Thursday, April 12, 2018

Harmon Rocket, N275JS, owned and operated by the front-seat pilot: Fatal accident occurred January 17, 2017 near Corona Municipal Airport (KAJO), Riverside County, California


The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Riverside, California
Textron Lycoming; Williamsport, Pennsylvania

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

Investigation Docket  - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Jeff C. Johnson: http://registry.faa.gov/N275JS



Aviation Accident Factual Report - National Transportation Safety Board

Location: Corona, CA
Accident Number: WPR17LA054
Date & Time: 01/17/2017, 1055 PST
Registration: N275JS
Aircraft: JOHNSON Harmon Rocket
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The private pilot, who was the owner and builder of the experimental amateur-built airplane, and a commercial pilot departed on a local flight and performed three touch-and-go practice takeoffs and landings. During the fourth takeoff, after reaching about 300 ft above the ground, the engine experienced a total loss of power. The airplane made a right turn and collided with terrain about 1,650 ft from the end of the runway. The single-engine airplane was constructed about 7 years before the accident, at which time the private pilot installed a newly-overhauled engine. The airplane had accrued about 100 total hours of time in service. During postaccident examination, the engine would not start but was found to operate normally when a different fuel servo was installed.

The Bendix fuel servo, manufactured in 1977, was designed to meter fuel in relation to the volume of air being consumed by the engine. The metering is accomplished by air and fuel diaphragms inside the unit that are connected by a valve stem that has a regulator ball affixed at its end. A pressure differential across the air diaphragm results in the regulator ball unseating and providing the engine with more fuel. Complete disassembly of the accident fuel servo revealed that the regulator stem was separated from the regulator ball, which would prevent the ball from being able to unseat and would subsequently block fuel from entering the engine, resulting in fuel starvation.

The servo manufacturer stated that the servo's internal components appeared to be original, although those components were required to be replaced every 12 years. There were no maintenance records pertaining to the servo, but its appearance indicated it was likely never overhauled. The maintenance entry for the engine overhaul noted that the airplane was equipped with a "serviceable fuel servo," which, according to a representative from the maintenance facility that performed the overhaul, was likely determined by an engine test run. Because the airframe and engine were classified as amateur-built experimental, the overhaul criteria are not required for airworthiness; however, it is likely that the failure of the regulator valve stem and ball would not have occurred if the servo components had been replaced in accordance with manufacturer specifications.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A total loss of engine power during takeoff due to fuel starvation as a result of a failure of internal components of the fuel servo. 

Findings

Aircraft
Fuel control/carburetor - Failure (Cause)
Fuel control/carburetor - Not serviced/maintained (Cause)

Personnel issues
Replacement - Maintenance personnel

Factual Information

History of Flight

Takeoff
Fuel starvation
Loss of engine power (total) (Defining event)

On January 17, 2017, at 1055 Pacific standard time, an experimental amateur-built Harmon Rocket, N275JS, impacted terrain following a total loss of engine power during the initial climb from Corona Municipal Airport (AJO), Corona, California. The private pilot (seated in the front seat) was fatally injured, and the commercial pilot (seated in the rear seat) sustained serious injuries; the airplane sustained substantial damage. The airplane was owned and operated by the front-seat pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which originated from AJO at 1026.

According to a Federal Aviation Administration (FAA) inspector, witnesses reported seeing the airplane initially take off from runway 25. The airplane then landed on runway 07 and immediately departed. After reaching 100-200 ft above ground level (agl), the engine experienced a loss of power. The airplane made a steep turn back toward the airport and collided with terrain, coming to rest on flat, soft vegetation on airport property. The accident site was located about 1,650 ft from the departure end of runway 07.

The airplane was equipped with an Advanced Flight Systems AF-4500sEF multifunction display (MFD) that recorded the flight and engine parameters in 5-second increments. The MFD revealed that the airplane departed at 1026 and circled over Lake Mathews, located about 9 miles to the southeast. Thereafter, the airplane returned to AJO and performed three practice takeoffs and landings on runway 25. The airplane then made a 360o turn to the west of the airport and performed a touch-and-go practice takeoff and landing on runway 07.

The airplane became airborne again at 1052:29 and climbed about 270 ft, to 770 ft mean sea level, at which point the fuel flow dropped from about 20 psi to less than 1 psi. The engine's rpm and exhaust gas temperature values drastically decreased, consistent with the engine experiencing a total loss of power. The airplane began a right turn about 1052:34 and collided with terrain at 1052:49. Figure 1 depicts the takeoff from runway 07 and the remainder of the flight.


