LEAGUE LANCAIR IV-TP

Full Narrative

HISTORY OF FLIGHT

On April 23, 2012, at 1017 Pacific daylight time, an experimental League Lancair IV-TP, N66HL, departed controlled flight and broke up inflight 5 nautical miles (nm) southeast of Sisters, Oregon. The private pilot and his certified flight instructor (CFI) received fatal injuries, and the airplane, which was owned and operated by the pilot, sustained substantial damage. The local 14 Code of Federal Regulations Part 91 instructional flight, which departed Roberts Field, Redmond, Oregon, about 0950, was being operated in visual meteorological conditions. No flight plan had been filed.

The purpose of the flight was for the CFI to conduct a flight review of the private pilot in his high-performance, experimental, amateur-built airplane. Flight track data recorded from the airplane's global positioning system (GPS) was extracted from the onboard Chelton multi-functional display (MFD) compact flash memory card that was recovered from the wreckage. The flight data file started at time 0948:34 and the data was captured at 1-second intervals.

The data spanned from 0948:34 to 1017:20, or 28 minutes and 46 seconds. A review of the data revealed that the airplane started at Roberts Field and followed a flight path consistent with a departure from runway 10. The plot continued in that direction for about 2 nm and then reversed course temporarily heading northwest while gradually increasing in altitude from the airport's elevation of about 3,050 feet (ft) mean sea level (msl) to about 10,500 ft msl. Starting about 1008:30, the airplane made several shallow banks heading southwest, then northwest, and then south and began a 7 nm southwest stretch all while maintaining an altitude of about 10,500 ft msl.

A review of the remaining data disclosed that at 1015:20, the airplane was at 10,455 ft msl and began a right turn. The turn continued and the airplane's track completed a 360-degree circular pattern with a diameter of about 2.8 nm over the span of about 1 minute and 30 seconds. While in the turn, the airplane initially descended to about 10,250 ft msl at 1015:42 and then began to climb 1,350 ft over the course of 1 minute to about 11,600 ft msl.

Thereafter, the airplane climbed to its highest altitude of about 11,720 ft msl at 1016:47 and then began to descend as the right turn tightened, creating a "hook" type shape as its end (about 0.4 nm in diameter). This hook encompassed the last hits of the flight track and occurred over 15 seconds, during which the airplane's altitude decreased over 3,900 ft to a recorded altitude of 6,715 ft msl. The last altitude recorded was 6,445 ft., at time 1717:13.

Starting at about 1716:40 (33 seconds before the end of the data), the pitch angle dropped steadily, from 9 degrees nose-up to 68 degrees nose-down at the end of the data. Simultaneously, the vertical speed dropped from a 2,000 feet per minute (fpm) climb to a 22,000 ft per minute (fpm) descent, the g-load increased to 7gs, and the indicated airspeed (KIAS) increased to about 310 kts.

PERSONNEL INFORMATION

Certified Flight Instructor

A review of the airmen records maintained by the Federal Aviation Administration (FAA) disclosed that the CFI, age 52, held a CFI and airline transport pilot certificate with airplane ratings for single-engine and multi-engine land, as well as instrument flight. His most recent second-class medical certificate was issued on February 22, 2012. The pilot had a history of severe obstructive sleep apnea treated with a Continuous Positive Airway Pressure (CPAP) device while sleeping, which he had reported to the FAA.

A National Transportation Safety Board (NTSB) investigator reviewed the CFI's personal flight logbooks. According to the logbooks, his total flight experience was 11,098.4 hours, with 5,320.2 in turbine-engine airplanes. There were entries in the logbook that indicated he had flown the accident airplane about 18 hours, all of which he logged as a CFI. The last flight recorded in the log was noted as taking place on April 14, 2012 in the accident airplane, totaling 2.5 hours flying from Redmond to Madras, Oregon to Bend, Oregon and back to Redmond. The first-pilot's weight was estimated to be about 220 pounds (lbs).

According to the CFI's spouse, he was having no problems sleeping and would regularly get between 7 to 9 hours of sleep. He never received any surgical treatment for the sleep apnea. She additionally reported that the CFI was in good health and took no medication. He had characterized the pilot-owner as being a "very meticulous guy especially with his airplane." He stated that he had not flown a Lancair that was better maintained than the accident airplane.

