Saturday, February 29, 2020

Fuel Contamination: Tecnam P-2004 Bravo, N319TA, fatal accident occurred August 18, 2017 near New Kent County Airport (W96), Quinton, Virginia












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

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Richmond, Virginia

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/N319TA

Location: Quinton, VA
Accident Number: ERA17LA280
Date & Time: 08/18/2017, 1100 EDT
Registration: N319TA
Aircraft: COSTRUZIONI AERONAUTICHE TECNA P2004 BRAVO
Aircraft Damage: Substantial
Defining Event: Fuel contamination
Injuries: 1 Fatal, 1 Minor
Flight Conducted Under: Part 91: General Aviation - Instructional 

HISTORY OF FLIGHT

On August 18, 2017, about 1100 eastern daylight time, a Costruzioni Aeronautiche Tecnam P-2004 Bravo, N319TA, was substantially damaged when it impacted terrain and a fence during a forced landing near Quinton, Virginia. The flight instructor was fatally injured and the commercial pilot receiving instruction received minor injuries. The airplane was registered to Mid Atlantic Air Adventures, Inc. and was operated by New Kent Flight Center as a Title 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed in the area, and no flight plan was filed for the local flight, which departed New Kent County Airport (W96), Quinton, Virginia, about 1030.

The commercial pilot reported that the accident flight was his first instructional flight in the airplane make and model. The pilots checked the weather and performed a preflight inspection using the checklists, which revealed no anomalies. Both fuel tanks were checked and were indicating 1/2 full on the left and slightly more than 1/2 full on the right. The instructor informed the pilot that they would stay in the airport traffic pattern until the weather improved. After completing a runup and pretakeoff checklist, they departed runway 29. The commercial pilot reported he "was pretty sure we did three takeoffs and touch and goes" on runway 29. Following the last takeoff, all indications appeared normal, but as the commercial pilot started a left climbing turn to the crosswind leg of the traffic pattern about 600 ft mean sea level (msl), the "power just quit."

The flight instructor took control of the airplane and attempted to restart the engine, however, the propeller was "frozen in place" and the engine did not restart. The airport was over 1 mile away and there was no possibility of return, so they attempted a forced landing on a horse pasture. The flight instructor performed the landing to an area that was bordered by two 5 foot fences; the airplane collided with the first fence before landing in the field, then collided with an additional fence before coming to a rest on a gravel road.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) airman records, the flight instructor held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, and instrument airplane; a flight instructor certificate with ratings for airplane single engine and instrument airplane; and a mechanic certificate with powerplant rating. His most recent first-class FAA medical certificate was issued on December 6, 2016, with a limitation for corrective lenses. On the application for that certificate, the pilot reported 4,800 total hours of flight experience with 350 hours in the previous 6 months.

The pilot receiving instruction held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, and instrument airplane. His most recent second-class FAA medical certificate was issued on August 2, 2017, with a limitation for corrective lenses. On the application for that certificate, he reported 256 total hours civilian flight experience. He also reported over 6,050 hours of military flight experience.

AIRCRAFT INFORMATION

The airplane was a special light sport airplane and received its airworthiness certificate on April 24, 2008. It was a two-place, internally braced, high-wing airplane, with a two-blade fixed pitch propeller that was driven by a Rotax 912 100 horsepower, four-cylinder, four-stroke liquid/air cooled engine.

Review of maintenance records indicated that, at the time of the most recent 100-hour inspection on July 10, 2017, the airplane had accumulated 1,164.5 hours total time; the engine had 599.3 hours total time and the tachometer registered 240.4 hours. During the inspection, all cylinder compressions were normal, the oil was changed, and the oil filter was inspected. In addition, the spark plugs were removed, inspected, and reinstalled; there were no discrepancies noted.

The previous 100-hour inspection was accomplished on June 15, 2016; the tachometer time and engine total time was 176.5 hours and 535.5 hours, respectively. During the inspection, the spark plugs were replaced and the carburetors were rebuilt.

The powertrain section of the airplane maintenance manual detailed interval operating hours. It stated that spark plug inspection was required every 100 hours with replacement every 200 hours unless leaded fuel was used more than 30% of the airplane's operational time, which reduced the replacement interval to 100 hours. It also stated that the engine oil must be drained and replaced every 50 hours, and the oil filter replaced every 50 hours and cut open to examine the filter for contaminants. Airplane records indicated that these maintenance actions were completed as required by the reduced intervals set forth in the maintenance manual

The owner of the airplane could not confirm if the operator was using 100LL aviation fuel on a regular basis. He did report that, in May 2017, the operator purchased 25 gallons of 100LL on two separate occasions. In addition, 100LL (blue) fuel was recovered from the airplane after the accident. Between the most recent inspection and the flight log for the day of the accident flight, 38.3 hours had elapsed; the 50-hour inspection and oil change was due in 12.3 hours.

METEOROLOGICAL INFORMATION

The 1055 observation at W96, 1 mile east-northeast of the accident site, included wind from 180° at 5 knots, 10 miles visibility, overcast ceiling at 1,400 ft above ground level, temperature 28°C, dewpoint 26°C, and an altimeter setting of 29.90 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane impacted a wooden fence just before touchdown, which sheared off one of the landing gear. The airplane slid for about 200 ft after touchdown before striking another wooden fence, which resulted in impact damage to the fuselage, empennage, engine, and wings. The left wing fuel tank was compromised during the impact. The airplane continued another 50 ft, where it came to rest on a gravel road on a magnetic heading of 315°. A section of fence board entered the engine compartment, punctured the firewall and instrument panel, then entered the cockpit .

One of the propeller blades was separated and shattered about 14 inches from the hub. The opposing propeller blade was cracked in several locations, but remained intact.

The engine was examined at a salvage facility following recovery from the accident site. The engine remained attached to its mounts, which were deformed. Several components, including the number 2 (No. 2 and No. 4 cylinder) carburetor, were found displaced; several wires and hoses, including the fuel return line, were found separated. The exhaust pipes were separated at the muffler.

The engine could not be rotated by hand and could not be operated by the starter. The ignition system was examined and was in good physical condition.

The spark plugs were removed and examined. The No. 1 cylinder top and bottom spark plugs displayed rust colored material between the insulator nose and inner bore of the thread. The bottom Nos. 1 and 2 spark plugs were filled with a rust-colored liquid. The No. 3 cylinder top and bottom spark plugs exhibited rust between the insulator nose and inner bore of the thread. The bottom No. 3 spark plug was filled with a soapy liquid. The No. 4 top and bottom spark plugs appeared normal in color and in good condition. When compared to the Champion-Aviation Check-a-Plug chart, the spark plugs exhibited signs of significant lead fouling on the Nos. 1, 2, and 3 cylinders.

The fuel pump was removed and tested by hand, and produced a liquid consistent with water when the plunger was activated. The fuel return line was found disconnected at its attachment point. No anomalies were found with the fuel lines.

The carburetor for cylinder Nos. 1 and 3 and its float bowl were removed and examined. The float bowl contained a liquid consistent with water. The top of the carburetor was disassembled and examined. The rubber diaphragm was found incorrectly installed, as the tab was protruding from the side. The diaphragm was removed and was found to be 180° from its proper location.

The carburetor for cylinder Nos. 2 and 4 and its float bowl were removed and examined. The float bowl contained a liquid consistent with water. The main jet was removed and examined for obstruction and proper size. No additional anomalies were found with the carburetor or its components.

The airframe fuel lines located forward of the firewall exhibited no anomalies. The gascolator was disassembled and inspected. The internal filter and bowl contained an unknown contaminant that lined the interior surface of the bowl, consistent with corrosion.

A clear plastic container was placed under the electric fuel pump to capture any contents. A liquid consistent with water poured out of the fuel pump upon removal. The liquid was tested with water-finding paste, which indicated the presence of water. The fuel filter was removed and found to be partially blocked (30%) with unknown sediment contamination on the filter.

The fuel from the right wing tank was drained and placed in a clear plastic container to facilitate examination. A liquid consistent with water was found sitting at the bottom of the container as seen in figure 1.

Figure 1. Drained fuel showing water.

Removal and examination of the reduction gearbox revealed no anomalies, and the internal gears easily rotated within the gearbox. Rotation of the engine was attempted following removal of the gearbox; however, the engine would not rotate.

The No. 2 cylinder head was removed, and examination of the combustion chamber revealed significant combustion residue adhering to the top of the No. 2 piston and the bottom of the No. 2 cylinder, which prevented rotation of the crankshaft. With the No. 2 cylinder head removed, the engine crankshaft could be rotated by hand.

Analysis of the spark plug and piston contamination samples revealed that the material was composed of 95% lead, 3% zinc, and 2% bismuth.

The airplane was equipped with an Advanced Flight Systems AF-3000 Electronic Flight Information System (EFIS). The memory card was sent to the NTSB Vehicle Recorders Division and read out using laboratory hardware. No accident-related data was found on the memory card.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the instructor was performed by Office of the Chief Medical Examiner of The Commonwealth of Virginia, Richmond, Virginia. The cause of death listed injuries that were consistent with being struck by the portion of fence board that entered the cockpit.

Toxicology testing performed by the FAA's Forensic Sciences Laboratory identified ketamine and its metabolite, norketamine; etomidate; and midazolam. The identified substances were consistent with postaccident medical treatment. 

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 38, Male
Airplane Rating(s): 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
Toxicology Performed: Yes
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 12/06/2016
Occupational Pilot:Yes 
Last Flight Review or Equivalent:
Flight Time: 4800 hours (Total, all aircraft) 

Pilot-Rated Passenger Information

Certificate: Commercial
Age: 67, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
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: 08/07/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 10/18/2015
Flight Time:  (Estimated) 6300 hours (Total, all aircraft), 4500 hours (Pilot In Command, all aircraft), 2 hours (Last 90 days, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: COSTRUZIONI AERONAUTICHE TECNA
Registration: N319TA
Model/Series: P2004 BRAVO NO SERIES
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Special Light-Sport; Normal
Serial Number: 125
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 07/10/2017, 100 Hour
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection: 38 Hours
Engines: 1 Reciprocating
Airframe Total Time: 1164 Hours as of last inspection
Engine Manufacturer: Rotax
ELT: Installed, not activated
Engine Model/Series: 912
Registered Owner: MID-ATLANTIC AIR VENTURES INC
Rated Power: 100 hp
Operator: New Kent Flight Center LLC
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: W96, 121 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1055 EDT
Direction from Accident Site: 245°
Lowest Cloud Condition:
Visibility:  10 Miles
Lowest Ceiling: Overcast / 1400 ft agl
Visibility (RVR):
Wind Speed/Gusts:5 knots / 
Turbulence Type Forecast/Actual: None / None
Wind Direction: 180°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.9 inches Hg
Temperature/Dew Point: 28°C / 26°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Quinton, VA (W96)
Type of Flight Plan Filed: None
Destination: Quinton, VA (W96)
Type of Clearance: None
Departure Time: 1030 EDT
Type of Airspace: Class G

Airport Information

Airport: NEW KENT COUNTY (W96)
Runway Surface Type: Grass/turf; Gravel
Airport Elevation: 120 ft
Runway Surface Condition: Rough; Soft; Vegetation
Runway Used: N/A
IFR Approach:None 
Runway Length/Width:
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire:None 
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 1 Minor
Latitude, Longitude: 37.497222, -77.149167


Andrew Jones 
 Flight Instructor
































9 comments:

  1. Fuel is hydroscopic,fuel tanks need topping up after every days flying to avoid condensation building up in the fuel tanks,either the aircraft has been left outside empty or there is a problem with the fuel storage itself.

    ReplyDelete
  2. Looked survivable until I saw the board sticking through the panel.

    ReplyDelete
  3. "Good taste, common sense, decency, and respect" simply do not exist anymore... Why are the comments section not locked down???? A man died.

    ReplyDelete
    Replies
    1. If you would like your internet censored then I suggest you move to China. Otherwise it might be a good idea to refrain from hitting the "comments" link or stop visiting this aviation blog all together if your so easily triggered by other people.

      Delete
    2. Thank you for the common sense KV. That poster has no idea of the dangers and threats to democracy and freedom when people's voices start getting censored because they don't like them. Previous generations learned that the hard way with Communism and Nazism. Apparently more recent generations want to repeat history.

      Delete
    3. "Why are the comments section not locked down???"

      Because we pilots value free opinions and comments on crashes so we can learn from them. This also means that some will make comments that you might find offensive or tasteless. If you don't like a free range of opinions, then don't read the comment section. Removing the comment sections in any forum because only YOU don't like what some person said is a fascist mentality.

      TL/DR - Grow up and put your big boy jeans on.

      Delete
  4. has to be one of the saddest cases ive read on this site he got it on the ground with only minor injuries to his student but yet that random fence board was fatal rest in peace captain you did a good job

    ReplyDelete
  5. Not to be a dictionary definition fascist, but I believe the term describing the tendency of materials to absorb moisture from the air is 'hygroscopic'. This is indeed a sad case, yet I wonder how something like checking for water in the fuel tanks was missed or skipped during a pre-flight inspection.

    ReplyDelete
  6. There are no under-wing sump ports for checking the tanks on a P2004 Bravo. The firewall gascolator drain check is all you can do. These guys did not fail to sump check the wing tanks - it cannot be done!

    The two tanks are integral to the front side of the spar, aluminum skinned & with internal ribs. Tying out with half full tanks invites condensation from temperature cycling. Would not take a lot of moisture migration from wing tanks to fill up the gascolator and feed water to the carbs.

    Here is the smooth under wing view, no sump port:
    http://airplanesusa.com/wp-content/uploads/2016/09/9519.jpg

    ReplyDelete