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NTSB Report

March 16, 1994 · Ayres S-2R · N40237

Reno, NV

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
March 16, 1994
Injury Outcomes
1 injury (1 fatality), 1 unknown outcome
Location
Reno, NV
Aircraft
Ayres S-2R
Tail Number
N40237
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
LAX94FA165

On the previous flight, the pilot made an unscheduled stop at Truckee due to high oil temperature & low oil pressure. After consulting with the owner/operator, the pilot arranged for a mechanic to check the magnetic drain plug & engine oil screen. The magnetic drain plug was free of particle debris & the screen had a few particles (not out of ordinary). A decision was made to ferry the plane to Reno/Stead, where experienced maintenance for Wright engines was available. During flight, the pilot reported problems with the engine & indicated he would land on a road. One witness said he saw a puff of white smoke followed by black smoke. While landing, the plane hit electrical lines along the roadway, then it struck a light post, the ground & a van. An exam revealed metal chips on the oil drain plug & in the oil screen. Tear-down of the engine revealed a worn master rod journal with heat discoloration. Toxicology tests showed 0.003 ug.ml of tetrahydrocannabinol carboxylic acid (marijuana) in the pilot's blood & 0.072 ug/ml in his urine.

NTSB Probable Cause

AN UNDETERMINED PROBLEM WITH THE ENGINE OIL SYSTEM, A DECISION TO FLY THE AIRPLANE WITH A KNOWN DEFICIENCY, AND PROGRESSIVE (PARTIAL) FAILURE OF THE ENGINE MASTER ROD AND BEARING.

Full Narrative

On March 16, 1994, at 1408 hours Pacific standard time, an Ayres S2R-R1820, N40237, lost power and collided with wires, a light post, and a van while attempting to land on a highway in Reno, Nevada. The airplane was being ferried to a maintenance facility by the operator, Grangeville Air Service, Grangeville, Idaho. The airplane was destroyed by impact forces and postimpact fire. The certificated commercial pilot and the driver of the van were fatally injured. The pilot departed Truckee, California, about 1350 hours and was destined for the Reno-Stead Airport for maintenance. The purpose of the flight was to ferry the airplane from Lincoln, California, to Lewiston, Idaho. The airplane was recently purchased by the operator from a company in Garden City, Kansas, and was flown to Lincoln, California, for installation of new radios. The airplane originally had departed the Lincoln Municipal Airport about 1050 hours and was scheduled to stop at Winnemucca, Nevada, to refuel before continuing to Lewiston, Idaho. The pilot made an unscheduled stop at the Truckee-Tahoe Airport. The pilot telephoned the airplane operator/owner and stated the engine oil temperature was high and the oil pressure was low. The airplane operator contacted a fixed-based operator (FBO) in Lewiston, Idaho, with experience in maintaining the type of radial engine installed in the airplane. The FBO contacted the pilot at the Truckee Airport to determine the nature of the problem. The pilot then went to a local mechanic at the Truckee Airport and arranged to have the airplane's engine case magnetic drain plug and engine oil sump screen removed and examined. According to the mechanic, the magnetic drain plug was free of any particle debris. The engine oil sump screen had a few particles, but nothing out of the ordinary. The engine oil sump screen and magnetic drain plug were installed back on the airplane. The pilot made some additional telephone calls and then departed the Truckee Airport. Visual meteorological conditions prevailed at the time. About 1408 hours, the pilot made a distress call on 121.5 mHZ. The distress call was monitored by the Reno-Cannon International Airport air traffic control tower. The pilot indicated he was several miles north of the airport and the airplane was having engine problems. The air traffic control tower cleared the pilot to land at the Reno-Cannon Airport. The pilot indicated the airplane was unable to make it to the airport and he was going to land on a road. The airplane was seen by ground witnesses heading eastbound over North McCarran Boulevard. One witness said he saw a puff of white smoke from the engine followed by black smoke. Many witnesses reported the airplane leaking engine oil. The witnesses said the airplane struck some electrical lines suspended across North McCarran Boulevard 30 feet in the air. The airplane was aligned with the eastbound lanes of the boulevard. The left wing then struck a light post in the center median of the boulevard breaking the post and separating about 30 inches of the left wing tip. The airplane rolled left towards the westbound lanes and struck the ground. The airplane cartwheeled and struck an oncoming van in the westbound lane of the State Highway 395 overpass. The airplane tumbled off the north side of the overpass, traveled over the southbound lanes of State Highway 395, and came to rest on the right shoulder of the northbound lanes. The airplane's engine separated at the firewall and came to rest away from the fuselage. Fuel was reported leaking from the airplane. A postimpact fire erupted and engulfed the fuselage and portions of the engine. Wreckage and Impact Information The airplane's wreckage was transported to the Reno-Stead Airport on March 16, 1994, and examined on March 17, 1994. The airframe skin was burnt exposing the internal structure of the fuselage and chemical hopper. The engine was being stored in a hangar away from the fuselage. Control continuity was established for the flight controls and for the engine controls from the cockpit to the firewall. The airplane instrument panel was destroyed by fire. The engine and accessory components were found intact in a hangar operated by Classic Aviation, Ltd. The lower left and rear areas of the engine were sooted and there was some evidence of heat damage. The number 7 cylinder head was found broken. Portions of the broken cylinder were found on North McCarran Blvd. The spark plugs, magnetic oil sump drain plug, and oil screen were removed. All spark plugs displayed normal operating signatures. The oil sump drain plug was covered with metal chips. Similar metal chips were found in the oil screen. The engine and its related accessory components were then transported to Aircraft Cylinder and Turbine, Inc., for detailed examination and disassembly. Medical and Pathological Information The postmortem examination on the pilot was conducted by the Washoe County Coroner's Office on March 17, 1994, with specimens retained for toxicological examination. The specimens were sent to the Federal Aviation Administration (FAA) Civil Medical Institute (CAMI), Oklahoma City, Oklahoma, for analysis. The toxicological analysis revealed positive results for carbon monoxide and drugs. According to the CAMI report, the carboxyhemoglobin saturation was 22 percent in the pilot's blood. CAMI tests for drugs were positive for Tetrahydrocannabinol Carboxylic Acid (Marihuana) in the pilot's blood and urine, and positive for Acetaminophen in the pilot's blood. Tests and Research The engine was examined at Aircraft Cylinder and Turbine, Inc., Sun Valley, California, on May 19-20, 1994. After disassembly of the engine, the master rod bearing was found worn. The crankshaft master rod journal was worn 0.182 inches. The journal was heat discolored. The engine oil cooler was inspected and flow checked. There was no evidence of mechanical failure or malfunction found. Additional Information The wreckage was released to the representatives of the owner on May 20, 1994.

Flight

Event TypeAccident
Event Time14:08 PST
Nearest Airport0nm
Runway0
Flight Plan FiledNone
Aircraft FireGrd
Aircraft ExplosionNo

Aircraft

AircraftAyres S-2R
Tail NumberN40237
Aircraft CategoryAir
DamageDestroyed
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsWright · R-1820 · Reciprocating · 1200
Seats1

People & Injuries

Injury Summary1 injury (1 fatality), 1 unknown outcome
Fatal1
Serious0
Minor0
Uninjured0
Total2
Crew 1Age 36 · Second Class

Conditions

ConditionsVMC
LightDaylight
Wind180° @ 22 kt
Visibility30 sm
CeilingOvercast 25000 ft
Temperature / Dew Point52 / 27 C
Altimeter29.00 inHg
Observation Time22:28
Weather SourceWFAC

Appendix: Source Data