Saturday, October 20, 2018

Smoke (Non-Impact): Enstrom F-28F Falcon, N52PD; incident occurred August 22, 2017 at Glendale Municipal Airport (KGEU), Maricopa County, Arizona

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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Scottsdale, Arizona

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


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


Aviation Incident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf 
 
http://registry.faa.gov/N52PD


Location: Glendale, AZ
Incident Number: WPR17IA198
Date & Time: 08/22/2017, 0904 MST
Registration: N52PD
Aircraft: ENSTROM F 28F
Aircraft Damage: None
Defining Event: Fire/smoke (non-impact)
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 
Analysis 

The flight instructor and student pilot were practicing hovering autorotations when the cockpit filled with smoke. The helicopter had just touched down, so the flight instructor secured the cockpit and both he and the student egressed the helicopter with the engine still running. About 5 minutes later, the engine stopped.

Postincident examination of the helicopter revealed no fire or other related damage. Maintenance personnel reported that the smoke appeared to have originated from the failure of an internal oil seal within the turbocharger-compressor that leaked oil into the turbocharger-compressor's exhaust system. No further examination or repair was accomplished and the turbocharger was replaced.

Further examination revealed damage to the turbocharger-compressor v-clamp assembly that was installed on the exhaust. The strap portion of the v-clamp assembly contained cracks on the outer face that emanated from three of the four spot welds. The edge of the strap portion exhibited evidence of bending deformation on both sides of the assembly. In the deformed areas, the distance between the edge of the retainer and the edge of the strap was smaller when compared to other, non-deformed areas. Further, microscopic examination of the largest crack revealed a fatigue crack emanating from the outer surface of the v-clamp assembly strap. It is likely that the v-clamp assembly bolts were tightened to an extent that caused the deformation in the strap. The damage found to the v-clamp was not related to the source of the smoke.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this incident to be:
An internal failure of the turbo-compressor, which resulted in oil leaking into the turbo-compressor's exhaust. 

Findings

Aircraft
Turbocharger - Malfunction (Cause)
Turbocharging (recip only) - Fatigue/wear/corrosion

Factual Information

On August 22, 2017, about 0904 mountain standard time, an Enstrom F-28F helicopter, N52PD, experienced smoke coming from the engine cowling area after touchdown at the Glendale Municipal Airport (GEU) Glendale, Arizona. The certified flight instructor and student pilot were not injured, and the helicopter was not damaged. The helicopter was registered to and operated by Airwest Aviation Academy LLC under the provisions of Title 14 Code of Federal Regulations Part 91, as an instructional flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed GEU about 0820.

The flight instructor reported that at the time of the incident, the student was practicing hovering autorotations. Several had been accomplished without incident. During the last one, the engine appeared to have stalled, but sounded as if it were running rough when the cockpit filled with smoke. The helicopter was on the ground and the flight instructor secured the cockpit and both he and the student evacuated the helicopter with the engine still running and smoke coming out of the right side air scoop. About five minutes later, the engine stopped running.

Postincident examination of the helicopter revealed that no fire or other related damage was present. Maintenance personnel reported that the source of the smoke appeared to have originated from the failure of an internal oil seal within the turbocharger-compressor that leaked oil into the turbocharger-compressor's exhaust system. No further examination or repair was accomplished and the turbocharger was replaced.

Further examination identified that the V-clamp assembly that was installed on the turbo-compressor exhaust was damaged. The V-clamp assembly was removed and sent to the National Transportation Safety Board Material Laboratory, Washington DC for further examination. The examination of the V-clamp assembly revealed that the strap portion of the assembly contained cracks on three of the four spot welds that emanated from the outer face of the strap. The edge of the strap portion exhibited evidence of bending deformation on both sides of the assembly. In the deformed areas, the distance between the edge of the retainer and the edge of the strap, were smaller when compared to other non-deformed areas. Microscopic examination of the longest crack revealed that a fatigue crack emanated from the outer surface of the strap. The damage to the V-clamp was unrelated to the source of the smoke. 