Pilot-Owner

According to the FAA airmen records, the pilot-owner age 68, held a private pilot certificate with an airplane rating for single-engine land (acquired in 1997), as well as a complex and instrument rating (acquired in 1998). His most recent second-class medical certificate was issued as a limited medical certificate on May 05, 1997. The pilot additionally held a repairman experimental aircraft builder certificate and built the airplane. According to his friends , the pilot did not hold a current medical because of health issues, and therefore always flew with flight instructors familiar with Lancairs. All of these CFIs were approved on the pilot's insurance policy.

The pilot owner's logbooks indicated he had amassed about 785 hours total time, of which 217 was accrued in high-performance turbine airplanes. The last flight was recorded as occurring on February 27, 2012 where he flew 1.7 hours as pilot in command logging 0.2 of that as occurring in actual instrument conditions. The pilot-owner's weight was estimated to be 210 lbs.

AIRCRAFT INFORMATION

The Lancair IV-TP is an amateur-built experimental airplane constructed mainly of composite materials. The high-performance, pressurized airplane is equipped with four seats, retractable tricycle landing gear, and traditional flight control surfaces. The accident airplane received a special airworthiness certificate in the experimental category for the purpose of being operated as an amateur-built aircraft in October 2008. The equipment on the airplane was a standard Lancair installation for an IV-TP and part of a quick-build where the pilot completed the construction in a facility that specializes in helping builders with their kit projects.

The airplane was equipped with a Walter/General Electric M601E-11A engine, serial number (s/n) 071007, and, according to the manufacturer, is rated at 751 shaft horse power (SHP). It had a constant-speed three-bladed Avia Propeller V508/E/84/B2 (s/n 910663007), that was manufactured in 2004; the blades were 84 inches (in) in length.

The airplane's test flight hours were completed in September 2009. Thereafter, the logbooks indicated that the pilot estimated that the airplane's stalling speed in the landing configuration (Vso), at a weight of 3,750 lbs and a CG of 137 inches aft of datum, was 61 knots.

Maintenance Records

The airplane's maintenance records were reviewed by a NTSB investigator. According to the records, the airplane, serial number LIV-578, had accumulated a total time in service of about 463 hours at the time of the last recorded maintenance on April 4, 2012. During that inspection, it was noted that the engine oil was changed, the fuel filter was replaced and the fuel control unit (FCU) was bled. A review of the airplane's documents further revealed that the engine was manufactured in 2007 and as of March 14, 2012, had amassed 457.2 hours and 339 cycles.

Fuel Quantity

Based on Chelton data, the airplane had a recorded total fuel quantity of 138 gallons (gals) at the time of startup, including 57 gals in the left and right wings (114 gals total). The last recorded data point indicated 52 gals in the right tank and 45 gals in the left tank, with a total quantity of 119 gals.

Weight and Balance

NTSB investigators estimated the airplane's gross take-off weight (GTOW) and center of gravity. The GTOW was estimated to be 3,934.4 lbs, with a center of gravity (CG) at 138.5 in aft of datum. The weight at the time of the accident was estimated to be 3,628 lbs, based on the GTOW and the recorded fuel burn.

The weight and balance record in the airplane indicated that the maximum allowable takeoff gross weight was 3,800 lbs, and the allowable CG range was from 132 to 144 in aft of datum. A sheet detailing the weight and balance computations is appended to this report.

The Lancair-recommended maximum GTOW for a Lancair IV-TP with the turboprop engine and winglets was 3,550 lbs. FAA regulations governing amateur-built aircraft identify the builder as the manufacturer of that individual aircraft and, as such, the builder is allowed to set the weight limits, including maximum GTOW, at any desired value.

Because each aircraft is unique in its construction, the builder must determine the stall speeds for that particular aircraft. Documents relating to the stall speeds specific for the occurrence aircraft were found during the investigation and are presented later in this report.

