NTSB Factual Report

HISTORY OF FLIGHT

On October 28, 2013, about 1300 Pacific daylight time, a Musick Lancair 235, N25DM, completed a low level aerobatic maneuver and collided into a house in a residential neighborhood in McMinnville, Oregon. The pilot was the registered owner and was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot, the sole occupant, sustained fatal injuries; the airplane was substantially damaged. The local personal flight departed from McMinnville Municipal Airport, McMinnville, Oregon, about 1215. Visual meteorological conditions prevailed, and no flight plan had been filed.

A friend of the pilot, who was also a pilot and airplane owner based at McMinnville, stated that they had met at the airport that morning to conduct a business transaction. Around 1000 they finished, and the pilot stated that he was intending to fly the accident airplane. The pilot noted that he hadn't flown for a while, and asked the friend to accompany him on the flight. The friend declined due to previously planned engagements, and that was the last time they interacted.

A helicopter flight instructor, was flying with a student in the traffic pattern around the same time as the pilot. He stated that the pilot was performing touch-and-go practice takeoff and landings on runway 04. The pilot was making wide patterns to the runway, and would then leave the pattern for a short time and reappear. While the flight instructor was in a low hover, the pilot made a radio transmission on the common airport frequency (UNICOM). The pilot stated that he was having trouble with his landing position indicators, and that only two of the airplane's three landing gear lights were illuminated. The pilot requested for the flight instructor to look at the landing gear's position while he perform a low-level pass over the runway.

The pilot maneuvered the airplane about 20 to 40 feet (ft) above ground level (agl) as he passed over runway 04. The flight instructor observed all the landing gear to be extended, and told the pilot of his observation. The pilot communicated that the conflicting observation was confusing, because the landing gear lights indicated that the right gear was not in the down and locked position. The pilot further stated that he was going to gain some altitude, and manually retract and extend his landing gear in an attempt to re-set the lights. He made a departure from the traffic pattern to the northeast, and made no further communications; shortly thereafter several grunts were heard over the radio.

Numerous witnesses observed the airplane flying about 300 ft agl and enter a loop maneuver, subsequently diving toward a house in a steep nose-low attitude. The woman that resided in the house stated that she heard a loud bang and ran outside uninjured.

PERSONNEL INFORMATION

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the pilot, age 56, held a private pilot certificate. His most recent second-class medical was issued on December 01, 2010, with the limitation that he must wear glasses for near vision to exercise the privileges of his certificate. According to the application for his medical certificate, he had about 1,620 hours of total flight experience. The medical certificate would no longer be valid after December 31, 2012.

A friend of the pilot stated that he would routinely perform 180-degree u-turns in the airplane. When in the traffic pattern at an airport, he would do extremely wide patterns and was determined that that was the way the airplane was to be flown. The pilot never performed aerobatics in the airplane; he was not adventurous and did not even like to perform steep turns.

AIRCRAFT INFORMATION

The Lancair 235 is an amateur-built experimental airplane that is sold as a kit. The low-wing airplane was equipped with two seats, retractable landing gear, and traditional flight control surfaces. The accident airplane, serial number (s/n) 36, received a special airworthiness certificate in the experimental category for the purpose of being operated as an amateur-built aircraft in June 1990. The pilot purchased the airplane in 1998.

According to cockpit gages, the airplane's total time in service was 609.4 hours; on an application for an airworthiness certificate in 2004, the total hours were listed as 1,090. Only a few of the records from the airplane were located in the pilot's hangar. The last recorded maintenance record was completed in November 2005 and the last record of an annual inspection was August 30, 2004. The airplane was equipped with a Lycoming O-290G engine, s/n 195424.

The airplane was last fueled prior to departure with the addition of 9.6 gallons of 100LL aviation fuel. According to the fueler, there was fuel in the fuselage tank and he had added 5 gallons in that tank and about 2 gallons in each wing tank.

A friend of the pilot noted the airplane's landing gear had a history of being problematic. He noted that he had not seen maintenance performed on the airplane since the summer of 2012 and thought it was likely out of annual. He commented that the airplane had seemed to always have been unprofessionally maintained and was in poor condition with wires hanging everywhere.

METEOROLOGICAL INFORMATION

A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) in McMinnville recorded weather conditions at 1253. It stated: skies clear; visibility 10 miles; wind from 050 degrees at 12 kts, gusting to 18 kts; temperature 59 degrees F; dew point 30 degrees Fahrenheit; and an altimeter setting of 29.85 inHg.