Figure 1: Takeoff Prior to Accident

Pilot Information

Certificate: Private
Age: 61, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 10/05/2015
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 2000 hours (Total, all aircraft), 250 hours (Total, this make and model)

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 75, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Rear
Other Aircraft Rating(s): Helicopter
Restraint Used:  Unknown
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 01/09/2017
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 20000 hours (Total, all aircraft), 200 hours (Last 90 days, all aircraft)

Front-Seat Pilot

According to the FAA Airman and Medical records, the front-seat pilot, who was the owner and builder of the airplane, held a private pilot certificate with ratings for airplane single- and multi-engine land as well as rotorcraft. He also held a repairman experimental aircraft builder certificate. The pilot was issued an FAA third-class medical certificate in October 2015, with a limitation that he must wear glasses for near vision.

The pilot's most recent personal flight records were not recovered. On his most recent application for a medical certificate, the pilot reported 2,000 total hours of flight experience.

Aft-Seat Pilot

The commercial pilot, positioned in the aft seat, held ratings for airplane single- and multi-engine land; single-engine sea; rotorcraft-helicopter; and instrument airplane. Additionally, he held a flight instructor certificate with ratings for airplane single- and multi-engine. His most recent FAA third-class medical certificate was issued in January 2017 with a limitation that he must have glasses available for near vision.

The pilot's personal flight records were not recovered. On his last application for a medical certificate, the pilot reported 20,000 total hours of flight experience, of which 200 hours was accumulated in the previous 6 months.

It could not be determined who was acting as pilot-in-command at the time of the accident. A witness who knew the owner of the airplane stated that the owner didn't like to fly the airplane without another pilot on board. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: JOHNSON
Registration: N275JS
Model/Series: Harmon Rocket
Aircraft Category: Airplane
Year of Manufacture: 2010
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 0471
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 10/17/2016, Condition
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines:
Airframe Total Time:
Engine Manufacturer:
ELT:
Engine Model/Series:
Registered Owner: On file
Rated Power:
Operator: On file
Operating Certificate(s) Held:  None 

The Harmon Rocket was a low-wing, single-engine, experimental airplane, constructed by the owner and completed in 2010 with serial number 0471. The last condition inspection was recorded as being preformed by the owner in October 2016 in accordance with 14 CFR Part 43, appendix D. The entry noted a total time in service of 90.71 hours.

The airplane was equipped with a Lycoming IO-540-C4B5 engine, serial number L-5545-48, modified for experimental use only. The last annual inspection logbook entry in October 2016, noted a total engine time of 90.71 hours. The engine was overhauled by Aircraft Engine Specialists, Chandler, Arizona, in May 2009 and shipped to the pilot shortly thereafter for installation on the airplane.

Fuel System

The airplane's fuel system was a gravity-fed design in which fuel flowed from the metal tanks in the inboard section of each wing, through a selector valve, and continued to an electric fuel pump. From the pump, the fuel was routed to a transducer where it was plumbed through the firewall to the gascolator, which contained a fuel screen. Thereafter, the fuel was directed to the engine-driven fuel pump, and then routed under the left cylinders to the fuel servo (located at the forward bottom of the engine). From the servo, the fuel was routed between the Nos. 1 and 3 cylinders to the fuel distribution manifold (i.e., spider) and then to each cylinder's injector.

Fuel Servo

The fuel servo was a Bendix RSA-5AD1 (part number 2524213-1, serial number 6507-T), manufactured in 1977. The major components of the servo include the airflow section, the flow metering section, and the fuel regulator section. Together, these sections are designed to meter fuel in direct ratio to the volume of air being consumed by the engine (see Figure 2).

The regulator assembly contains an air diaphragm, a fuel diaphragm, and regulator stem that has a regulator ball affixed at the end. The air diaphragm senses impact air and compares it to venturi suction. The fuel diaphragm compares metered and unmetered fuel pressure. The diaphragms are connected by the regulator stem, which passes through the center body section of the regulator. The four chambers in the regulator section of the servo act in unison to cause the diaphragms to equalize and regulate the appropriate amount of fuel to the engine when the airflow is altered. When the engine is operating at a constant throttle setting, opposing forces of the fuel and air diaphragms cause the regulator valve stem to unseat to a specific position and an appropriate quantity of fuel is provided to the engine. As the throttle setting is increased, velocity of air through the venturi increases and pressure decreases within the suction side of the air chamber relative to the impact side. This creates a pressure differential across the air diaphragm and causes the regulator valve (ball at the end of the regulator stem) to move toward a more open position. As the regulator valve opens (ball moves off the seat), more fuel is provided to the engine. Once the pressure differential across the fuel diaphragm stabilizes and reaches a force in equilibrium with the air diaphragm, fuel flow is again stabilized.


Figure 2: Drawing of the Fuel Servo (showing regulator valve)


Maintenance

Several pictures of the accident servo were provided to a representative from Precision Airmotive, which purchased Bendix in 1988. He stated that the internal parts appeared to be original to the servo. He stated that all of the parts inside the regulator side are required replacement items at the time of overhaul. At the time of the servo's manufacture, the overhaul requirements were the same as the time between overhaul specified by the engine manufacturer. In 1991, Precision issued a calendar requirement, wherein the servo must be overhauled every 12 years. After overhaul, the servo should have a yellow data plate attached; the accident servo still had the original black data plate.