Performance Study

An NTSB engineer used the Chelton MFD data and a simulation of the Lancair IV-TP to compute additional performance information about the flight. In the simulation, the airplane's flight controls were manipulated so as to approximately match the recorded GPS track and MFD altitude data. These calculations are described in a memorandum contained in the public docket for this accident.

The simulations used a simple model of the Lancair IV-TP (flaps in the retracted position), a weight of 3,628 lbs (the estimated GTOW less the recorded fuel flow during the flight), and the weather conditions recorded at the time of the accident. The engine power in the simulation was based on recorded propeller speed (Np) and engine torque (Q) data.

Lancair was not able to provide any usable aerodynamic or performance data with which to construct a simulator model; consequently, the simulator model used in the performance study was based on theoretical aerodynamic relationships grounded in classical aerodynamics and the airplane's geometry; a report of flight tests from 2009 in the accident airplane; estimated stall speeds provided by the Transportation Safety Board of Canada (TSB); estimates of angle of attack, lift, and drag based on the recorded MFD data from the accident flight; and comparisons with other aircraft.

The objectives of the simulation were to:
-obtain a "match" of the recorded MFD GPS positions using the recorded pitch and roll information and engine power.
-verify the self-consistency of the recorded data by comparing the MFD data to self-consistent simulation data.
-provide estimates of performance parameters that were not recorded on the MFD.
-quantify the lift coefficient (CL) required to fly the final maneuver recorded by the MFD and determine its proximity to CLmax (the value of CL at stall).

The simulation was able to generate a reasonably good match of the recorded motion of the airplane. Furthermore, the highest CL achieved in the simulation was about 1.03. The CLmax (at flaps up) implied by the stall speeds obtained during flight tests of the airplane was about 1.30, suggesting that the accident maneuver only required about 79 percent of the available lift from the wing, and consequently did not involve a stall. Instead, the maneuver described by the MFD and simulation is a steepening spiral dive, with increasing roll angle, speeds, and normal load factor (nlf), with nlf reaching about 7 G's and the calibrated airspeed reaching 310 knots at the end of the recorded data.

Pilot's Operating Handbook (POH)

A Pilot Operating Handbook (POH) for an exemplar Lancair IV-TP, provided by Lancair contained stall speeds, from which an estimate of CLmax was made. In a table titled "Aircraft Operating Speeds," the POH listed the following:

-Stall Speed Clean (Vs)=69 KCAS
-Stall Speed landing configuration (Vso)=61 KCAS

The table did not indicate the airplane weight associated with these stall speeds, but the stall speeds published in the POHs of small general aviation aircraft generally correspond to the maximum gross weight of the airplane. The exemplar POH stated that the maximum takeoff weight was 3,200 lb.; assuming that the published stall speeds corresponded to this weight, the resulting CLmax is 2.03 at flaps up, and 2.59 at flaps down. These values are high compared to the flight test results from the accident airplane, the calculation of the former engineer with Lancair, and the CLmax values of other small general aviation airplanes.

The POH for the exemplar Lancair IV-TP contains the following information in the "Emergency Procedures" section (p. III-7):

-The best glide speed tested to date is 120 IAS (indicated airspeed), 1,570 FPM (feet per minute) resulting in a 7.7:1 glide ratio.
-Glide distance is approximately 0.75 nm per 1,000 feet of altitude loss, however this may vary significantly. It is suggested that it be established for your individual aircraft.

1,570 ft./min. at 120 kts. IAS is indeed a 7.7:1 glide ratio. However, a 7.7:1 glide ratio results in a forward distance of 7,700 ft. (1.27 nm) for every 1,000 ft. of altitude loss, so the statement in the POH that the "glide distance is approximately 0.75 NM per 1000 feet of altitude loss" is inconsistent with the 7.7:1 glide ratio information provided in the preceding sentence. 0.75 NM forward travel for 1,000 ft. altitude loss is a glide ratio of about 4.6:1, considerably below the 7.7:1 figure. It is noteworthy that the "Emergency Procedures" section of this exemplar airplane POH contains conflicting glide performance information, with no way to determine which data, if any, are correct.