History of Flight

Autorotation
Fire/smoke (non-impact) (Defining event)

Landing
Fire/smoke (non-impact)

After landing
Engine shutdown

Flight Instructor Information

Certificate: Flight Instructor; Commercial; Private
Age: 43, Male
Airplane Rating(s): None
Seat Occupied: Right
Other Aircraft Rating(s): Helicopter
Restraint Used: 4-point
Instrument Rating(s): Helicopter
Second Pilot Present: Yes
Instructor Rating(s): Helicopter
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 04/03/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 12/18/2015
Flight Time:  (Estimated) 1300 hours (Total, all aircraft), 1280 hours (Total, this make and model), 1220 hours (Pilot In Command, all aircraft), 90 hours (Last 90 days, all aircraft) 

Student Pilot Information

Certificate: Private; Student
Age: 40, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s):
Restraint Used: 4-point
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: 12/13/2016
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: ENSTROM
Registration: N52PD
Model/Series: F 28F
Aircraft Category: Helicopter
Year of Manufacture: 1996
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 807
Landing Gear Type: Skid
Seats: 2
Date/Type of Last Inspection: 07/06/2017, Annual
Certified Max Gross Wt.: 2600 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 6264.3 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Not installed
Engine Model/Series: HIO-360-F1AD
Registered Owner: AIRWEST AVIATION ACADEMY LLC
Rated Power: 190 hp
Operator: AIRWEST AVIATION ACADEMY LLC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KGEU, 1071 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 0853 MST
Direction from Accident Site: 90°
Lowest Cloud Condition: Scattered / 15000 ft agl
Visibility:  10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 20°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.98 inches Hg
Temperature/Dew Point: 33°C / 14°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: GLENDALE, AZ (GEU)
Type of Flight Plan Filed: None
Destination: GLENDALE, AZ (GEU)
Type of Clearance: VFR
Departure Time: 0820 MST
Type of Airspace: Class D

Airport Information

Airport: Glendale Municipal Airport (GEU)
Runway Surface Type: Unknown
Airport Elevation: 1071 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Precautionary Landing

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: None
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude:  33.526944, -112.295278 (est)

NTSB Identification: WPR17IA198
14 CFR Part 91: General Aviation
Incident occurred Tuesday, August 22, 2017 in Glendale, AZ
Aircraft: ENSTROM F 28F, registration: N52PD
Injuries: 2 Uninjured.

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 used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

On August 22, 2017, about 0904 mountain standard time, an Enstrom F-28F helicopter, N52PD, experienced smoke emanating from the engine cowling area while the flight instructor and student pilot were practicing hovering auto-rotations at the Glendale Municipal Airport (GEU) Glendale, Arizona. The helicopter had just touched down and therefore an immediate engine shutdown was accomplished. The flight instructor and student pilot were not injured. The helicopter was not damaged. The helicopter was registered to and operated by Airwest Aviation Academy LLC as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The local flight departed GEU about 0750.

The helicopter was recovered to a secure facility for further examination.

Loss of Engine Power (Partial): Beech A36, N48TZ; accident occurred August 17, 2017 near Louisiana Regional Airport (KREG), Gonzales, Ascension Parish, Louisiana


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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Baton Rouge, Louisiana
Continental Motors; Mobile, Alabama 
 
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


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

Aviation Accident Data Summary - National Transportation Safety Board:  https://app.ntsb.gov/pdf
 
http://registry.faa.gov/N48TZ




Location: Gonzales, LA
Accident Number: CEN17LA328
Date & Time: 08/17/2017, 0927 CDT
Registration: N48TZ
Aircraft: BEECH A36
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

Analysis 

During the initial climb on an instructional flight, the private pilot and instructor noticed a partial loss of engine power. The pilot performed a forced landing into a hay field and the airplane nosed over. Following the accident, the mechanic who normally performed maintenance removed and discarded all twelve spark plugs, as several were worn. A subsequent examination and test run of the engine revealed a leaking fuel hose due to a loose B-nut. The loss of engine power was consistent with an inadequate fuel supply due to a fuel line leak. Further, it is likely that the worn spark plugs would also have contributed to the loss of engine power. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A partial loss of engine power due to inadequate maintenance, including worn spark plugs and a leaking fuel hose fitting. 

