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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

December 6, 1991 · Glasair SH-2R · N614LS

Nuevo, CA

Overview

Report Status
Probable Cause
Event Type
Accident
Date
December 6, 1991
Injury Outcomes
1 injury (1 fatality)
Location
Nuevo, CA
Aircraft
Glasair SH-2R
Tail Number
N614LS
Operator
Saber Lloyd E
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
LAX92FA064

The airplane collided with rugged terrain after a loss of engine power. It struck the north face of 20 degree slope of an east-west ridge, just below the crest. The airplane then slid about 20 ft down the slope where a post-impact fire destroyed the plane. An exam of the engine spark plugs revealed the #1 & #3 cylinder spark plug gaps were bridged with cinder-like deposits with metallic globules starting to fill the firing end cavity & worn center electrodes. According to the spark plug manufacturer, severely fouled plugs will operate colder causing misfires, and will also misfire at higher power because of the conductive nature of the deposits at elevated temps. Bridged gaps will short out the spark plug. Such a malfunctioned plug will misfire at all power settings in a manner similar to a oil fouled plug. Bridged gaps bridged by beaded lead globule will not clear up by engine operation & can be corrected only by replacing the malfunctioning spark plug with a serviceable unit. The acdnt time was estd be at 1530 PST.

NTSB Probable Cause

THE FAILURE OF THE PILOT TO PERFORM PREVENTATIVE MAINTENANCE ON THE AIRPLANE'S POWERPLANT WHICH RESULTED IN A LOSS OF PERFORMANCE DURING AN UNKNOWN PHASE OF OPERATION. CONTRIBUTING TO THE ACCIDENT WAS FOULED SPARK PLUGS AND THE PARTIAL LOSS OF AIRCRAFT PERFORMANCE.

Full Narrative

THE AIRPLANE COLLIDED WITH RUGGED TERRAIN AFTER A LOSS OF ENGINE POWER. IT STRUCK THE NORTH FACE OF 20 DEG SLOPE OF AN EAST-WEST RIDGE, JUST BELOW THE CREST. THE AIRPLANE THEN SLID ABOUT 20 FT DOWN THE SLOPE WHERE A POST-IMPACT FIRE DESTROYED THE PLANE. AN EXAM OF THE ENGINE SPARK PLUGS REVEALED THE #1 & #3 CYLINDER SPARK PLUG GAPS WERE BRIDGED WITH CINDER-LIKE DEPOSITS WITH METALLIC GLOBULES STARTING TO FILL THE FIRING END CAVITY & WORN CENTER ELECTRODES. ACCORDING TO THE SPARK PLUG MANUFACTURER, SEVERELY FOULED PLUGS WILL OPERATE COLDER CAUSING MISFIRES, AND WILL ALSO MISFIRE AT HIGHER POWER BECAUSE OF THE CONDUCTIVE NATURE OF THE DEPOSITS AT ELEVATED TEMPS. BRIDGED GAPS WILL SHORT OUT THE SPARK PLUG. SUCH A MALFUNCTIONED PLUG WILL MISFIRE AT ALL POWER SETTINGS IN A MANNER SIMILAR TO A OIL FOULED PLUG. BRIDGED GAPS BRIDGED BY BEADED LEAD GLOBULE WILL NOT CLEAR UP BY ENGINE OPERATION & CAN BE CORRECTED ONLY BY REPLACING THE MALFUNCTIONING SPARK PLUG WITH A SERVICEABLE UNIT. THE ACDNT TIME WAS ESTD BE AT 1530 PST.

Flight

Event TypeAccident
Event Time15:30 PST
Nearest Airport0nm N
Runway0
Flight Plan FiledNone
Aircraft FireGrd
Aircraft ExplosionNo

Aircraft

AircraftGlasair SH-2R
Tail NumberN614LS
Aircraft CategoryAir
DamageDestroyed
OperatorSaber Lloyd E
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · O-360-B1E · Reciprocating · 180
Seats2

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 62 · Second Class

Conditions

ConditionsVMC
LightDaylight
WindCalm
Visibility5 sm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Weather SourceWIT

Appendix: Source Data