A review of maintenance records and invoices showed that the maintenance entry for the engine overhaul was dated May 2009 and noted that the airplane was equipped with a "serviceable fuel servo RSA-5AD1, pn 252-4213-1, sn 6507-T." A representative from the maintenance facility that performed the overhaul stated that "serviceability appears to have been determined by a functional check during the test run of the complete engine." There were no other maintenance records found regarding the servo. Because the airframe and engine were classified as amateur-built experimental, the overhaul criteria are not required for airworthiness.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: AJO
Observation Time: 1856 UTC
Distance from Accident Site:
Direction from Accident Site:
Lowest Cloud Condition: Clear
Temperature/Dew Point: 17°C / -1°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 6 knots, 110°
Visibility (RVR):
Altimeter Setting: 30.12 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Corona, CA (AJO)
Type of Flight Plan Filed: None
Destination: Corona, CA (AJO)
Type of Clearance: None
Departure Time:  PST
Type of Airspace:

Airport Information

Airport: CORONA MUNI (AJO)
Runway Surface Type: N/A
Airport Elevation: 533 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing:  Forced Landing

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude:  33.895278, -117.594167 (est)

Medical And Pathological Information

The front-seat pilot survived the impact but died in the hospital later that day. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens from the pilot. The testing revealed 0.006 (ug/ml, ug/g) tetrahydrocannabinol carboxylic acid (THC-COOH), an inactive metabolite of the primary psychoactive drug in marijuana tetrahydrocannabinol, detected in blood. Additionally, the report documented Midazolam, a potent anesthetic used during emergency treatment, consistent with postaccident medical intervention. The presence of trace amounts of THC-COOH in femoral blood is consistent with past use of marijuana, but blood testing did not identify the impairing drug marijuana. 

Tests And Research

The front seat had a control quadrant on the left side; the levers were all bent and folded over to the right. The throttle was positioned in a mid-range position and the fuel mixture and propeller controls were full forward.

Both wings remained attached to the airframe; the left fuel tank was breached. Fuel was recovered from both wing tanks. The fuel selector valve was found in the "OFF" position, but witnesses reported that first responders had repositioned the selector. The fuel selector was removed and, when operated, turned smoothly and displayed proper valve function. The fuel pump was removed and investigators connected it to a power source. The pump clicked and air egressed from the outlet. The transducer was removed and disassembled; the wheel was intact and no anomalies were found. The gascolator contained trace amounts of fuel and was free of debris. The upper housing of the fuel manifold was removed; there was no evidence of fuel and the diaphragm was dry.

The engine was mounted on a test stand and fuel was plumbed to the fuel pump; the fuel flowed freely and there was no evidence of blockage. Fuel was then plumbed to the fuel servo and investigators were unable to obtain flow to the outlet. The fuel servo was then removed and replaced with a similar model and fuel ran freely.

The fuel source was then attached to the mechanical fuel pump inlet and the system was reconnected with the exemplar servo. The propeller, damaged from the accident, was removed from the engine and a club propeller was installed. The engine was successfully started and ran for over 5 minutes at various power settings from idle to about 2,700 rpm. A magneto check was conducted on the left and right magnetos with a minimal rpm drop per magneto; no anomalies were found during the engine run.


Figure 3: Fuel Servo's Valve Stem Separated from the Regulator Ball


Fuel Servo

The fuel servo was completely disassembled. The safety wire on the regulator housing had a crimp with a stamp that read "AKB." Upon disassembly of the regulator, investigators noted that the valve stem was separated from the regulator valve (ball) as shown in Figure 3. The accident servo was reassembled and investigators affixed the exemplar servo's regulator section. A fuel source was connected and fuel flowed normally through the servo. The accident regulator section was installed on the exemplar servo and tested; the fuel would not flow. The complete examination notes with pictures are contained in the public docket for this accident.



NTSB Identification: WPR17LA054
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 17, 2017 in Corona, CA
Aircraft: JOHNSON Harmon Rocket, registration: N275JS
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On January 17, 2017, about 1055 Pacific standard time, an experimental Johnson Harmon Rocket, N275JS, collided with terrain shortly after takeoff from Corona Municipal Airport, Corona, California. The private pilot, who was the owner and builder, was operating the airplane under the provisions of 14 CFR Part 91. The private pilot and certified flight instructor (CFI) were fatally injured; the airplane sustained substantial damage. The local personal flight originated from Corona about 1040. Visual meteorological conditions prevailed, and a flight plan had not been filed.

Witnesses reported observing the airplane initially taking off from runway 25. The airplane then landed on runway 07 and immediately departed. After reaching about 100 to 200 ft, the engine experienced a loss of power. The airplane made a steep turn back toward the airport and collided with terrain. The airplane came to rest on the airport property about 2,000 ft southwest of the end of the runway surface. The airplane was recovered for further examination.

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