Sunday, September 22, 2019

Fuel Starvation: Piper PA-32-300, N4027W; accident occurred January 17, 2018 at Reno/Tahoe International Airport (KRNO) , Washoe County, Nevada

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Reno, Nevada
Piper Aircraft Inc; Vero Beach, Florida

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


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms 
 
http://registry.faa.gov/N4027W


Location: Reno, NV
Accident Number: WPR18LA070
Date & Time: 01/17/2018, 1520 PST
Registration: N4027W
Aircraft: PIPER PA 32-300
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional 

On January 17, 2018, about 1520 Pacific standard time, a Piper PA-32-300 airplane, N4027W, was substantially damaged when it impacted the ground shortly after takeoff from Reno/Tahoe International Airport (RNO), Reno, Nevada. The private pilot and flight instructor were not injured. The airplane was registered to and operated by the private pilot under the provision of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the cross-country flight which was originating at the time of the accident. The flight was destined for Hawthorne Industrial Airport (HTH), Hawthorne, Nevada.

According to the flight instructor, who was the pilot-in-command (PIC) at the time of the accident, he was providing instruction to the pilot to satisfy a checkout requirement imposed by his insurance company. Prior to takeoff, a weight and balance computation were performed, the fuel quantity was visually inspected, the oil quantity was verified, and a walk-around inspection of the airplane's control surfaces was accomplished. Both main fuel tanks had been filled to their capacity and some residual fuel remained in the auxiliary tanks. After an uneventful engine start, the instructor contacted ground control who directed him to taxi to runway 16L. The instructor reported that he followed the airplane's "before takeoff" checklist and performed an engine run-up to 2,000 rpm, at which time he leaned the fuel/air mixture about 50° rich of peak to accommodate a departure from a high field elevation. The instructor and pilot observed a drop of about 100 rpm when they selected each magneto. During this time, the analog fuel pressure gauge was normal, and the JP Instruments, Inc. engine monitor appeared to be operational. The instructor then set 10° of wing flaps, verified the fuel selector was on the left main fuel tank and turned the auxiliary fuel pump on. The pilot, who occupied the left seat, performed the takeoff and initial climb, which were uneventful; however, when the airplane reached an altitude about 300 ft above ground level, a total loss of engine power occurred. According to the instructor, the engine stopped firing rapidly with no pre-indication. The pilot then transferred the controls to the instructor and declared an emergency to air traffic control, who cleared them to land on runway 16R. The instructor started a turn to the right over runway 16R, but quickly determined the airplane would not be able to land on the remaining runway and continued the turn. Despite their previous agreement that the instructor would control the airplane in an emergency, the pilot took the controls back from the instructor after the airplane's stall warning light appeared during the descent. The flight instructor did not recall any details beyond the illumination of the stall warning light. The pilot subsequently lowered the nose and flared when the airplane was over a gravel surface. During touchdown, the airplane impacted the gravel, slid, and came to rest between taxiways "A" and "B."

Pilot Information

Certificate: Private
Age: 44, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
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: 02/27/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 10/30/2017
Flight Time: 110 hours (Total, all aircraft), 0 hours (Total, this make and model)

Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 67, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 07/18/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 12/21/2017
Flight Time:   916 hours (Total, all aircraft), 38 hours (Total, this make and model), 732 hours (Pilot In Command, all aircraft), 27 hours (Last 90 days, all aircraft), 12 hours (Last 30 days, all aircraft), 2 hours (Last 24 hours, all aircraft) 

The 67-year-old flight instructor held a flight instructor certificate with ratings for single-engine land and instrument airplane. The instructor's most recent second-class medical certificate was issued on July 18, 2016, which included the limitation, "must wear glasses." According to the instructor he had accumulated 916 hours of total flight time in all aircraft, of which 38 hours was in the accident airplane make and model.

The 44-year-old private pilot held a private pilot certificate with a rating for single-engine land. His most recent third-class medical certificate was issued on February 27, 2017, which did not include any limitations. According to the pilot, he had accumulated a total of 110 hours of flight time in all aircraft, and no time logged in the accident airplane make and model.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N4027W
Model/Series: PA 32-300 301
Aircraft Category: Airplane
Year of Manufacture:1966 
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: 32-40043
Landing Gear Type: Tricycle
Seats: 6
Date/Type of Last Inspection: 12/01/2017, Annual
Certified Max Gross Wt.: 3400 lbs
Time Since Last Inspection: 6 Hours
Engines: 1 Reciprocating
Airframe Total Time: 5979 Hours as of last inspection
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series: IO-540-K1G5D
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was powered by a Lycoming IO-540-K1G5D, a normally-aspirated, direct-drive, air-cooled, 300-horsepower engine. Aircraft logbooks furnished by the pilot showed that the airplane's most recent annual inspection was completed on December 1, 2017, at which time the airplane had accumulated 5,979 total flight hours. The entry listed a tachometer time of 747.1 flight hours at the time of the inspection. At the time of the airplane's most recent service, the engine had accrued a total of 1,231.6 hours since major overhaul.

The pilot reported that he purchased the accident airplane in December 2017, and on the day of the accident, he had planned to fly with his instructor and observe the performance of a recently installed engine monitor.

An airframe and powerplant mechanic employed by Advanced Aviation Reno, Inc., the maintenance facility partially owned by the pilot of the accident airplane reported that he had been asked to install a JP Instruments engine monitor in the accident airplane. The day before the accident, the company received fittings for the fuel flow sending unit portion of the assembly; however, the fittings were not the correct size for the fuel pump inlet line. The mechanic informed his director of maintenance of the error and then reinstalled the fuel line with a stubby wrench and reported to the director of maintenance that the fuel line had been tightened. He did not re-torque the fitting, as he was under the impression that the installation would be completed before the airplane was returned to service. When the pilot came to retrieve the airplane, the mechanic was working on another aircraft and had assumed the pilot was not going to fly the airplane.

According to the fitting manufacturer, the line must be torqued between 135 – 90 lb/in.

The director of maintenance corroborated the mechanic's statement and further added that he didn't know the airplane had been returned to service or even left the hangar.

According to JP Instrument, Inc's website, the installation of the JPI unit requires the completion of an FAA Form 337 major alteration/repair under Federal Regulations Part 43 appendix A. A major alteration requires the signature of a mechanic who holds inspection authorization (IA) in the aircraft logbook. According to the mechanic, the director of maintenance was the only IA mechanic at the time the service was completed, as the company's other IA had not been to work in at least a month.

The pilot stated that he didn't know if the mechanic knew they had planned to fly the airplane. He never asked the mechanic if the airplane had been returned to service or was ready to fly.

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: RNO, 4414 ft msl
Distance from Accident Site:
Observation Time: 1539 PST
Direction from Accident Site:
Lowest Cloud Condition: Few / 12000 ft agl
Visibility:  10 Miles
Lowest Ceiling: Overcast / 24000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 270°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.22 inches Hg
Temperature/Dew Point: 15°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: RENO, NV (RNO)
Type of Flight Plan Filed: None
Destination: HAWTHORNE, NV (HTH)
Type of Clearance: VFR Flight Following
Departure Time: 1520 PST
Type of Airspace: Class C 

Airport Information

Airport: RENO/TAHOE INTL (RNO)
Runway Surface Type: Concrete
Airport Elevation:4414 ft 
Runway Surface Condition: Dry
Runway Used:16L 
IFR Approach:None 
Runway Length/Width: 9000 ft / 150 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: 39.499722, -119.768056 

Additional Information

The airplane was examined by representatives of the manufacturer with oversight from the NTSB Investigator-in-Charge. Examination of the fuel sump revealed several ounces of fuel that resembled 100 low lead aviation grade gasoline that did not contain any water contamination or debris. The fuel selector was moved through its detents and the auxiliary fuel pump motor was audible when the pump was engaged at the cockpit.

The airplane was then moved to an open area outside of the owner's hangar and secured with wheel chocks and a tether to facilitate an engine run; the engine was run with its original propeller. Approximately three gallons of 100 low lead aviation grade gasoline was deposited into the left tip tank. The airplane started normally and was set at idle power (~1,000 rpm) for about one minute before the test began. The throttle was then advanced to three separate power settings: 1,600 rpm, 1,900 rpm, then 2,600 rpm. The fuel pump was engaged during engine runs at the first two power settings. During the test run, an excessive quantity of fuel was expelled from the engine driven fuel pump hose. However, the results showed that the engine could achieve a maximum power of 2,600 rpm. According to the airplane flight manual, the airplane's published maximum power is 2,700 rpm.

The engine driven fuel pump, manufactured by Lear Romec, was examined and tested by the manufacturer under the supervision of the FAA. The examination revealed wear on the drive shaft and pinion. Further, the drive pinion rotated freely about 40°; a newly manufactured pump would rotate less than 10°. The unit failed the external leakage and seal leakage tests, as flow testing showed that the seal behind the drive pinion leaked profusely. While the pump failed two discharge pressure tests, it functioned during each test and failed by a margin of 3%.

2 comments:

Pantdino said...

Did the pilot save the lives of himself and the instructor by putting the plane down when he did? Sounds like another stall / spin fatality in the making otherwise to me.

Anonymous said...

"Did the pilot save the lives of himself and the instructor by putting the plane down when he did? Sounds like another stall / spin fatality in the making otherwise to me."

I think you're right.