Findings

Aircraft
Engine (reciprocating) - Incorrect service/maintenance (Cause)
Spark plugs/igniters - Fatigue/wear/corrosion (Cause)
Fuel system - Damaged/degraded (Cause)

Personnel issues
Maintenance - Maintenance personnel (Cause)

Factual Information 

On August 17, 2017, about 0927 central daylight time, a Beech A36 airplane, N48TZ, was substantially damaged during a forced landing after departing from the Louisiana Regional Airport (REG), Gonzales, Louisiana. The pilot and flight instructor were not injured. The airplane was registered to and operated by Gulf Central Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed for the local flight, which departed without a flight plan about 0926.

According to the pilot, he departed from Runway 17, following a normal engine run up and takeoff roll. After reaching about 150 ft agl, the pilot noticed the airplane was no longer climbing and lowered the airplane's nose. Based on his perceptions of a partial engine power loss, the pilot checked the throttle and mixture lever positions, both of which were full forward. After maneuvering to avoid trees, the pilot initiated a forced landing into a hay field. During the landing roll, the airplane impacted a small ridge and nosed over, which damaged the engine firewall.

Examination at the recovery location revealed the ignition harness connecting the magnetos to each of the top sparkplugs had been disconnected from the sparkplugs. All twelve sparkplugs appeared new, with no combustion deposits noted. Without authorization, a mechanic who normally performed maintenance on the airplane stated he had removed and discarded the spark plugs due to several having a worn-out condition. Not realizing the airplane should not be disturbed during the investigation, the mechanic had also removed the fuel screen.

Examination of the throttle and mixture control cables revealed proper attachment to their respective control arms. Borescope inspection of piston domes, cylinder wall surfaces, and intake and exhaust valves revealed normal wear patterns and combustion signatures, except for the No. 5 cylinder exhaust valve, which had a green crescent-shaped discoloration on the bottom of the valve face.

After the fuel screen was returned by the mechanic, an engine test run was performed. The engine rotated and ran on the first attempt but stopped after several seconds. A fuel leak was observed adjacent to the fuel pump, with a flexible fuel hose leaking at a B-nut. The nut was tightened about ¼ turn, which seated the nut onto the fitting. The engine driven fuel pump and the adjacent oil filter adapter were stained with a blue color.

A second fuel leak was observed at the throttle body/metering unit, with the fuel mixture arm and shaft bent in a manner consistent with impact damage. A second engine test run was conducted, during which power was not increased above 1,100 rpm, due to a damaged propeller. The engine was operated at varying speeds and a magneto check was accomplished, with no anomalies. The throttle was reduced to idle power and the engine ran smoothly.

The oil on the oil rod was very dark in color. A logbook review revealed the engine had accumulated 163.7 hours since the last oil and oil filter change. The manufacturer recommends oil change intervals of 50 hours for an engine equipped with external filters installed.

History of Flight

Initial climb
Loss of engine power (partial) (Defining event)

Landing
Hard landing



Pilot Information

Certificate: Private
Age: 43, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
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: 08/28/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 09/19/2016
Flight Time:  302 hours (Total, all aircraft), 165 hours (Total, this make and model), 148 hours (Pilot In Command, all aircraft), 18 hours (Last 90 days, all aircraft), 11 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft)

Flight Instructor Information

Certificate: Airline Transport; Flight Instructor
Age: 58, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 02/21/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 05/12/2017
Flight Time:  (Estimated) 18100 hours (Total, all aircraft), 3000 hours (Total, this make and model), 17200 hours (Pilot In Command, all aircraft), 100 hours (Last 90 days, all aircraft), 25 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N48TZ
Model/Series: A36
Aircraft Category: Airplane
Year of Manufacture: 1980
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-1804
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 08/08/2016, Annual
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 163 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6184 Hours at time of accident
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-520
Registered Owner: GULF CENTRAL AVIATION LLC
Rated Power: 285 hp
Operator: GULF CENTRAL AVIATION LLC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KREG, 14 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 0935 CDT
Direction from Accident Site: 17°
Lowest Cloud Condition: Scattered / 300 ft agl
Visibility: 10 Miles
Lowest Ceiling:
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 230°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 30°C / 26°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: GONZALES, LA (REG)
Type of Flight Plan Filed: None
Destination: GONZALES, LA (REG)
Type of Clearance: None
Departure Time: 0926 CDT
Type of Airspace: Class G

Airport Information

Airport: LOUISIANA RGNL (REG)
Runway Surface Type: Asphalt
Airport Elevation: 14 ft
Runway Surface Condition: Dry
Runway Used: 17
IFR Approach: None
Runway Length/Width: 5003 ft / 100 ft
VFR Approach/Landing: Forced Landing

Wreckage and Impact Information

Crew Injuries: 2 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 30.153889, -90.937778 (est)



NTSB Identification: CEN17LA328
14 CFR Part 91: General Aviation
Accident occurred Thursday, August 17, 2017 in Gonzales, LA
Aircraft: BEECH A36, registration: N48TZ
Injuries: 2 Uninjured.

