NTSB Identification: ERA11LA142
14 CFR Part 91: General Aviation
Accident occurred Sunday, February 13, 2011 in Dawsonville, GA
Probable Cause Approval Date: 12/01/2011
Aircraft: KENNEDY MICHAEL M LANCAIR 320, registration: N351E
Injuries: 2 Uninjured.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
After about 25 minutes of flight, the pilot began transferring fuel from the left and right main fuel tanks to the 10-gallon header tank which fed the engine. Ten minutes after completing that operation, the engine began to lose power. The pilot activated the fuel boost pumps and adjusted the throttle and mixture controls. He stated that the engine surged as though it was running out of fuel. When engine power could not be restored, the pilot performed a forced landing to the median of a divided highway, and a hard landing resulted in substantial damage to the left wing tip, rudder, and propeller. A postacciddent examination of the fuel filter revealed traces of sediment and water, while the gascolator bowl contained water and debris. The filter and bowl were then reinstalled and an engine run was completed using the airplane’s own battery and fuel system. The engine started immediately, accelerated smoothly, and ran continuously without interruption.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s inadequate preflight inspection and failure to detect water-contaminated fuel, which resulted in a loss of engine power.
On February 13, 2011, about 1100 eastern standard time, an experimental amateur-built Kennedy Lancair 320, N351E, was substantially damaged after a loss of engine power and forced landing near Dawsonville, Georgia. The certificated commercial pilot/owner and the private pilot-rated passenger were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight departed Gwinnett County Airport (LZU), Lawrenceville, Georgia, about 1020, and was destined for Barrow County Airport (WDR), Winder, Georgia.
In a written statement, the pilot/owner gave a comprehensive account of the preflight planning, preflight inspection, takeoff, and flight to an area north of his departure airport with no anomalies noted. Once established in an area clear of traffic, the pilot allowed his passenger to do some maneuvering, and become accustomed to the airplane, as it was his first flight in a Lancair. After about 25 minutes of flight, the pilot/owner began transferring fuel from the left and right main fuel tanks to the 10-gallon “header tank” which fed the engine. Ten minutes after completing that operation, the engine began to lose power.
The pilot said that he resumed control of the airplane and performed troubleshooting that included activating the fuel boost pumps and adjusting throttle and mixture controls. When engine power could not be restored, the pilot elected to conduct a forced landing to a roadway, as the nearest airport selected on his GPS receiver was beyond the glide distance of the airplane. The pilot described the engine power as “surging, like it was running out of fuel.”
The pilot described maneuvering close to the ground to avoid wires and road traffic, and the resultant hard landing to a median in the roadway. The passenger’s account of events by telephone and his written statement were consistent with the pilot’s.
The pilot/owner held a commercial pilot certificate with ratings for airplane single engine and multiengine land, and instrument airplane. His most recent Federal Aviation Administration (FAA) first class medical certificate was issued April 2010. The pilot reported approximately 1,900 total hours of flight experience, and approximately 500 hours of experience in Lancair airplanes.
The pilot-rated passenger held a private pilot certificate with ratings for airplane single engine land. His most recent FAA third class medical certificate was issued June 2009. The passenger reported approximately 230 total hours of flight experience, none of which was in Lancair airplanes.
According to maintenance records, the airplane had accrued 479 total aircraft hours. Its most recent conditional inspection was completed on February 1, 2010, at 437 total aircraft hours.
The 1105 weather observation at Cherokee County Airport (47A), 21 miles west of the accident site, included clear skies and winds from 260 degrees at 3 knots. The visibility was 10 miles. The temperature was 12 degrees C and the dew point was -1 degrees C. The altimeter setting was 30.30 inches of mercury.
Examination of the airplane at the scene by an FAA inspector revealed the airplane sustained substantial damage to the left wing tip, rudder, and propeller. A detailed examination was performed in Griffin, Georgia, on February 17, 2011, by the same inspector. The propeller was replaced, and the fuel filter and gascolator were inspected. The fuel filter showed only traces of sediment and water, but the gascolator bowl contained water and debris. The filter and bowl were then reinstalled in preparation for an engine run.
An engine start was then attempted on the airframe, utilizing the airplane’s own battery and fuel system. The engine started immediately, accelerated smoothly, and ran continuously without interruption.
