NTSB CAROL · Event
Event WPR22FA335
Aircraft involved
Probable cause & findings
The pilot’s improper maintenance of the ignition system, which led to an ignition system failure and a loss of engine power.
Factual narrative
HISTORY OF FLIGHTOn September 05, 2022, about 0948 Pacific daylight time, a Rutan Varieze, N10EZ, was substantially damaged when it was involved in an accident near Columbia, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot had been performing maintenance on the accident airplane and upgrading various systems. The weeks before the accident, he installed an Electroair electronic ignition system. The accident flight was the first flight out of maintenance. The radar and ADS-B data indicated that the airplane departed runway 17 about 0845. The airplane continued southeast about 8 nautical miles (nm) and then retuned back to the airport, landing on the same runway about 0858. The recorded data then shows that around 0903 the airplane departed and continued southeast in a climb for about 35 nm. After about 18 minutes, the airplane made a 180° left turn while passing through 13,500 ft mean seal level (msl). The airplane climbed to a peak altitude of 16,475 msl and then began a descent, maneuvering into a left traffic pattern for runway 35. The airplane made a high-speed pass over runway 35 and then continued north-northeast for about 5 nm. The airplane returned back to the airport; around 0945, it passed over the center of the airport at an altitude of 2,850 ft (see Figure 1 below). The airplane turned right and joined the right traffic pattern for runway 17. At 0946:56, the airplane turned onto the base leg and the airspeed decreased. Figure 1: Recorded ADS-B Data from the end of the flight A comparison of the first flight and the accident flight revealed that the speeds were similar during the landing approach. The first flight passed near the location of the last recorded ADS-B return about 75 ft higher (see Figure 2 below). Figure 2: Comparison of first flight and accident flight AIRCRAFT INFORMATIONThe amateur-built airplane was powered by a rear-mounted Continental O-200 reciprocating engine rated at 100 horsepower, and drove a fix-pitched, two-bladed propeller. A review of Federal Aviation Administration (FAA) records revealed that several individuals had owned the airplane and the accident pilot had purchased the airplane in May 2021. The Hobbs meter at the accident displayed 668.1 hours, equating to 11.4 hours before the last recorded maintenance; the reason for the discrepancy of hours is unknown. The last annual inspection was recorded as being completed on October 6, 2021, at a total airframe time of 676.4 hours and 701.4 hours of engine time since the last major overhaul. During that inspection the mechanic noted that both magnetos needed to be replaced and were overdue for a 500-hour inspection; additionally, the carburetor had reached the maximum time-between-overhauls (in excess of 10 years). According to VariEze Owner’s Manual, during an engine-out emergency landing, the landing gear should be down, and the pilot should turn off the electrical power and magnetos to minimize any potential fire hazard. AIRPORT INFORMATIONThe amateur-built airplane was powered by a rear-mounted Continental O-200 reciprocating engine rated at 100 horsepower, and drove a fix-pitched, two-bladed propeller. A review of Federal Aviation Administration (FAA) records revealed that several individuals had owned the airplane and the accident pilot had purchased the airplane in May 2021. The Hobbs meter at the accident displayed 668.1 hours, equating to 11.4 hours before the last recorded maintenance; the reason for the discrepancy of hours is unknown. The last annual inspection was recorded as being completed on October 6, 2021, at a total airframe time of 676.4 hours and 701.4 hours of engine time since the last major overhaul. During that inspection the mechanic noted that both magnetos needed to be replaced and were overdue for a 500-hour inspection; additionally, the carburetor had reached the maximum time-between-overhauls (in excess of 10 years). According to VariEze Owner’s Manual, during an engine-out emergency landing, the landing gear should be down, and the pilot should turn off the electrical power and magnetos to minimize any potential fire hazard. WRECKAGE AND IMPACT INFORMATIONThe accident site was located in a sparsely populated residential neighborhood in uneven terrain made up of large boulders, loose rocks, and numerous trees and brush. The main wreckage, consisting of a majority of the airframe and engine, was about 0.5 nm north of the runway threshold (see Figure 3 below). There was a northwest-southeast oriented main-road located 375 ft east of the accident site and numerous other streets in the immediate area. Figure 3: Main wreckage in reference to the runway The first identified point of impact was a 50-ft maple tree that had several severed limbs. Adjacent to the tree was a small portion of the outboard right-wing cuff. The second point of impact was a large 80-ft tall fir tree that had severed branches about 35 ft up the tree. The airplane fuselage came to rest inverted, and the wings remained attached. The wreckage was consistent with the nose gear being in the down position. Complete control continuity could not be verified due to the extensive impact-related damage. The airplane sustained major crush damage to the front cockpit. The fuel tanks were all intact and there was no evidence of a breach. There was no fuel found in the left tank, about 2 gallons found in the right tank, and about 6 ounces in the header tank. The fuel found was free of water and debris. There was evidence of seepage out of the vented cap in the header tank (blue staining). The same liquid was found when activating the accelerator pump in the carburetor, but the bowl was dry. The impact and position that the airplane came to rest made it impossible to determine the total fuel quantity at the time of impact. A Safety Board investigator performed a complete disassembly of the Continental O-200 engine. Investigators established continuity of the valve and gear train by rotating the crankshaft via the crankshaft flange (exerting force on the propeller); compression was detected in all cylinders. Normal lift action was observed at each rocker assembly. Clean, uncontaminated oil was observed at all four rocker-box areas. There was no evidence of valve-to-piston face contact observed. The pistons and their respective rings were intact. The valves were intact and undamaged. The back of the intake valves and the intake pipes were sooty down through the intake manifold to the area above the butterfly valve of the carburetor. The two-bladed fixed pitch propeller remained intact and attached to the engine with no visible chordwise scratches or leading-edge damage. One blade was cracked at the tip as a result of coming to rest on a rock. Ignition