NTSB Factual Report

HISTORY OF FLIGHT

On October 12, 1997, shortly after 1728 Pacific daylight time, an experimental Adrian Davis Long EZ, N555JD, crashed into the Pacific Ocean near Pacific Grove, California. The airplane was destroyed and the pilot, the sole occupant, received fatal injuries. The accident occurred during a local, personal flight, visual meteorological conditions and no flight plan was filed.

An aircraft maintenance technician who assisted the pilot in removing the airplane from a hangar before the accident flight stated that he observed the pilot perform a preflight check that took about 20 minutes. He stated that the pilot borrowed a fuel sump cup and drained a fuel sample to check for contaminants. He did not observe whether the pilot visually verified the quantity of fuel aboard the airplane. He did not see the pilot check the engine oil level.

The technician stated that he and the pilot talked about the inaccessibility of the cockpit fuel selector valve handle and its resistance to being turned. The handle was located behind the pilot's left shoulder. They attempted to extend the reach of the handle, using a pair of vice grip pliers. But this did not solve the problem as the pilot could not reach the handle. The pilot said he would use the autopilot inflight, if necessary, to hold the airplane level while he turned the fuel selector valve.

According to the maintenance technician, the pilot declined an offer of fuel service. The pilot told him that he would only be flying for about 1 hour. The pilot then got in the airplane and proceeded with his preflight duties, including checking the operation of the control surfaces According to the technician, he observed the fuel selector handle in a vertical position. (see Aircraft Information section for a discussion of fuel selector handle ). The technician said that he went into the hangar to put away his tools, and he heard the engine start; however, it soon quit. He walked out of the hangar and observed the pilot turned in his seat to the left, toward the fuel selector location. The technician said he believes that the pilot changed the fuel selector and restarted the engine.

A review of the Monterey Peninsula Airport Air Traffic Control Tower (ATCT) tapes revealed that the pilot contacted ground control at 1702 and obtained a taxi-for-takeoff clearance from the hangar. At 1709, the pilot contacted the local controller, reported ready for takeoff on runway 28, and requested to stay in the traffic pattern for some touch-and-go landings. He was subsequently cleared for takeoff at 1712, and performed three touch-and-go landings before departing the traffic pattern about 1727. At this time the controller asked the pilot to recycle his transponder code, and the pilot did so. The ATC tapes revealed no recorded distress calls from the pilot, and the pilot did not indicate any aircraft or engine malfunctions.

A certified audio cassette re-recording of the transmissions between the accident airplane and the Monterey ATCT local control position was sent to the Safety Board's audio laboratory for analysis. The radio transmissions were examined on an audio spectrum analyzer in an attempt to identify any background sound signatures that could be associated with either the engine or the propeller. Analysis of nine transmissions between 1714 and 1728:06 showed engine speed harmonics between 2,100 and 2,200 revolutions per minute (rpm). At the last radio transmission attributed by the Federal Aviation Administration (FAA) to the accident aircraft (at 1728:06), the measured frequency was to 2,200 rpm. A copy of the laboratory report is attached.

Twenty witnesses to the accident were interviewed. Some of the witnesses observed the airplane descend into the ocean near Point Pinos approximately 150 yards off shore, where the water is 30 feet deep. Depending on where they were when the crash occurred; four of the witnesses indicated that the airplane was originally heading west; five of them observed the airplane in a steep bank, with four of those five reporting the bank was to the right (north). Twelve witnesses saw the airplane in a steep nose-down descent, and 6 of them saw the airplane hit the water. Witnesses estimated the airplane at 350 to 500 feet over the residential area while heading toward the shoreline. Eight of the witnesses said that they heard a "pop" or "backfire," along with a reduction in the engine noise level just before the airplane descended into the water.

PILOT INFORMATION

The pilot's logbook was not recovered. During the investigation, the pilot's FAA airman and medical records were obtained from the Airman and Medical Records Certification Branch, FAA, in Oklahoma City, Oklahoma. On his most recent medical application of record, dated June 13, 1996, he reported a total flight time of 2,750 hours. He held a private pilot certificate, with airplane ratings for single and multiengine land, single-engine sea and gliders. He also held an instrument airplane rating and a Lear Jet type rating.

Another Long EZ pilot (hereinafter referred to as the "checkout" pilot), gave the pilot about 1/2 hour of ground and flight checkout in the accident airplane in Santa Maria, California on the day before the accident, before the pilot's departure for Monterey. He said that they performed two touch-and-go landings and some slow flight maneuvers, and that they discussed the aircraft systems, including the fuel selector location. He said that he had made arrangements with the pilot to relocate the fuel selector handle while the pilot, a musical performer, was away on tour. He also said that a pillow was placed on the back of the pilot's seat to assist him in reaching the rudder pedals.