DAWSONVILLE - A small single-engine plane made an emergency landing in the median of Georgia 400 in Dawson County Sunday.
The pilot was William Reister of Dunwoody.
He left from Briscoe Field in Lawrenceville Sunday morning and planned to land the two-seat Lancair 320 at the same airfield. However, the plane uncontrollably lost altitude and was unable to reach its destination.
Reister reported the loss of power before landing the plane in the median of the four-lane highway near Dawson Forest Rd. No one was injured, and there were no major traffic delays resulting from the emergency landing.
Original article can be found here: http://accesswdun.com
The NTSB changed their story after they were provided proof from the on board Engine Monitoring System (EMS) that the header tank did not at any time contain less than 5 gallons of fuel; that proof invalidated their first attempt to blame the pilot without actually conducting an investigation (i.e. they claimed pilot simply ran the header tank out of gas and never transferred fuel as reported; EMS log proved that fuel was transferred exactly as and when reported by pilot). In a telephone call with the NTSB, they told the pilot that they did NOT find water in the gascolator - although of course that may have been a ruse to see if they could provoke a confession of some other error or omission on the part of the pilot.
ReplyDeleteAs for the insinuation that a proper pre-flight was not performed - poppycock. Pilot arrived an hour before co-pilot and performed a meticulous pre-flight. All three sump locations were tested for water per the pre-flight checklist. That does not mean there was not water in one or both wing tank which was later transferred into the header tank; pilot was not the builder of the plane and any number of design or construction flaws could have allowed for some water to be trapped in the wing in such a way as not to be expelled during the sump check but later pumped to the header.
From pilot's perspective, the NTSB appeared determined to find a way to blame the pilot rather than spend any time and / or money to investigate the actual cause. This experience is consistent with several other verbal reports received from other pilots concerning their treatment by the NTSB.
Pilots beware, document everything.
Is this a true statement? "An engine start was then attempted on the airframe, utilizing the airplane’s own battery and fuel system. The engine started immediately, accelerated smoothly, and ran continuously without interruption."
ReplyDeleteThat is what they said, and I have no reason not to believe them. It fits with the in-flight symptoms.
ReplyDeleteWe had about 4 minutes total from the initial loss of power until touchdown. During the entire time the engine behaved as if "fuel deprived" (which is exactly how it would behave if some water were being introduced with the fuel, interfering with ignition). The engine alternately produced momentary power in a smooth “surge” and then acted as if not running. There was no backfiring or other indication of a problem with the ignition system. The surges grew weaker as we proceeded to touchdown.
Given that it started almost immediately after topping off the header tank, our best guess after the fact is that there WAS water in one or both of the wing tanks which did not appear when testing the sumps, it got into the gascolator until there was too much to avoid sending some to the engine, and that there was enough that it did not get sufficiently purged before touchdown to restore power. There are in fact a few possible reasons this could have happened, all of which might not be apparent to the pilot in a normal pre-flight. It is entirely possible, perhaps even probable, that given a few more minutes' grace enough of the water would have been sucked through the system for normal flight to have resumed and it would have been a non-issue.
FWIW, from a practical standpoint I can understand why the NTSB approaches the investigations the way they do. Firstly, the percentages suggest pointing to the pilot as the most likely cause absent a clear mechanical failure – and in fact not all pilots may be happily willing to acknowledge their role. Second, budget - this was a relatively inexpensive airplane, no one was hurt, no property (apart from the plane) was damaged, and it is far cheaper to simply interrogate the pilot than pull the parts apart and have each sent to a lab.
However, on a personal level the approach of the individual I dealt with to questioning was accusatory to the point of being unprofessional - more an inquisitor demanding a confession than honest pursuit of the facts. It was truly annoying to come across this version of the NTSB report saying, "The pilot’s inadequate preflight inspection and failure to detect water-contaminated fuel..." That verbiage does not match the report I was sent, and given that I had incontrovertibly disproved each of their prior attempts to assign blame one would think they would come to the correct conclusion that the detailed report provided was factual. Calling the Cause "water in the fuel" may be factual, but contending that the pilot did not pre-flight properly is both unsubstantiated and unprofessional.
I will also say that I understand not all NTSB personnel behave the same, and that they all face pressures from their bosses to "close the case." That said, if you are a pilot you should be aware that if there any action you cannot prove with hard evidence you will most likely be assumed "guilty until proven innocent."