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 August 17, 2017, about 0927 central daylight time, a Beech A36 airplane, N48TZ, was substantially damaged during a forced landing after departing from Louisiana Regional Airport (REG), Gonzales, Louisiana. The private pilot and flight instructor were not injured. The airplane was registered to and operated by Gulf Central Aviation LLC under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed for the local flight, which departed about 0926. 

According to the pilot, the departure occurred on Runway 17, following a normal engine run up and takeoff roll. After climbing to about 150 ft agl, the pilot noticed the airplane was no longer climbing and lowered the nose. Based on his perceptions of a partial engine power loss, the pilot checked the throttle and mixture lever positions, which were both full forward. After maneuvering to avoid trees, the pilot initiated a forced landing into a hay field. During the landing roll, the airplane impacted a small ridge and nosed over, which damaged the engine firewall.

Abnormal Runway Contact: North American SNJ-4, N243CC; accident occurred August 12, 2017 at Ashland County Airport (3G4), Ohio




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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Cleveland; North Olmsted, Ohio

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


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



Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf 

http://registry.faa.gov/N243CC



Location: Ashland, OH
Accident Number: CEN17LA323
Date & Time: 08/12/2017, 1117 EDT
Registration: N243CC
Aircraft: NORTH AMERICAN SNJ-4
Aircraft Damage: Substantial
Defining Event: Abnormal runway contact
Injuries: 1 Serious, 1 Minor
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The private pilot of the tailwheel-equipped airplane stated that, during a "wheel landing," the airplane bounced twice upon touchdown then veered off the runway into a grass area. The pilot was unable to return the airplane to the runway surface because the airplane was "slipping on the grass" while the pilot applied left rudder and left wheel brake. The airplane nosed over when it came to a stop in the grass area and came to rest inverted. The pilot stated that there were no mechanical malfunctions or failures with the airplane. According to the Airplane Flying Handbook, corrective action from a bounced landing is dependent upon its severity, and such action can range from an application of power to cushion a subsequent landing to performance of a go-around.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's improper recovery from a bounced landing, which resulted in a loss of directional control.

Findings

Aircraft
Landing flare - Not attained/maintained (Cause)

Personnel issues
Incorrect action performance - Pilot (Cause)

Factual Information

On August 12, 2017, at 1117 eastern daylight time, a North American SNJ-4, N243CC, experienced a bounced landing and veered off runway 19 at Ashland County Airport (3G4), Ashland, Ohio. The airplane nosed-over, impacted terrain, and received substantial damage. The private pilot sustained serious injuries, and a passenger sustained minor injuries. The airplane was registered to and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The flight originated from Akron Fulton International Airport (AKR), Akron, Ohio, about 1100 and was destined to 3G4.

The pilot stated that during a "wheel landing" on runway 19, the airplane bounced on touch down and during the second bounce veered off the runway into a grass area. The pilot was unable to return airplane to the runway surface because the airplane was "slipping on the grass" while he applied left rudder and left wheel brake. The airplane nosed-over when it came to a stop in the grass area and impacted the ground.

The pilot stated there was structural damage to the airframe, left wing, and empennage. He stated there was no mechanical malfunction/failure with the airplane.

The Airplane Flying Handbook (FAA-H-8083-3B) stated in part:

"Since a bounce occurs when the airplane makes contact with the ground before the proper touchdown attitude is attained, it is almost invariably accompanied by the application of excessive back-elevator pressure. This is usually the result of the pilot realizing too late that the airplane is not in the proper attitude and attempting to establish it just as the second touchdown occurs.

The corrective action for a bounce is the same as for ballooning and similarly depends on its severity. When it is very slight and there is no extreme change in the airplane's pitch attitude, a follow-up landing may be executed by applying sufficient power to cushion the subsequent touchdown and smoothly adjusting the pitch to the proper touchdown attitude."

"…When a bounce is severe, the safest procedure is to execute a go-around immediately. Do not attempt to salvage the landing. Apply full power while simultaneously maintaining directional control and lowering the nose to a safe climb attitude. The go-around procedure should be continued even though the airplane may descend and another bounce may be encountered. It is extremely foolish to attempt a landing from a bad bounce since airspeed diminishes very rapidly in the nose-high attitude, and a stall may occur before a subsequent touchdown could be made."

History of Flight

Landing-flare/touchdown
Abnormal runway contact (Defining event)

Landing-landing roll
Loss of control on ground
Runway excursion
Attempted remediation/recovery
Nose over/nose down



Pilot Information

Certificate: Private
Age: 67, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/10/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 04/25/2017
Flight Time:  1565 hours (Total, all aircraft), 71 hours (Total, this make and model), 1463 hours (Pilot In Command, all aircraft), 14 hours (Last 90 days, all aircraft), 6 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: NORTH AMERICAN
Registration: N243CC
Model/Series: SNJ-4
Aircraft Category: Airplane
Year of Manufacture: 1943
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 88-13243
Landing Gear Type: Retractable - Tailwheel
Seats: 2
Date/Type of Last Inspection: 05/16/2017, Annual
Certified Max Gross Wt.: 5265 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 14658.7 Hours as of last inspection
Engine Manufacturer: Pratt & Whitney
ELT: Installed, not activated
Engine Model/Series: R1340 AN-1
Registered Owner: Pilot
Rated Power: 600 hp
Operator: Pilot
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: MFD, 1297 ft msl
Distance from Accident Site: 13 Nautical Miles
Observation Time: 1207 EDT
Direction from Accident Site: 145°
Lowest Cloud Condition: Scattered / 2400 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 3100 ft agl
Visibility (RVR): 
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 300°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 22°C / 16°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Akron, OH (AKR)
Type of Flight Plan Filed: None
Destination: Ashland, OH (3G4)
Type of Clearance: None
Departure Time: 1100 EDT
Type of Airspace: Class E

Airport Information

Airport: Ashland County Airport (3G4)
Runway Surface Type: Asphalt
Airport Elevation: 1206 ft
Runway Surface Condition: Dry
Runway Used: 19
IFR Approach: None
Runway Length/Width: 3501 ft / 75 ft
VFR Approach/Landing: Full Stop; Traffic Pattern 

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Minor
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Serious, 1 Minor
Latitude, Longitude: 40.900000, 82.260000 (est)





NTSB Identification: CEN17LA323
14 CFR Part 91: General Aviation
Accident occurred Saturday, August 12, 2017 in Ashland, OH
Aircraft: NORTH AMERICAN SNJ-4, registration: N243CC
Injuries: 1 Serious, 1 Minor.

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 August 12, 2017, at 1117 eastern daylight time, a North American SNJ-4, N243CC, experienced a bounced landing and veered off runway 19 at Ashland County Airport (3G4), Ashland, Ohio. The airplane nosed-over, impacted terrain, and received substantial damage. The private pilot sustained serious injuries and a passenger sustained minor injuries. The airplane was registered to and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The flight originated from Akron Fulton International Airport (AKR), Akron, Ohio, about 1100 and was destined to 3G4.

Navion Navion G Rangemaster, registered to Kalea Company LLC and operated by SkyWalker Flying, N249KC: Accident occurred August 11, 2017 near Lenawee County Airport (KADG), Adrian, Michigan

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Belleville, Michigan
Continental Motors; Mobile, Alabama 

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


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



Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf


http://registry.faa.gov/N249KC

Location: Adrian, MI
Accident Number: CEN17LA316
Date & Time: 08/11/2017, 1200 EDT
Registration: N249KC
Aircraft: NAVION NAVION G
Aircraft Damage: Substantial
Defining Event: Loss of engine power (partial)
Injuries: 2 Serious
Flight Conducted Under: Part 91: General Aviation - Instructional 

Analysis 

The flight instructor and private pilot had completed training maneuvers and were returning to the airport when the engine experienced a partial loss of power about 1,000 to 1,500 ft above ground level. They were unable to glide the airplane to an open field and descended into a wooded area. The airplane impacted trees and became wedged between trees, suspended above the ground. The engine and empennage separated from the rest of the airplane and came to rest on the ground nearby. The fuel tanks were damaged and most of the remaining fuel spilled onto the ground.