System The airplane was equipped with a dual ignition system that the pilot had configured in the month before the accident; there was one electronic ignition and one magneto installed at the time of the accident. The ignition system was configured with the Electroair routed to the top spark plugs and the left magneto to the bottom spark plugs. Investigators confirmed that they were both timed correctly. The magneto was operated by a keyed ignition and the electric ignition was operated by a single-pole single-throw (SPST) switch. The airplane’s wiring in the front of the airplane was found hanging over a boulder and it is unknown how much damage was due to impact. The key was not in the magneto ignition, and the switch was in the “off” position. The master switch was the sole toggle switch in the “on” position. The position of the electronic ignition could not be confirmed, and it was not attached in the airframe. The magneto had two P-leads connected. Both wires were routed to the keyed ignition switch: one attached to the “right” and one to the “left” position. This would result in the magneto not being operable in the OFF, RIGHT, and LEFT positions, with only the BOTH position producing an operational magneto. This would have made it impossible for the pilot to verify that both ignition systems were operable during the runup. The Electroair unit was removed from the airplane. The wire from the coil pack to the bus (Bundle #3; 10 amp) was separated at the butt splice and had not been properly crimped on one side (the barrel not depressed on one side); the wire was also chaffed where it had been routed along the fuel lines. The wire strand had wires that were deformed on one side and then bent back under adjacent wires, consistent with the wires being pulled out of a crimped connection and reinserted at an unknown time. Although there was evidence of a prior loose connection, the wire strand was consistent with having a sufficiently tight connection before separation. There was scraping damage on one side of the insulator with elements commonly associated with rock and soil transferred to the damaged areas of the insulator and the adjacent wires next to the insulator. This was consistent with sliding contact with the terrain sufficient to damage the insulator with at least some connection to the wires. The wire from the controller to the bus (Bundle #4; 3 amp) connection had a tighter crimp and had sliding contact marks through the crimp barrel that was consistent with it making contact, despite the crimp not being secured on both sides. Two wires in the strand had been cut, and several others had substantial scraping damage next to the insulator cut. The electronic ignition switch had a tang bent and one wire was not connected; the switch was broken internally; however, the investigation was not able to determine if the damage occurred before or during impact. Figure 4: Electronic system showing wire separation Disassembly of the magneto revealed a fine carbon dust in the housing and the distributor brush was worn, both consistent with extensive wear. The pilot had been performing maintenance on the airplane and upgrading various systems. The accident flight was the first flight out of maintenance. According to radar and ADS-B data, the airplane departed and the pilot executed several maneuvers before returning to the runway. The airplane then made a high-speed pass over the airport, reversed course, and approached the runway again. After a second high-speed pass over the runway, the airplane joined the traffic pattern for landing. As the airplane turned on final approach it was about 680 ft above ground level (agl) at an airspeed of about 70 knots. Over the next 24 seconds, it descended toward terrain at an airspeed of about 66 knots, coming to rest about 0.5 nautical miles (nm) from the runway. A comparison of the airplane’s two approach paths revealed similar speeds and altitudes until the final approach., where the accident flight ADS-B data ends abruptly. At the last ADS-B return, the airplane would have been around 200 ft agl and there was a well-traveled road beneath the flight path. Postaccident examinations revealed no definitive evidence of a failure with the flight control systems. The engine exhibited no evidence of preimpact catastrophic mechanical malfunction or failure, but the negligible damage to the propeller suggests that the engine was not operating at the time of impact. The close proximity of the accident site to the runway’s surface, additionally suggests that the airplane did not have adequate power to reach the runway. The exact fuel quantity at impact could not be determined due to the airplane’s position at the accident site, though there was likely sufficient fuel. During recent maintenance, the pilot modified the airplane to a dual-ignition system, replacing one of the magnetos with an electronic ignition system. The remaining magneto was improperly wired to the ignition, rendering it inoperable unless the keyed-ignition switch was set to the “BOTH” position. This would have made it impossible for the pilot to verify that both ignition systems were operable during the runup unless the electronic switch was activated and was operable, which could not be definitively determined. Disassembly of the magneto revealed fine carbon dust and a worn distributor brush, which could have impaired its performance. The ignition key was found removed from the switch, which was in the OFF position, while the master switch was in the ON position. This suggests that the pilot was likely troubleshooting the ignition system before impact, as it is unlikely he would remove the key without turning off the master switch during an engine-out procedure. The electronic ignition system wiring had two separations where the splices were not properly crimped, allowing the wires to come loose. It is unclear if these separations occurred during the impact. The electronic ignition switch was also found broken internally, with one disconnected wire, and therefore it is unknown if the electronic switch was ever operable. The wiring at the front of the airplane was stretched and hanging over a boulder, making it difficult to determine the damage to the wiring before impact. If the electronic ignition wiring or switch had not been intact on the flight, the engine would have been operating solely on the magneto. If the pilot then turned the keyed ignition switch to the LEFT or RIGHT position, the magneto would have shut off, resulting in a total loss of power. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Aircraft-Aircraft power plant-Ignition system-Ignition system wiring-Incorrect service/maintenance
- — Aircraft-Aircraft power plant-Ignition system-Switching-Inoperative
Verbatim from NTSB's published report. Source file
NTSB_2022_WPR22FA335.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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