was “making power.” He watched the airplane takeoff on runway 28 and observed that, although the engine continued to run smoothly, it did not appear to be making full power. The airplane continued down the runway and “finally towards the end it lifted off.” The airplane cleared trees off the end of the runway, but then lost altitude, and he lost sight of it behind the tree line.

Another witness, who was the owner of the aircraft maintenance facility, also observed the airplane takeoff on runway 28. He reported that, during the takeoff ground roll, the engine was “not turning to full takeoff power.” The pilot continued with the takeoff, and the airplane lifted off the runway, but did not climb. The airplane “barely” cleared the trees off the end of the runway, and a few seconds later, the airplane banked right and nosed down out of sight. He and the other witness drove to the accident site, which was in a vineyard about 1/2 mile from the departure end of the runway. When they arrived, the airplane’s engine was still running “at a fairly high rpm,” and he shut off the fuel to turn off the engine.

Due to the pilot’s injuries, he was unable to provide a written statement until January 8, 2012, about 4 months after the accident. In this statement, the pilot reported that the before takeoff engine run-up was normal and that the engine developed “normal full power” on takeoff. About 100 feet above ground level, there was a “slight change in power (with not enough runway left to put back down and stop).” Subsequently, the engine lost “most all” power, and he made a forced landing in the vineyard.

PILOT INFORMATION

The pilot held a commercial pilot certificate with airplane single engine land, airplane single engine sea, airplane multi-engine land, airplane multi-engine sea, instrument airplane, and helicopter ratings. His most recent third-class medical certificate was issued on December 21, 2010. He reported that he had accumulated a total flight time of about 8,300 hours, of which over 2,000 hours were in Lake airplanes.

AIRCRAFT INFORMATION

The airplane’s maintenance logbooks were not located during the investigation. According to records provided by the pilot and maintenance personnel that had performed the work, the most recent annual inspection of the airplane was completed on August 17, 2010, at an airplane total time of about 501 hours. The airplane’s total time at the time of the accident was about 508 hours.

The pilot reported that the airplane was for sale, and, on May 21, 2011, he had flown it from Napa, California, where it was based, to Lampson Field Airport to meet with a prospective buyer. They flew the airplane for about 2 hours and made several landings. The pilot left the airplane at the maintenance facility at Lampson Field for repair of “occasional plugging of the [engine fuel] injectors with a fine particle” and a plugged fuel drain. Repairs were made, and, on June 10, 2011, the pilot conducted a 15-minute test flight and found that there was “still an occasional loss of power from either a fouled plug or an injector.” The maintenance facility conducted further troubleshooting and recommended that the fuel servo and fuel flow divider be overhauled. After these items were overhauled and reinstalled, the pilot conducted a test flight during which the airplane performed normally. The pilot reported that this test flight took place immediately prior to the accident flight.

The owner of the maintenance facility stated that a work order was initiated on May 24, 2011, for the airplane that listed the following discrepancies and corrective actions.

“Discrepancy #1: Engine won’t run right. Corrective action: Cleaned, gapped, and tested spark plugs. Clean and inspect all fuel injectors. Run compression check: cylinder #1 – 74/80, #2 – 32/80, #3 – 52/80, #4 – 52/80, (customer declined any corrective action at this time).

Discrepancy #2: Fuel drain on left side won’t drain, fuel [drain] line plugged. Corrective action: Removed baggage tunnel under fuel tank, removed plugged 90-degree elbow. Clean and reinstall with new fuel drain valve.

Discrepancy #3: Problem with charging system, circuit breaker pops. Corrective action: Re-position alternator SCAT cooling hose to clear alternator field terminals.”

The owner of the maintenance facility reported that the work was completed on June 3, 2011, the airplane was test flown the next day by the pilot, and “the fuel injector nozzles on cylinder #1 and #3 were plugged.” After further troubleshooting, a new work order was initiated on June 14, 2011, for the airplane that listed the following discrepancies and corrective actions.

“Discrepancy #1: Engine still runs rough due to plugged nozzles. Corrective action: Re-clean all fuel injectors and cleaned fuel screens.

Discrepancy #2: Recommend to send fuel servo and flow divider off for overhaul. Corrective action: [Send fuel servo and fuel flow divider to certified repair station for overhaul. Reinstall after overhaul.]

Discrepancy #3: Determined that the injectors were still plugged even after the fuel servo and flow divider were overhauled. Corrective action: Install all new fuel injector lines and secure with new hardware.

Discrepancy #4: AD 08-14-07 External Fuel Injection Fuel Lines (Repetitive inspection per paragraph (j). Corrective action: Verified fuel injection system was re-installed per guidelines of Textron Lycoming Mandatory Service Bulletin MSB 342F.”

The owner of the maintenance facility reported that the work was completed on August 22, 2011. The pilot test flew the airplane and told the owner of the maintenance facility that the engine “ran fine, except the prop[eller] was surging.” According to the owner of the maintenance facility, the pilot again flew the airplane on the morning of the day of the accident and then called him and told him that “the engine was running great.” Later that day, the owner of the maintenance facility witnessed the accident takeoff.

METEOROLOGICAL INFORMATION

At 1656, the reported weather at Ukiah Municipal Airport, Ukiah, California, elevation 614 feet, located about 15 nautical miles to the northwest, included wind from 270 degrees at 11 knots; visibility 10 statute miles, sky clear; temperature 36 degrees Celsius; dew point 1 degree Celsius; and altimeter setting 29.80 inches of Mercury.

AIRPORT INFORMATION

Lampson Field Airport, elevation 1,380 feet, had one paved runway, runway 10/28, which was 3,600 feet long. There was a flat, mowed grassy area extending for about 950 feet from the departure end of runway 28. An orchard with trees that were about 20 feet tall was located beyond the grassy area.

WRECKAGE AND IMPACT INFORMATION

A Federal Aviation Administration inspector responded to the accident site and examined the airplane. The inspector reported that that the leading edge of the left wing sustained impact damage from the sponson to the wing tip, and the right wing sustained minimal impact damage. The fuselage was torn open on its left side near the middle of the cabin and bent upwards aft of the cabin. The windshield and both clamshell cabin doors had separated, and the cabin roof was displaced aft. The empennage was intact and undamaged. The engine pylon was bent to the right. The engine and propeller remained in place and appeared to be undamaged. The main fuel tank was intact and contained clean, blue fluid that appeared to be aviation fuel. The throttle control was torn from its mounting location on the cabin roof. The mixture, propeller, and alternate air controls were intact and continuity was confirmed; however, the position of these controls during the accident could not be determined due to the bending of the engine pylon.

On October 19, 2011, the engine was examined under the supervision of a National Transportation Safety Board investigator. The top spark plugs were removed from the engine; the left and right magneto “P” leads were disconnected; and the engine was manually rotated by hand using the propeller. Thumb compression was obtained on all four cylinders, and spark was produced at all ignition leads. Throttle control continuity was established from the cockpit control to the engine. The throttle cable attach bracket at the top of the engine pylon was found separated; the fracture surface was bright in appearance and appeared to be impact related.

NTSB Probable Cause

The pilot's decision to continue the takeoff with reduced engine power, which resulted in a collision with terrain during the takeoff initial climb. Contributing to the accident was the partial loss of engine power for reasons that could not be determined because postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation.