Sunday, September 22, 2019

Fuel Related: Lancair 360, N92WL; accident occurred May 02, 2018 near West Woodward Airport (KWWR), Oklahoma













Aviation Accident Final Report - National Transportation Safety Board 

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

Additional Participating Entity: 

Federal Aviation Administration / Flight Standards District Office; Oklahoma City, Oklahoma

Investigation Docket - National Transportation Safety Board:


Location: Woodward, OK
Accident Number: CEN18LA156
Date & Time: 05/02/2018, 1620 CDT
Registration: N92WL
Aircraft: LAMINAR Lancair 360
Aircraft Damage: Substantial
Defining Event: Fuel related
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis

The airline transport pilot was conducting a personal flight with a pilot-rated passenger in an experimental, amateur-built airplane. The pilot reported that, during flight at 10,000 ft, the airplane experienced moderate to severe turbulence for a few seconds. Shortly after, the engine stopped producing power without warning. The pilot immediately attempted to restart the engine to no avail. He flew at best glide speed toward the nearest airport, located about 12 nautical miles away, but landed short of the runway in a pasture, during which the airplane encountered sagebrush, which caused the landing gear to collapse as the airplane bounced and skidded to a stop; the fuselage sustained substantial damage.

The examination of the airplane at the accident site revealed that the emergency fuel shutoff valve, which was located on the right side of the center console under the instrument panel, was about 1/4 of the way between the on (horizontal) position and the off (vertical) position. The valve could not be seen by the pilot. Further, the pilot-rated passenger stated that he could not see the emergency fuel shutoff valve. He was not sure if his knee hit the valve handle and shut off the fuel flow from the header fuel tank to the engine during the turbulence event. The onboard flight and engine monitoring system indicated that the airplane was about 10,000 ft mean sea level when it experienced about a 2g vertical acceleration. The engine data indicated a rapid decrease of fuel flow after the 2g acceleration with a coinciding decrease in exhaust gas temperatures and fuel pressure.

About 30 gallons of fuel was drained from the airplane before it was transported to the recovery facility. An engine examination and test run were conducted, and the engine performed satisfactorily. A second test was conducted to determine the effectiveness of the emergency fuel shut off valve and where it needed to be positioned before it cut off all fuel to the engine. There was no indication of a power loss until the valve handle was in the full vertical position, which then caused the engine to stop within about 10 seconds.

The pilot-rated passenger reported that he had recently purchased the airplane and that he and the pilot were flying the airplane to his home base. He stated that although he and the pilot were experienced pilots, neither had any flight time in the airplane except for the orientation flight that the pilot had received.

Given the engine data, it is likely that the pilot-rated passenger's knee inadvertently hit the emergency fuel shutoff valve during the turbulence event and caused it to shut off the fuel flow from the header tank to the engine. Further, had the pilot been familiar with the airplane, he would have known where the fuel selector valve was, regardless of whether it was easy to see, and would have checked it when the engine lost power as a memory item check in the emergency procedures.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot-rated passenger's inadvertent contact with and closure of the emergency fuel shutoff valve, which resulted in the total loss of engine power due to fuel starvation. Contributing to the accident was the pilot's lack of experience in the accident airplane.

Findings

Aircraft Fuel - Fluid level
Personnel issues (general) - Passenger
Personnel issues Total experience w/ equipment - Pilot

Factual Information

On May 2, 2018, about 1620 central daylight time, an experimental, amateur-built Laminar Lancair 360 airplane, N92WL, experienced a total loss of engine power during cruise flight and impacted terrain during a forced landing to a field about 1/2 mile from the Woodward Municipal Airport (WWR), Woodward, Oklahoma. The pilot and pilot-rated passenger were not injured, and the airplane sustained substantial damage. The airplane was owned by an individual and operated by the pilot under the provisions of the Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident, which was operated on an instrument flight plan. The personal flight departed the Lee Summit Municipal Airport (LXT), Lee's Summit, Missouri, about 1416, and was en route to the Dalhart Municipal Airport, Dalhart, Texas.

The pilot reported he was in cruise flight at 8,000 ft but requested 10,000 ft to stay clear of clouds. As the airplane reached 10,000 ft, the airplane experienced moderate to severe turbulence for a few seconds. Shortly after the turbulence, the engine stopped producing power without any prior indications, such as sputtering. The pilot immediately started a descent and turned on the fuel boost pump, fuel transfer pumps, and changed throttle and mixture settings to try restart the engine but without success.

The pilot-rated passenger declared a MAYDAY and determined the course to the nearest airport, which was WWR located about 12 nautical miles to the southeast. The pilot flew the airplane at best glide airspeed by putting the propeller lever to the coarsest pitch, which produced a glide ratio with a 1,000 to 1,100 fpm rate of descent. About 5,700 ft above mean sea level (msl), the pilot decided that it did not look favorable to make it to the airport, so he pushed the propeller back in and attempted to restart the engine. However, the rate of descent increased to 1,800 to 2,000 fpm. The engine did not restart so the pilot decided to conduct a forced landing to a road, but once he saw that power lines and trees near the road, he decided to land in a pasture. He lowered the landing gear (the flaps were found in the retracted position).

As the airplane landed in the pasture, the airplane encountered sagebrush which caused the landing gear to collapse as the airplane bounced and skidded to a stop. Later, the pilot examined the airplane and the only anomaly he reported was that "the main fuel cutoff valve (hidden in the co-pilot's foot well) was just partially moved." He stated that he was not sure if the valve was moved during the turbulence event or while bouncing across the pasture.

The pilot-rated passenger stated that he could not see the main fuel cutoff valve located on the right side of the center console and under the instrument panel. He was not sure if his knee hit the valve handle and shut off the fuel flow from the header fuel tank to the engine during the turbulence event. He stated that the fuel valve handle was found about ¼ of the way from the on position (horizontal) to the off position (vertical). He stated that the handle moved without much resistance.

The airplane's builder reported that he used 2 similar stainless steel, Teflon coated ball valves with 3/8-inch lines in constructing the airplane. Both valves had orange handles. One of the valve handles was located on the left side of the center console on the pilot's side and under the instrument panel. The pilot's side valve was an emergency gear dump valve. The valve dumped hydraulic pressure to allow the landing gear to lower if the hydraulic pumps were inoperative. The other orange valve handle was the emergency fuel shutoff valve located on the right side of the center console on the passenger's side, which could not be seen by the pilot. The valve shut the fuel off from the airplane's header tank to the engine. The handle for the emergency fuel shutoff valve was in the horizontal position for normal operations. To turn the fuel off, the handle was placed in the vertical position.

The airplane was equipped with a Garmin EFIS which provided flight and engine monitoring data. The SD card was downloaded, and it provided engine performance data that included exhaust gas temperatures (EGT) for all cylinders, tachometer (rpm), fuel flow, oil pressure, and manifold pressure. The flight data indicated that the airplane was at about 10,000 ft msl when it experienced about a 2g vertical acceleration. The data for the engine indicated a rapid decrease of fuel flow within 20 seconds of the 2g acceleration with a coinciding decrease in EGTs and fuel pressure.

The airplane wreckage was partially disassembled and transported to an aircraft recovery facility. About 30 gallons of fuel was drained from the airplane before transporting it to the recovery facility. The header tank was found "nearly" full, and the rest of the fuel came from the wing tanks. The National Transportation Safety Board conducted an examination/engine run at the recovery facility. The engine was a 180-horsepower four-cylinder Lycoming IO-360-C1E6 engine. The engine was started and run at various power settings. The magneto drop was "high" but similar between both left and right magnetos. The engine performed satisfactorily during the test, and a reason for the lost power on the accident flight was not found.

A second test was conducted to determine the effectiveness of the emergency fuel shut off valve and where it needed to be positioned before it cut off all fuel to the engine. The engine was started and run at 2,090 rpm at 18.3 inches of manifold pressure. The emergency fuel shut off valve was slowly moved from the on position (horizontal) to the vertical position. There was no indication of a loss of power until the valve handle was in the full vertical position, which then caused the engine to stop within about 10 seconds.

The pilot-rated passenger reported that he had recently purchased the airplane and that he and the pilot were flying the airplane to his home base. He stated that although he and the pilot were experienced pilots, neither had any flight time in the airplane except for the orientation flight that the pilot had received. 

History of Flight

Enroute-cruise Turbulence encounter
Enroute-cruise Fuel related (Defining event)
Enroute-cruise Fuel starvation
Enroute-cruise Loss of engine power (total)
Emergency descent Off-field or emergency landing
Landing-landing roll Collision with terr/obj (non-CFIT)
Landing-landing roll Landing gear collapse

Pilot Information

Certificate: Airline Transport; Commercial
Age: 41, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
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 Without Waivers/Limitations
Last FAA Medical Exam: 03/26/2018
Occupational Pilot:Yes 
Last Flight Review or Equivalent:
Flight Time: 5000 hours (Total, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: LAMINAR
Registration: N92WL
Model/Series: Lancair 360
Aircraft Category:Airplane 
Year of Manufacture: 2016
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 719-320-563
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection:  Condition
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 90 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO-360-C1E6
Registered Owner: LOWEN WILLIAM H
Rated Power: 180 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: WWR, 2189 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1555 CDT
Direction from Accident Site: 90°
Lowest Cloud Condition: Scattered / 4700 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 23 knots / 32 knots
Turbulence Type Forecast/Actual:
Wind Direction: 160°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.78 inches Hg
Temperature/Dew Point: 27°C / 15°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Lee Summit, MO (LXT)
Type of Flight Plan Filed: IFR
Destination: Dalhart, TX (DHT)
Type of Clearance: IFR
Departure Time: 1416 CDT
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 36.443611, -99.515000 (est)

Landing Gear Collapse: Cessna 310R, N372WP; accident occurred March 22, 2018 at Charles B. Wheeler Downtown Airport (KMKC), Kansas City, Missouri

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

Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri


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/N372WP


Location: Kansas City, MO
Accident Number: CEN18LA128
Date & Time: 03/22/2018, 1800 CDT
Registration:N372WP 
Aircraft: CESSNA 310R
Aircraft Damage: Substantial
Defining Event: Landing gear collapse
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On March 22, 2018, about 1800 central daylight time, a Cessna 310 airplane, N372WP, sustained substantial damage when the right landing gear collapsed during landing roll at the Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The pilot and passenger were not injured. The airplane was owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 on a personal flight. Visual meteorological conditions prevailed for the flight, which was on an instrument flight rules flight plan. The flight departed from the Shreveport Downtown Airport, (DTN), Shreveport, Louisiana, with MKC as the destination airport.

The pilot reported that the landing gear position lights were all green during the approach and the landing was normal. During landing rollout, the right landing gear collapsed. A witness who observed the landing stated that the landing appeared normal and was not a hard landing. After the landing gear collapsed, the airplane skidded for about 1,200 to 1,500 ft and veered off the side of the runway, which resulted in substantial damage to the horizontal stabilizer and elevator.

The airplane's landing gear parts that were broken during the accident were shipped to the National Transportation Safety Board's Materials Laboratory for examination. The parts that were examined included: 1) end fitting bolt with a mating spacer, 2) end fitting assembly with mating adjusting screw, 3) bellcrank assembly bolt with mating nut, and 4) part of a flange.

The examination of the fracture surfaces of the end fitting assembly mating adjustment screw, the bellcrank assembly bolt, and the flange revealed that the fracture features were consistent with overstress. The failure mode of the end fitting bolt could not be determined due to smearing and secondary damage to the fracture surface.

The examination of the fracture surfaces of the end fitting bolt with a mating spacer revealed that it had separated through a thread root on the end of the bolt. The bolt was bent, which prevented easy removal of the mating spacer and bushing. The fracture surface was approximately flat, but significant smearing and secondary damage obscured the finer features. Two crescent-shaped marks on the fracture surface aligned with mounded material on the sides, which was consistent with impact damage. The exact cause of the end fitting bolt separation could not be determined.

Pilot Information

Certificate: Airline Transport
Age: 57, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 01/05/2018
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  11987 hours (Total, all aircraft), 1890 hours (Total, this make and model), 21 hours (Last 90 days, all aircraft), 8 hours (Last 30 days, all aircraft)

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N372WP
Model/Series: 310R
Aircraft Category: Airplane
Year of Manufacture: 1977
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 310R0904
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection:  Annual
Certified Max Gross Wt.: 5501 lbs 
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 6362 Hours at time of accident
Engine Manufacturer: Continental
ELT: C126 installed, not activated
Engine Model/Series: IO-520-MB
Registered Owner: On file
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: MKC, 756 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1654 CDT
Direction from Accident Site: 0°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 120°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.11 inches Hg
Temperature/Dew Point: 20°C / 2°C
Precipitation and Obscuration: No Precipitation
Departure Point: Shreveport, LA (DTN)
Type of Flight Plan Filed: IFR
Destination: Kansas City, MO (MKC)
Type of Clearance: IFR
Departure Time: 1430 CDT
Type of Airspace: Class D

Airport Information

Airport: Downtown Air (MKC)
Runway Surface Type: Concrete
Airport Elevation: 756 ft
Runway Surface Condition: Dry
Runway Used: 19
IFR Approach: None
Runway Length/Width: 6827 ft / 150 ft
VFR Approach/Landing: Full Stop

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 None
Latitude, Longitude: 39.123056, -94.592778

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

Airplane at Accident Site.
Federal Aviation Administration

View of Accident Airplane from Right Wing.
Federal Aviation Administration

Left Wing Root.
Federal Aviation Administration

Forward View of Accident Airplane.
Federal Aviation Administration

Engine Accessory Case with Separated Fuel Line.