METEOROLOGICAL INFORMATION

The conditions over Oregon at 10,000 feet indicated the following conditions: south-southwest winds near 30 kts, a temperature of 3 degrees Celsius, with a 2 degrees temperature-dew point spread in Salem, Oregon, located approximately 80 miles northwest of the accident site.

Roberts Field had an Automated Surface Observation System (ASOS) and reported the following conditions near the time of the accident: wind 090 degrees at 7 knots; visibility 10 statute miles (sm); cloud condition clear; temperature 21 degrees Celsius; dew point 07 degrees Celsius; altimeter setting 29.93 in of Mercury.

A NTSB Weather Study was performed. The meteorologist reported that satellite data indicated that there was no thunderstorms or cumulonimbus activity over the accident site, and that visual meteorological conditions (VMC) prevailed. Water vapor imagery did not depict any significant moisture channel darkening typically associated with turbulence or mountain wave activity. No advisories were current for any organized areas of turbulence or icing conditions over the region.

COMMUNICATIONS

The Redmond Air Traffic Control (ATC) Facility provided the recorded radio communications between the pilot and controllers. The airplane was cleared to make a left downwind departure for runway 10 and made no further radio communications until the time of the accident. The Redmond local control frequency recorded a series of transmissions that came from an unknown source at that time. The first transmission did not contain any eligible words, and the verbal transmission sounded like a grunt. A transmission followed seconds later that sounded distant, as if a person in the background was speaking. Only one word was slightly discernible, and was an expletive. Another transmission was heard after a second, but no words were transmitted.

WRECKAGE AND IMPACT INFORMATION

NTSB investigators did not travel to the accident site, the information contained in the section was gathered from parties to the investigation, the FAA, and local law enforcement. The accident site was located in flat unpopulated terrain, about 5 nautical miles (nm) southeast of Sisters. The main wreckage was located at an estimated 44 degrees 13.107 minutes north latitude and 121 degrees 30.547 minutes west longitude, at an elevation of about 3,400 feet mean sea level (msl). The distance from Redmond (departure city) is about 15 miles on a bearing of about 80 degrees true.

The wreckage debris was scattered over an estimated 1,600-foot area of flat terrain that was populated with trees and brush. At the far west parameter of the debris field were the heavier portions of the airplane, including the cockpit and engine. The remaining portions of the airplane were scattered on a heading of about 140 degrees true. A wreckage diagram prepared by a Lancair representative is contained in the public docket for this accident.

MEDICAL AND PATHOLOGICAL INFORMATION

The Clackamas County Office of the Medical Examiner completed an autopsy of both pilots.
The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on tissue specimens from both pilots.

The CFI's autopsy report indicated that he died as a result of massive blunt force trauma. The autopsy was unable to determine the presence of preexisting medical pathology due to loss of tissue integrity as a result of massive fragmentation of the body. CAMI Toxicology report (#201200084002) detected ethanol in the brain and muscle. Due to significant tissue destruction, the prolonged time between the accident and autopsy and putrefaction of tissues the ethanol detected may be from sources other than ingestion. Toxicology also identified two unreported medications Rosuvastatin and Metoprolol in the tissues.

The Pilot-owner's autopsy determined that the pilot died as a result of massive blunt force trauma. The autopsy was unable to determine the presence of preexisting medical pathology due to loss of tissue integrity as a result of massive fragmentation of the body. CAMI Toxicology report (#201200084001) was positive for ethanol from sources other than ingestion. Toxicology also identified two unreported medications Rosuvastatin and Metoprolol.

Since both pilots had the same medications in their tissues it is possible that with the high impact and fragmented remains, cross contamination of tissues could occur.

TEST AND RESEARCH

The main wreckage consisted of the cockpit and engine. The wings had separated and were located in the debris field. The elevator flight controls remained attached to the horizontal stabilizer. All major components of the airplane were accounted with the exception of the baggage door panel, which was not located. The hinges and latches showed grooves and evidence that it was locked during the breakup sequence. Multiple fragmentation of the airplane's systems prohibited investigators from obtaining complete control continuity.