WRECKAGE AND IMPACT

The main wreckage was located in a garage, which was situated at the most easterly end of a single-family residence and about 3.4 miles from the airport on a bearing of 304 degree. The main wreckage consisted of the empennage, cockpit area, vertical stabilizer and a majority of the rudder. Both wings, horizontal stabilizers and elevator control surfaces were found in the debris field, which stretched about 100 ft and was primarily west of the garage.

The main wreckage came to rest on a wall dividing two rooms: an office (to the south) and a bedroom (to the north). The debris path through the garage to the wall of the garage door was at a 285 degree heading. The garage's exterior impact damage consisted of a hole about 12 ft by 12 ft at its longest points. Inside, the structural 2 x 4 ceiling gussets were knocked free. The fuselage and area forward of the firewall came to rest in the bedroom and the engine was about 15 ft to the west in the bathroom.

The right main landing gear was found in the house and the wheel was detached. The left main landing gear was found under the left wing with the gear doors nearby. The nose landing gear arm was found bent, consistent with being extended at the time of impact.

MEDICAL AND PATHOLOGICAL INFORMATION

The Clackamas Oregon Medical Examiner completed an autopsy of the pilot. The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on the pilot. According to CAMI's report the toxicological findings were negative for ethanol. Pheniramine was detected in the urine, but not in the blood samples.

Clinical testing at the FAA laboratory detected glucose in the vitreous at 82 mg/dl and in the urine at 2514 mg/dl. Post mortem glucose levels in the vitreous are considered normal below 125 mg/dl. However, post mortem urine glucose levels above 100 are considered abnormal. Hemoglobin A1C, a test that measures average blood sugar over several weeks, was tested in femoral blood and found to be 8.6 percent. According to the American Diabetes Association a hemoglobin A1C of 6.5 percent or greater is diagnostic of diabetes

TESTS AND RESEARCH

Investigators from the National Transportation Safety Board and Lycoming Engines examined the wreckage on October 30, 2013 at the facilities of Nu Venture Air Services LLC in Dallas, Oregon.

Control continuity was established from the cockpit area to the control surfaces.

The top cylinder spark plugs were removed and examined; the number two spark plug was dark consistent with oil saturation from the position that the engine came to rest. The carburetor was disassembled, and the float appeared clean; there was fluid in the bowl, and upon removal of the float the seat appeared intact and moved freely. The magneto, which was the right magneto, was rotated, and spark was observed through each post. The other source of ignition appeared to be from an electronic module that was called electro air direct ignition system. All oil screens were clean from debris (both pick up and pressure).

A borescope examination of each cylinder revealed that piston faces were all consistent with one another and showed normal combustion patterns according to the Lycoming representative. Upon rotation of the engine by the propeller hub revealed continuity throughout the engine with equal lift action at each valve. Thumb compression was obtained during rotation, and each rocker arm attained comparable action. The vacuum pump was removed and the carbon inside showed wear patterns consistent with rotation, and was broken in numerous places with the housing showing late scoring consistent with rotation during impact. Dry and intact family gear teeth and housing did not show any signs of wear.

There was no evidence of pre impact mechanical malfunctions or failures.

ADDITIONAL INFORMATION

According to the FAA Airplane Flying handbook (FAA-H-8083-3A), under the heading Landing Gear Malfunctions,

"Once the pilot has confirmed that the landing gear has in fact malfunctioned, and that one or more gear legs refuses to respond to the conventional or alternate methods of gear extension contained in the AFM/POH, there are several methods that may be useful in attempting to force the gear down. One method is to dive the airplane (in smooth air only) to VNE speed (red line on the airspeed indicator) and (within the limits of safety) execute a rapid pull up. In normal category airplanes, this procedure will create a 3.8 G load on the structure, in effect making the landing gear weigh 3.8 times normal. In some cases, this may force the landing gear into the down and locked position. This procedure requires a fine control touch and good feel for the airplane. The pilot must avoid exceeding the design stress limits of the airplane while attempting to lower the landing gear. The pilot must also avoid an accelerated stall and possible loss of control while attention is directed to solving the landing gear problem."

NTSB Probable Cause

The pilot's failure to maintain airplane control while intentionally performing maneuvers in an effort to troubleshoot a landing gear malfunction.