Pilot Debrief

GIBBS LANCAIR 320 near Van Nuys, CA — 2015-01-09

Final reportWPR15FA081
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Date
2015-01-09
Location
Van Nuys, CA, USA
Airport
VNY
Aircraft
GIBBS LANCAIR 320
Registration
N7ZL
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's improper decision to take off despite low fuel alerts, which resulted in a total loss of engine power due to fuel exhaustion, his subsequent failure to maintain adequate airspeed and his exceedance of the airplane's critical angle of attack, which led to an aerodynamic stall and loss of control at too low of an altitude to recover. Contributing to the accident was the pilot's distraction due to his sending e-mails and being rushed during taxi and takeoff, which resulted in reduced vigilance about the airplane's fuel status.

Contributing factors

Contributing to the accident was the pilot's distraction due to his sending e-mails and being rushed during taxi and takeoff, which resulted in reduced vigilance about the airplane's fuel status.

NTSB narrative

The commercial pilot was taking off for a personal, cross-country flight. Several witnesses reported that, shortly after takeoff, when the airplane was about 400 ft above the ground, they heard the engine "pop" at least twice, sputter, and then go silent, consistent with a loss of engine power. About this time, the pilot reported to the tower controller very quickly but not very clearly that "I have an engine failure I think." The tower controller subsequently issued the pilot the current altimeter setting and attempted to contact the pilot but did not receive any further radio transmissions. The airplane continued straight, turned right, and then spun to the ground. A postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The airplane was last refueled before its previous flight in Flagstaff, Arizona, 4 days before the accident; the airplane was then flown from Flagstaff to the Van Nuys Airport, Van Nuys, California. Although a narrow stream of what smelled like gasoline and engine oil was found near the wreckage, there was no fuel remaining in the fuel tanks. The airplane was equipped with an electronic flight instrument system (EFIS), which has a low fuel alert that is set by the pilot or a mechanic. When fuel decreases to the specified amount, an alert pops up front and center on the EFIS, and it will not disappear until the pilot acknowledges it. Given that the pilot mostly conducted his own maintenance, it is highly likely he was familiar with the EFIS and knew that the airplane was low on fuel and how much fuel remained but decided to take off anyway. As a result of his decision, the engine lost engine power shortly after takeoff due to fuel exhaustion at too low of an altitude for the pilot to recover from the stall and subsequent spin. A friend of the pilot reported that the pilot texted him about 1249 when he arrived at the airport. He said that the pilot normally arrived about 1230. The pilot seemed to be in a rush that day because he was supposed to fly home the day before, and apparently he and his wife had argued about the issue. In addition, the pilot's friend noted that the pilot had recently become more conscious about where he bought fuel. Based on the directions the pilot received from the air traffic controller to stay below 2,000 ft if flying to Burbank, the friend believes it is likely the pilot was attempting to fly to Whiteman Airport about 5 nautical miles away that had cheaper fuel before continuing to his destination. According to the air traffic control recordings, the pilot first contacted the ground and tower controllers about 1308, and he was cleared for takeoff at 1311. Just before takeoff, the pilot's work e-mail documented nine messages, three of which were sent by the pilot, the last of which was sent at 1311. In the emails, the pilot indicated confusion about an issue, which may have been a further distraction to him. The evidence indicates that the pilot was rushed and sending e-mails, which likely distracted him during the taxi and takeoff and decreased his vigilance about the airplane's fuel status.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked fuel levels before takeoff to prevent engine failure.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • Photos
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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