Disassembly of the engine revealed that the number two bearing, bearing housing, and rear shaft were intact and showed a dark coloration, which the GE representative stated was consistent with normal operation. The accessory gearbox was removed and oil filter was disassembled. The filter was clean of debris and the gasket was pliable. The oil pressure relief and bypass valve did not show evidence of mechanical malfunction and the spring and ball assembly moved freely when pressure was applied.

The first stage compressor blades were intact with the slight curling of five blades at the trailing edge tips in the opposite direction of rotation (clockwise); the right hand side of the compressor casing, aft looking forward (first stage blade land) contained a light rub and grooves consistent in size and orientation to that of the compressor blade tips. The impeller vanes were intact with the exception of several vane tips that were rubbed and showed discoloration. The impeller shroud contained a circumferential area in radial alignment with the impeller vane rub area. The impeller shroud rub area was in alignment with the right hand engine ground impact area.

The propeller hub was disassembled from the propeller shaft (flange). One of the eight bolts was slightly bent; none of the holes showed any evidence of elongation or stretching. According to the GE representative, on Avia Propeller model V508 the shift of feedback ring showed that the propeller blades were in the "BETA" range.

Disassembly of the FCU revealed that the spring and flapper valve were intact and the flapper moved freely. The speeder spring was removed and the fly weights appeared to be closed inward, which is the normal at-rest position. The entire accessory gear box spline shaft was removed (with bearing and fly weights still attached). The spline shaft was noted to be bent in the location just aft of the drive spline. Examination of the gear teeth revealed no evidence of wear or failure. The emergency solenoid was removed and found in the non-activated position.

The fuel screen (last chance filter) from the overflow fuel valve to the altitude compensation cavity was clean and free of debris. The teeter valve located between the screen and the bellows was intact and no anomalies were noted. The housing below the rubber diaphragm had a light rub mark that was similar in size and orientation to a corner of one of the four feet, consistent with it making contact during impact. The main metering valve was removed and trace amounts of fuel were recovered. The seals were in good condition and no anomalies were noted. The engine control throttle was removed (alpha 1), the bearing was free to rotate and the cam showed no evidence of excessive wear.

The examination revealed no evidence of pre impact mechanical malfunction or failure that would have precluded normal operation.

The engine examination report is contained in the public docket for this accident.

ADDITIONAL INFORMATION

Lancair

Lancair International, Inc. is based in Redmond, Oregon and was founded in 1984. The Lancair fleet includes a wide range of aircraft from early 235, 320, and 360 two-seat models to the two-seat Lancair Legacy, fixed-gear Lancair ES, the IV, the pressurized IV-P, the turbine IV-TP, and the latest model, the Evolution. Over 2,000 Lancair kits have been sold in more than 34 countries.

The Lancair IV was a progression from the Lancair 235 and the 320. The kit manufacturer wanted to build a four-place retractable landing-gear airplane that had competitive performance relative to certified aircraft. According to Lancair, the IV is essentially a scaled-up version of the 320 with a 30-ft wingspan and a turbo-charged 350-hp reciprocating engine equipped with a three-blade constant-speed propeller. Since its introduction in 1990, the Lancair IV has broken numerous airspeeds and altitude records for its class type, and at altitude has reached sustained speeds in excess of 340 mph. The entire airframe is constructed of vacuum-formed, oven-cured, prepreg carbon fiber. The company estimates a build time of approximately 2,500 hours.

A former Lancair engineer stated that he worked for the company from March 2002 to April 2009 as a General and Engineering manager, with his last project consisting of helping in the design of the Evolution. He stated that the Lancair IV was originally designed for a reciprocating Teledyne Continental Motors (TCM) engine with a gross weight of about 3,200 lbs (and an empty weight of 1,800-1,900 lbs). Thereafter, desiring to increase performance, Lancair designed the airplane to be fitted with a TCM turbocharged and modified and pressurized the airframe, resulting in the Lancair IV-P. The addition of the structural enhancements to the wing increased the gross weight to about 3,550 lbs.