Federal Aviation Administration


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%.

Loss of Control in Flight: Ted Smith Aerostar 601, N7529S; fatal accident occurred December 10, 2017 near Miami Executive Airport (KTMB), Miami-Dade County, Florida

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Miramar, Florida
Lycoming; Williamsport, Pennsylvania

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/N7529S




William Rollo Carman

Location: Miami, FL
Accident Number: CEN18FA050
Date & Time: 12/10/2017, 1450 EST
Registration: N7529S
Aircraft: SMITH AEROSTAR 601
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 10, 2017, at 1450 eastern standard time, a Smith Aerostar 601 airplane, N7529S, collided with terrain shortly after takeoff from Miami Executive Airport (TMB), Miami, Florida. The pilot was fatally injured, and the airplane was destroyed by impact forces. The airplane was registered to the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which was originating at the time of the accident.

An employee of the flight school where the airplane was tied down stated that the pilot arrived about 1000 and began to preflight the airplane. About 1030, the pilot fueled the airplane, adding 105.2 gallons of 100LL aviation fuel. How the fuel was distributed between the airplane's three fuel tanks could not be determined. The pilot then taxied the airplane to the ramp in front of the flight school hangar where he kept a toolbox. The witness stated that the pilot was working on the airplane when he noticed a fuel leak and stated that he should have "fixed that" before he fueled the airplane. Both the employee and another witness stated that fuel was leaking from the aft fuselage belly area. They stated that the pilot had two or three 5-gallon orange buckets under the airplane to catch the fuel as he worked to stop the leak. Neither witness saw how much fuel was in the buckets or what the pilot did with the fuel. One witness asked the pilot if he fixed the problem, and the pilot responded that he had.

The pilot was cleared for takeoff from runway 31 at 1426; however, the pilot aborted the takeoff and landed the airplane back on the runway. The controller asked the pilot if he needed assistance, to which the pilot replied, "… not sure what happened just yet but so far so good." The pilot then requested to taxi back to the runway to take off again. The airplane was cleared to take off at 1447, and 32 seconds later, the pilot declared an emergency. The controller cleared the pilot to land on any runway.

Two pilots in an airplane waiting to take off from runway 31 stated that they did not notice anything unusual about the takeoff until they heard the pilot declare an emergency. They reported that the airplane was between 400 ft and 800 ft above the ground and in a left turn toward runway 9R. They stated that they thought the pilot was going to make it back to the runway, but then the left bank increased past 90° and the nose suddenly dropped. One of the pilots likened the maneuver to a stall/spin, Vmc roll, or snap roll-type maneuver. The airplane subsequently impacted a cornfield east of the approach end of runway 9R.

The following day, a 12-ft-by-16-ft stain was observed on the ramp where the airplane had been parked. One of the witnesses stated that the stain was from fuel that leaked out of the airplane.

Pilot Information

Certificate: Private
Age: 62, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 08/04/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 
Flight Time: 1000 hours (Total, all aircraft)

The pilot held a private pilot certificate with airplane single- and multi-engine land ratings. His most recent FAA first-class medical certificate was issued on August 4, 2015, with the limitation that he must wear corrective lenses. On the application for that medical certificate, the pilot reported 1,000 hours total flight experience, with 30 hours in the preceding 6 months. The medical certificate expired for all classes on August 31, 2017. The pilot's logbook was not available during the investigation and his flight time could not be determined. The pilot was not a certificated airframe and powerplant mechanic. 



Aircraft and Owner/Operator Information

Aircraft Make: SMITH
Registration: N7529S
Model/Series: AEROSTAR 601
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 61-0161-082
Landing Gear Type: Retractable - Tricycle
Seats:6 
Date/Type of Last Inspection:
Certified Max Gross Wt.: 6001 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT: Installed, not activated
Engine Model/Series:IO-540-S1A5
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None 

The accident airplane was a six-place, turbo-charged twin-engine airplane with retractable landing gear. The airplane was powered by two Lycoming IO-540-S1A5 300-horsepower engines.

The pilot purchased the airplane on March 3, 1998, and had it advertised for sale at the time of the accident.

The last annual inspection recorded in the airframe, engine, and propeller logbooks was dated December 9, 2016. The airframe total time was listed as 3,571.7 hours. The left engine time since major overhaul (SMOH) was listed as 124.7 hours and the time SMOH for the right engine was 56.9 hours. The last entry in the airframe logbook was dated June 3, 2017, at which time the recorded airframe time was 3,576 hours.


Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dawn
Observation Facility, Elevation: TMB, 10 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1953 UTC
Direction from Accident Site: 90°
Lowest Cloud Condition: Clear
Visibility:   10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 340°
Turbulence Severity Forecast/Actual: 
Altimeter Setting: 30.21 inches Hg
Temperature/Dew Point: 16°C / 2°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Miami, FL (TMB)
Type of Flight Plan Filed: None
Destination: Miami, FL (TMB)
Type of Clearance: VFR
Departure Time: 1450 EST
Type of Airspace: Class C

Airport Information

Airport: MIAMI EXECUTIVE (TMB)
Runway Surface Type: N/A
Airport Elevation: 10 ft
Runway Surface Condition:
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Precautionary Landing 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 25.644444, -80.455833 

The accident site was located in a cornfield about 0.90 mile northwest of the approach end of runway 9R. There was an odor of fuel at the accident site. Aerial photographs taken 2 days after the accident showed an area of blight surrounding the accident site.

The wreckage came to rest on a heading of 210°. The empennage was reportedly folded over the fuselage area and pulled back by first responders. The pilot's seatbelt was cut by first responders during the extraction process. Both engines were buried 1.5 to 2 ft deep at a 45° angle. Portions of two propeller blades were visible on each engine.

The top of the cockpit was separated and the rest of the cockpit was destroyed. The throttle quadrant was separated from the surrounding structure. The fuel mixture and propeller levers were full forward. The throttle levers were broken off and the bases of the levers inside the quadrant were in the full-forward position. The instrument panel was fragmented. All of the fuel tank selector knobs and switches were either broken or missing, and their preimpact positions could not be determined. The left tank fuel quantity gauge indicated 10 gallons; however, the needle was loose. The fuselage tank gauge indicated 0 gallons and the needle was frozen in place. The right tank fuel quantity gauge indicated 12 gallons and the needle was frozen in place. The bladder fuselage fuel tank was ruptured.

The empennage was separated from the rest of the airplane. The vertical stabilizer, rudder, horizontal stabilizer, elevator, and respective trim tabs were intact and all remained attached to the empennage. The push-pull tubes for the elevator and rudder were disconnected and broken within the empennage.

The Janitrol heater was inside the empennage. The fuel line remained attached at the heater and the line was broken forward of the heater.

The fuel sump drain had broken out of the sump and was not located. The right side filter was clean. The left side filter contained a small amount of debris, which appeared to be cloth fibers. Examination of the fuel valves showed that the right main fuel valve was in the open position. The left main fuel valve, the left crossfeed valve, and the right crossfeed valve were in the closed position. The position of the valves was consistent with the fuel being shut off to the left engine and the right engine drawing fuel from the right fuel tank and the fuselage tank.

Examination of both engines did not reveal any mechanical failures or anomalies that would have precluded normal operation. The left engine fuel injection servo contained about 2 teaspoons of fuel and the right engine fuel injection servo contained about 2 ounces of fuel.

The fuel valves and fuel boost pumps were examined and functionally tested at the Aerostar facility in Hayden, Idaho. The fuel valves, with the exception of the left main valve, functioned normally when power was applied. The left main fuel valve was opened and internally intact. Power was again applied to the valve and the shaft of the motor drive gear was turned by hand. The motor began to operate intermittently; however, the gear housing immediately began to get hot.

The left engine fuel boost pump sustained internal impact damage, which prevented it from functioning when tested. The right engine fuel boost pump functioned when tested.

The airplane was equipped with an Insight GEM-1200 engine data monitor. The unit was sent to the National Transportation Safety Board Vehicle Recorder Laboratory for download. The unit records exhaust gas temperatures (EGT) and cylinder head temperatures (CHT). The unit sustained significant impact damage, which rendered it inoperable. The memory chip was removed from the unit and placed in a surrogate unit for download. The unit contained data from 12 flights, including the accident flight. Data was recorded every 6 seconds.

Data for all recorded flights showed that the left engine No. 5 CHT recorded a constant value of 32° Fahrenheit (°F) and the right engine No. 4 CHT recorded erratic values ranging from 32°F to 1382°F. These parameters were considered erroneous. The other data points were relatively consistent between both engines.

MEDICAL AND PATHOLOGICAL INFORMATION

The Miami-Dade County Medical Examiner's Department, Miami, Florida, performed an autopsy of the pilot. The reported listed the cause of death as blunt force trauma.

Toxicology tests performed at the FAA Forensic Sciences Laboratory were negative for carbon monoxide and cyanide. The testing was negative for drugs in the testing profile. Ethanol was detected in muscle tissue at 46 (mg/dL, mg/hg). Because ethanol was not detected in other tissue, the finding was consistent with postmortem production.