The checkout pilot stated that about a month before the accident, he had flown in the front seat with the pilot on a demonstration flight in the accident airplane. He said the pilot had also flown in the backseat on two other Long EZ demonstration flights.

A certified true copy of the pilot's FAA medical record files were obtained and reviewed by Safety Board investigators. According to the pilot's FAA medical records, the physician who examined the pilot on June 13, 1996, issued a third-class medical certificate to the pilot at the conclusion of the examination. His FAA medical records further showed that on November 6, 1996, the FAA Civil Aeromedical Certification Division sent the pilot a letter by certified mail, return receipt requested, acknowledging receipt of his June 13, 1996, medical application and stating, in part:

We had previously received an interim report from H. C. Whitcomb, Jr., M.D., pertinent to your alcohol problem. Dr. Whitcomb reported that "in general averages two to four drinks of either wine or beer/week when he's traveling." He further stated that there has been no abuse, (see footnote 1) ...in our letter of October 18, 1995, we specified that your "continued airman medical certification remains contingent upon your total abstinence for use of alcohol."

The letter informs the pilot that based on the above information, he did not meet the medical standards prescribed in Part 67 of the Federal Aviation Regulations, and a determination was made that he was not qualified for any class of medical certificate at that time. The letter further states: "If you do not wish to voluntarily return your certificate, your file may be sent to our regional office for appropriate action." According to U. S. Postal Service markings on the envelope, the letter was returned unclaimed to the FAA on December 2, 1996.

Examination of the FAA medical file disclosed that following the return of the unclaimed November 6, 1996, letter there was no followup action by the FAA until March 25, 1997, when the agency sent the pilot a second letter by certified mail, return request requested, again notifying him that he was medically disqualified. The return receipt for the certified letter was examined by Safety Board investigators; however, the signature of the person who had signed for the mail was illegible.

AIRCRAFT INFORMATION

The accident airplane was an experimental amateur built canard (1) type aircraft. The data plate indicated a manufacture date of June 1987. The airplane was designed by Rutan Aircraft Factory and was built from the Rutan plans by Adrian D. Davis, Jr. Review of FAA Aircraft Registry records for the airplane revealed that the original builder applied for an airworthiness certificate in the amateur-built, experimental category on May 5, 1987. The airworthiness certificate was issued by an FAA Airworthiness Inspector from the Houston, Texas, Flight Standards District Office on June 12, 1987. On the application, the inspector checked the box stating "I have found the aircraft described meets the requirements for the certificate requested." A letter of operating limitations was also issued on that date and included the statement: "This aircraft shall contain the placards, listings and instrument markings required by FAR 91.3 (Subsequently redesignated 14 CFR 91.9).

The airplane was equipped with an electric force bias trim system for both the pitch and roll axis, and an electrically actuated speed brake that deploys from the fuselage belly. The switches for the electric trim and the speed brake were located on the side stick controller. The airplane was equipped with a single axis roll autopilot, but the autopilot was not recovered.

According to the checkout pilot, and confirmed by the seller, the canard had the Ronz No. 1145ms airfoil.

According to the operator's manual, the Long EZ was designed either for a rear mounted Continental O-200 (100 horsepower (hp)) or a Lycoming O-235 (115 hp) engine. The engine installed on the accident airplane was a Lycoming O-320-E3D, producing 150 hp and consumes 8.5 to 10 gallons of fuel per hour depending on the power setting. This engine installation also required the installation of 50 pounds of ballast in the nose. An electrical starter was also installed on the engine.

The airplane's designer provided a written statement to the Safety Board in response to an inquiry regarding the compatibility of the airframe with the Lycoming O-320 engine. He stated that "the only engines approved by the factory for installation" are the Continental models O-200 or O-240, or the Lycoming O-235. The designer reported that he is aware that some Long EZ's have been modified with engines of up to 200 horsepower and operate at weights 50 percent above the prototype limit, and that "this level of experience with growth versions does indicate that there are substantial margins in the design. According to the pilot who sold the airplane to the accident pilot and the checkout pilot, disclosed that no ballast was installed in the nose. However, two batteries, totaling 40.8 pounds, were relocated in the nose section, one directly in front of the foremost bulkhead and the other just behind it.