In 2001, Lancair selected the Walter/General Electric 601E as the trial turboprop engine to design/retrofit the airframe for higher performance. As part of this design modification, the airframe structure underwent several significant changes including: the nose became about 13 inches longer (more with the inclusion of the propeller and spinner), and the fuel tank located in the belly increased from 9.5 gals to 35 gals. With the heavier airframe structure and engine/equipment, the gross weight increased.

The engineer further stated that other aerodynamic changes occurred during this modification. Specifically, with the increase of nose length, the airplane's pitch and yaw axes were destabilized, and with the larger diameter propeller (that had greater inertia), the two axes were destabilized further. In effect, these changes resulted in the nose section becoming a destabilizing "flying nose," that, in response to an increase in pitch, would produce lift, generating an additional nose-up pitching moment. With the airplane's increased empty weight, the wing loading increased dramatically, which he estimated at about 40-45 lbs per square ft. He stated that with the laminar flow wing design and the already-present aggressive stall characteristics, the stall characteristics were aggravated further which makes the Lancair IV-TP a challenging airplane to fly, which without adequate training, makes it a "dangerous airplane" because it was not designed for such a high horsepower engine.

According to another Lancair IV-TP expert, he had performed a variety of tests in the airplane which included stalling in a variety of scenarios, configurations, altitudes and power settings. He stalled the airplane from 31,000 to 15,000 feet incrementally with 1-4 G's of loading. After hundreds of stalls and over 1,500 hours testing in the Lancair IV-TP he offered the following remarks:

He stated that the airplane will stall and the nose will drop about 15-degrees and with symmetrical wings (as built), will remain wings-level. A wing can drop left or right depending on slight induced yaw. For the straight ahead stall and subsequent recovery it is critical to keep the ball centered or the wing will drop. It is very sensitive to a ball slightly out of center. During recovery it is very responsive to lowering the nose and reducing the angle attack. The recovery is immediate with a reduction in angle of attack. Never apply power applied until 20 percent above the indicated stall speed. If power is on during the stall entry, reduce to idle immediately upon stall onset.

Lancair Fleet and Accident Rate

The following breakdown was provided by the Lancair Owners and Builders Organization (LOBO) and gives the best estimate of the accident rate for the Lancair fleet:

Lancair Model : Flying, Accidents, %Accidents, Fatal, %Fatal Accidents
Lancair 200/235: 103--32--31%--16--50%
Lancair 320/360: 301--76--25%--28--37%
Lancair ES: 96--4--4%--3--75%
Lancair IV/IV-P: 240--51--21%--27--53%
Lancair IV-TP: 57--15--26%--11--73%
Legacy: 121--27--22%--14--52%
Lancair Evolution: 50--2--1%--0--0
Totals: 922--207--22%--99 9%

At the time of this report, of the 57 Lancair IV-TPs that were registered (and presumably flying), there is an accident rate of 26-percent and a fatal accident rate of 19-percent.

FAA and Lancair

The FAA convened two safety groups specifically to address, as stated in their documents regarding the studies, the Lancair's "unusually high accident and fatality rate compared to other amateur-built aircraft." The purpose of each group was to "bring the issue to attention of the FAA so appropriate action may be taken." These internal FAA groups were initiated by the Office of Accident Investigation and Prevention (AVP)-100 and conducted studies over the course of a six-month period in both 2008 and 2012-2013. The end conclusion of the studies determined that the FAA has the ability and, given the safety findings that surfaced over the studies, "the responsibility to expose its findings and take the appropriate safety enhancement actions it believes would reduce the likelihood of certain Lancair accidents."

According to copies of the notes from the studies, there were internal FAA concerns that any agency requirement imposed upon Lancair would be analogous to the FAA becoming involved in experimental aircraft design certification or in some way intruding in an area for which it had no authority. There was also concern that taking action on Lancair would create a precedent throughout the amateur-built aircraft industry and that the FAA would then be forced to take action on every safety issue affecting an amateur-built aircraft. There were limitations concerning the FAA's role which was centered on the general airworthiness inspection when the aircraft is submitted for airworthiness certification (unless there is specific safety data available).