A postaccident examination of the engine revealed no pre-impact anomalies that would have precluded normal operation or production of rated horsepower; however, an examination of the gascolator showed that it had been leaking fuel from three locations and contained a significant amount of debris. In a postaccident examination, the gascolator was subjected to the relevant service bulletin testing and did not pass the test due to the leaking seals and drain valve. Since the gascolator was unable to seal properly, it would have allowed air into the fuel system, which would have resulted in a loss of engine power. A review of the airplane maintenance records revealed no record of compliance with the service bulletin, nor was compliance mandatory.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
A leak in the gascolator, which allowed air to enter the fuel system and resulted in a partial loss of engine power.

Findings

Aircraft
Fuel distribution - Damaged/degraded (Cause)
Fuel distribution - Not serviced/maintained (Cause)

Personnel issues
Scheduled/routine inspection - Maintenance personnel
Scheduled/routine maintenance - Maintenance personnel


Factual Information

On August 11, 2017, about 1200 eastern daylight time, a Navion G airplane, N249KC, impacted trees after a loss of engine power near Adrian, Michigan. The flight instructor and private pilot were seriously injured and the airplane sustained substantial damage. The airplane was registered to Kalea Co. LLC and operated by Sky Walker Flying under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time of the accident and a flight plan had not been filed. The local flight departed Lenawee County Airport (ADG), Adrian, Michigan, about 1000.

According to the flight instructor, the engine experienced a loss of power about 1,000 ft above ground level (agl) while over a wooded area and she was unable to glide the airplane to a nearby field. She stated to the sheriff's office that after the accident she walked to a nearby road and waited for a car to pass by for help.

The private pilot stated to the sheriff's office that he was flying the airplane and they were returning to the airport after completing training maneuvers. He stated that the engine experienced a partial loss of power about 1,500 ft agl. He added that the engine still had a little power available during the event.

The responding Federal Aviation Administration (FAA) inspector reported that the airplane was found wedged between trees with the empennage separated from the rear fuselage and engine separated from the firewall (figure 1). There was a smell of aviation fuel at the accident site.


Figure 1 – The airplane suspended above the ground and wedged between trees

A postaccident examination of the airplane was conducted by the FAA inspector and a technical representative from Continental Motors. The examination revealed that more than 4 gallons of fuel was drained from left wing tip tank, which remained intact. The right wing tip tank was found breached and had separated from the wing; there was no fuel present in the tank. The fuel gascolator, which is the low point of the center main fuel tanks, did not contain any fuel. There were fuel stain marks underneath the gascolator as it was installed on the airplane. The gascolator was removed for further testing.

An examination of the engine revealed the engine sustained impact damage concentrated mostly to the left rear side and the crankcase remained intact. All six cylinders remained attached to the engine and displayed impact damage signatures with the left side cylinders sustaining more damage than the right. The induction and exhaust systems both displayed impact damage signatures, but there were no signs of exhaust or induction leaks noted. The fuel pump was impact damaged as were several of the fuel line fittings. The throttle and metering assembly remained attached to the engine and displayed impact damage signatures; both the throttle and mixture arms were broken. The fuel manifold valve remained attached to its installation point and displayed impact damage signatures at the rear fitting. All of the fuel nozzles remained installed in their cylinders and there were no signs of fuel leaks near the nozzles. The 2 magnetos were undamaged and produced a spark at each ignition lead when manually rotated. The ignition harness displayed impact damage signatures to several of the left side cylinder ignition leads. All of the spark plugs remained installed in their cylinders and the top left spark plugs displayed impact damage signatures. The three-blade, constant speed propeller remained attached to the crankshaft and one of the blades was impact damaged. There were no pre-impact anomalies with the engine that would have precluded normal operation or production of rated horsepower.

The gascolator top and bottom seals were comprised of rubber gaskets which were meshed to a wire screen by a glass cylinder. As assembled the glass cylinder was tightened between two caps which each contained the rubber gaskets and wire mesh. The gascolator was examined by an FAA inspector who reported that there were fuel stains on the top seal and the drain valve, indicative of a fuel leak at some point during the life of the unit (figure 2).