FAA records indicate that the seller who sold the airplane to the accident pilot purchased the airplane from the builder on March 5, 1994. On April 13, 1996, the seller changed the registration number from N5LE to N228VS. According to the seller, the airplane was sold to the accident pilot on September 27, 1997. The airplane was then (by the checkout pilot) flown from Santa Ynez to Santa Maria, California, to be repainted in connection with the sale to the pilot. During the repainting of the aircraft, the registration number of was changed by the pilot to N555JD.

At Santa Maria, the airplane was sanded, primed, and painted. Telephone interviews with personnel at the paint shop revealed that the old paint was not stripped off. No control surfaces were removed at any time. The only items removed during the painting were the two wing-mounted cargo pods, which were painted in a multicolored scheme and reinstalled. As applied, the paint weighed about 4 pounds per 100 square foot, according to paint shop personnel.

During the investigation, copies of a empty airplane weight and balance document, dated May 18, 1996, were located at Craftsmans Corner, Santa Paula, California. It listed an airplane empty weight of 1,061 pounds and center of gravity (CG) at 110.0 inches. In an interview, the manager of Scaled Composites, Inc., (Rutan Aircraft) estimated that, based on the total wetted area of the airplane, the paint applied at Santa Maria would have added 30 pounds to the empty weight for a total of 1,091 pounds with a CG at 110.0 inches.

Based the weight and balance document and estimates of the airplane's probable fuel load at the accident flight's departure from Monterey, gross weight and CG conditions were calculated and are appended to this report. Those calculations show that at the beginning of the accident flight, the airplane would have had a gross weight of approximately 1,310 pounds, with a CG at 103.65 inches. At the time of the accident, the airplane would have had a gross weight of approximately 1,280 pounds, with a CG at 103.63 inches. According to Scaled Composites Inc., the design gross weight limit is 1,425 pounds and the CG range is from the forward limit of 98 inches to the rear limit of 103 inches.

In a telephone interview on June 15, 1998, an engineering representative from Scaled Composites, Inc., reported that the airplane was designed with a published aft limit of 104 inches, and the prototype was extensively tested and flown at this limit. Subsequently, in the interests of conservative margins, the designer changed the published limit to 103 inches. According to the designer during flight tests, the prototype was flown at 106 inches and flew all test points satisfactorily, and no adverse handling characteristics were noted.

The representative from Scaled Composites, Inc., also reported that the company flew the same profile as that believed to have been flown during the accident flight (start, taxi, run-up, takeoff, three touch-and-goes, and a pattern departure) in a Lycoming O-320-equipped Long-EZ and measured the fuel consumed at 3.6 gallons. After running one tank dry, a time interval of 6 to 8 seconds was measured between changing the fuel selector and the resuming of engine power. The representative stated that although the fuel tanks of the airplane were extensively damaged, during the wreckage reconstruction he observed that the fuel tanks were built to plan specifications. The representative of Scaled Composites, Inc. said the system does not appear to have an unusable quantity. Two sumps, each having about a quart capacity, are located in the tanks. The tank is designed so that the fuel will feed into the sumps in all flight attitudes. The representative said the only known condition that would tend to favor an unporting is in a prolonged descent with just a few gallons of fuel in the tank.

According to the designer of the airplane and the drawings issued to the builder, the fuel selector is to be located just aft of the nose wheel position window between the pilot's legs. The accident airplane's fuel selector handle was positioned by the builder on the bulkhead behind the pilot's left shoulder. The selector valve was installed inside the engine firewall 45 inches aft of the selector handle. The handle and valve were joined by steel and aluminum tubing, connected by a universal joint.

According to the designer and the seller, this type of airplane has two 26-gallon fuel tanks in the wing roots that contain usable fuel. The fuel quantity is determined by viewing non-linear sight leave gauges located in the rear cockpit at the wing roots. The sight gauges show an amount of actual fuel supporting a red float. Postaccident examination of the airplane disclosed that the sight gauges were not marked or calibrated for quantity.

The maintenance technician who helped the pilot move the airplane out of the hangar before the accident flight mentioned that the fuel sight gauges were only visible to the rear cockpit occupant. The pilot then asked the technician about the quantity of fuel shown. The technician told the pilot that he had "less than half in the right tank and less than a quarter in the left tank." The technician said

NTSB Probable Cause

the pilot's diversion of attention from the operation of the airplane and his inadvertent application of right rudder that resulted in the loss of airplane control while attempting to manipulate the fuel selector handle. Also, the Board determined that the pilot's inadequate preflight planning and preparation, specifically his failure to refuel the airplane, was causal. The Board determined that the builder's decision to locate the unmarked fuel selector handle in a hard-to-access position, unmarked fuel quantity sight gauges, inadequate transition training by the pilot, and his lack of total experience in this type of airplane were factors in the accident.