The FAA group that convened did note in response to these concerns that they indeed have the "statutory and regulatory responsibility to issue airworthiness certificates to amateur-built aircraft and the existing guidance [FAA Order 8130.2F, Section 153 (a)] on this process specifically permits the FAA to impose operating limitations deemed necessary in the interest of safety." As of this publishing of this report, the current guidance is FAA Order 8130.2G, Chapter 4, Section 9, Paragraph 4104 (a), since FAA Order 8130.2F was cancelled April 16, 2011. Further, the authority of the FAA is flexible and imposing limitations is authorized in 49 USC 4704 (d)(1), which provides that "the Administrator may include in an airworthiness certificate terms required in the interest of safety."

In specific reference to the Lancair IV-TP, the FAA remarked that certified and experimental aircraft with similar high-performance characteristics require specific training. On numerous occasions (e.g., Viperjet, Robinson Helicopters, Mitsubishi MU-2), the FAA has made type-specific safety determinations when finding that the safe operation of such aircraft requires specific training, proficiency and/or equipment. It was noted in both the studies that many of the Lancairs would be classified as Technically Advanced Aircraft (TAA), with an EFIS-equipped cockpit.

These conclusions were derived based on accident statistics between 2004 and 2008 that indicated that amateur-built aircraft experienced a fatal accident rate of about 5-6 accidents per 100,000 flight hours; the overall general aviation accident rate for that period was about 1-2 accidents per 100,000 hours. The Lancair fatal accident rate in the same time period was about 7-8 accidents per 100,000 flight hours. Specifically, in 2008 Lancair comprised 3.2-percent of the amateur-built aircraft fleet and 19-percent of the fatal accidents that occurred that year, with 78.6-percent of Lancair accidents being fatal.

The internal study noted that based on the statistics, Lancairs are involved in fatal accidents at "a rate that is disproportionate to their fleet size."

The study found that with extensive use of laminar flow airfoils, low thickness, low surface velocities, gradual velocity changes and low skin friction, Lancairs' stall characteristics are critical (abrupt, unusual) when compared with more traditional certified aircraft. In character, "the stall occurs abruptly, even during a slow deceleration just above 70 kts with a 20-degree pitch break and a wing drop as much as 50 degrees."

As part of its 2008 safety review, the FAA remarked that there were "strong indications" that Lancair would be receptive to FAA directives that would result in incorporation of type-specific training and stall warning devices as part of its kit sales.

As a result of the Lancair Task Force, the study documents indicate that recommendations were made to FAA management in November 2008. The recommendations included: publishing an article in FAA Aviation News, issuing a SAIB with regards to flight training and equipment recommendations on applicable models, drafting an InFO based on the SAIB, revising the language for the passenger warning placard applicable to amateur-built aircraft, initiating informal resolution in coordination with industry, and tracking accident data regularly in order to identify any changes in the Lancair accident trends.

The FAA issued InFO notice 09015 on September 25, 2009, with the subject of "Safety Concerns of Lancair Amateur-Built Experimental Airplanes." The notice indicated that while Lancairs represented a little over 3-percent of the amateur-built experimental aircraft fleet, they contributed to 16-percent of all amateur-built fatal aircraft accidents in the prior 11 months, of which 65-percent of those were fatalities. In the four years prior, 53-percent of Lancair accidents were fatal, and a majority were a result of a loss of control while in the traffic pattern. The notice further stated that pilots must take the following corrective actions for safe operation:

-review and thoroughly understand all information regarding stall characteristics and obtain specialized training regarding slow flight handling characteristics, stall recognition, and stall recovery techniques.
-install a high-quality angle of attack indicator to provide a warning of impending stall.
-have their airplane evaluated by an experienced Lancair mechanic to ensure proper rigging, wing alignment, and weight and balance.

The notice was recalled shortly after its release; this is the only InFO notice that has ever been recalled. Although the original InFO (InFO 09015) was supported by LOBO, Lancair contested that they were not the only manufacturer to have a high-performance amateur-built airplane. As a result, InFo 09015 was retracted and InFO 10001 was issued March 09, 2010, which expanded the InFO to include other aircraft with the same characteristics and covered "amateur-built experimental Lancair and other amateur built airplanes possessing high wing loading and stall speeds in excess of 61 knots."