Figure 2 – Gascolator installed on the airplane 

Sierra Hotel Aero, Inc. (SHA) holds the type certificate for the Navion. In May of 2007, SHA issued Navion Service Bulletin (SB) 106A - Fuel System - Inspection of the fuel system continued safe operation. The purpose of the SB was to require accomplishment of one time inspection of entire fuel system. This included from firewall aft for condition of all fuel lines installed including tip tanks, metal lines, fittings, hoses, vent system, vapor return, boost pump, and fuel strainer. The SB further states, inspect fuel strainer for evidence of fuel staining and leaking. Disassemble strainer and clean fuel screen. Inspect for damage and reassemble. Perform vacuum test of gascolator to include: connect hand operated vacuum pump and apply 24" of vacuum, verify bleed down does not exceed 4" over one minute, replace gaskets, fuel drain and/or gascolator as needed to ensure proper operation.

The gascolator was subjected to postaccident testing as prescribed in the Navion SB No. 106 A. The outlet port was plugged using an appropriate AN plug fitting. The gascolator was filled with clean 100LL fuel. After the fuel was added, a significant amount of foreign debris was observed floating in the gascolator. A 7-inch aluminum line with AN fittings was attached to the inlet port and the other end to the gascolator. This line was previously leak checked with no anomalies found. The inspector applied 24 inches of vacuum pressure using a hand vacuum pump; the gascolator was tested and failed to hold the required 24 inches of vacuum pressure for any amount of time. During the test the gascolator was leaking from the top seal, bottom seal, and the drain valve.

A review of the airplane maintenance logbooks revealed no record of compliance with the Navion SB No. 106 A, and there was no mention of gascolator maintenance from December 2006 to July 2017. 

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 52, Female
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 12/01/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 06/23/2016
Flight Time:  1700 hours (Total, all aircraft), 32 hours (Total, this make and model), 1500 hours (Pilot In Command, all aircraft), 80 hours (Last 90 days, all aircraft), 30 hours (Last 30 days, all aircraft)

Pilot Information

Certificate: Private
Age: 49, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/23/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 12/13/2015
Flight Time: (Estimated) 

Aircraft and Owner/Operator Information

Aircraft Make: NAVION
Registration: N249KC
Model/Series: NAVION G
Aircraft Category: Airplane
Year of Manufacture: 1964
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: NAV-4-2499
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 07/05/2017, Annual
Certified Max Gross Wt.: 
Time Since Last Inspection: 5 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2089.06 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: IO-520BA
Registered Owner: KALEA CO LLC
Rated Power: 285 hp
Operator: Skywalker Flight School, LLC.
Operating Certificate(s) Held: None
Operator Does Business As: SkyWalker Flying
Operator Designator Code: 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KADG, 796 ft msl
Distance from Accident Site: 2 Nautical Miles
Observation Time: 1153 EDT
Direction from Accident Site: 355°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 7 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 220°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.99 inches Hg
Temperature/Dew Point: 22°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ADRIAN, MI (ADG)
Type of Flight Plan Filed: None
Destination: ADRIAN, MI (ADG)
Type of Clearance: None
Departure Time: 1000 EDT
Type of Airspace: Class E

Airport Information

Airport: LENAWEE COUNTY (ADG)
Runway Surface Type: 
Airport Elevation: 798 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 2 Serious
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Serious
Latitude, Longitude: 41.829167, -84.074444 (est)









NTSB Identification: CEN17LA316
14 CFR Part 91: General Aviation
Accident occurred Friday, August 11, 2017 in Adrian, MI
Aircraft: NAVION NAVION G, registration: N249KC
Injuries: 2 Serious.

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 August 11, 2017, about 1000 eastern daylight time, a Navion G airplane, N249KC, impacted trees after a loss of engine power near Adrian, Michigan. The flight instructor and private pilot were seriously injured and the airplane sustained substantial damage. The airplane was registered to Kalea Co. LLC and operated by Sky Walker Flying under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight departed Lenawee County Airport (ADG), Adrian, Michigan, at an unknown time. 

The responding Federal Aviation Administration (FAA) inspector reported that the airplane was found wedged between two trees and the engine had separated from the firewall (figure 1). 

According to the flight instructor, the airplane's engine experienced a total loss of power about 1,000 ft above ground level.

The airplane has been retained for further examination.