Fuel Servo Debris
The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Tampa, 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/N1401J
Location: Clearwater, FL
Accident Number: ANC18LA010
Date & Time: 11/19/2017, 1030 EST
Registration: N1401J
Aircraft: ROCKWELL INTERNATIONAL 112A
Aircraft Damage: Substantial
Defining Event: Fuel related
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Personal
On November 19, 2017, about 1030 eastern standard time, a Rockwell International 112 airplane, N1401J, impacted trees during a forced landing on a city street about one mile northeast of Clearwater Air Park (KCLW), St. Petersburg, Florida, following a total loss of engine power. The private pilot and sole passenger sustained no injuries and the airplane was substantially damaged. The flight was being operated as a 14 Code of Federal Regulations (CFR) Part 91 visual flight rules personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed Zephyrhills Airport (KZPH), Zephyrhills, Florida about 1008 for the roughly 35 nautical mile flight to KCLW.
According to the pilot, prior to departing KZPH, he added about 30 gallons of fuel to the airplane, which filled the left fuel tank completely and the right tank was about 7/8 full. He performed a walk-around inspection, but did not sump the fuel system for contaminants prior to departure. The roughly 20-minute flight was conducted with the fuel selector on the left tank. When descending through 1,200 ft msl, the pilot conducted the before landing checklist, which included increasing the mixture to full rich, turning on the auxiliary fuel pump and switching the fuel selector to the "BOTH" position. He then reduced the throttle to slow the aircraft and felt "slight resistance" on the throttle lever. About 10 seconds after switching the fuel selector, he began to lose airspeed faster than anticipated. When he looked at the fuel flow indicator, he saw it slowly transition from 8 gallons per hour to zero and the engine subsequently lost all power. He placed the fuel selector back to the left fuel tank, but the engine would not restart. During the forced landing, the airplane impacted a tree in the median of a 4-lane street prior to impacting and coming to rest in a stand of trees adjacent to the roadway.
Video footage captured the airplane as it approached the roadway as well as the final impact. The initial impact with the tree in the median was not captured. The video depicts the airplane in a controlled, level descent. Due to the quality of the video, propeller rotation could not be determined.
The engine was examined on December 6, 2017 at the facilities of Florida Air Recovery, Jacksonville, FL under the auspices of the National Transportation Safety Board, (NTSB). The engine remained attached to the airframe by the engine mount. The engine had sustained impact damage to the underside. The exhaust system had been displaced up and aft. The fuel injection servo sustained impact damage to the underside, which resulted in a cracked and displaced mounting flange. In addition, the throttle linkage was damaged and displaced.
The engine was prepped to be test run, which included replacing the propeller, and attempting to seal the induction leaks created by the cracked and displaced fuel injection servo with metal tape. In addition, the throttle linkage was secured with tie wraps and the damaged exhaust pipe tip was removed.
Fuel was introduced upstream of the engine driven fuel pump but downstream of the electric driven fuel pump. A fuel can with 100LL Avgas was placed below the engine and the engine was primed with a separate auxiliary electric driven fuel pump. The engine was not run at full power due to impact damage to the airframe and engine, but it was operated at various idle power settings while cycling through both magnetos. At about 1600 rpm, a drop of about 50 rpm was noted for the left and right magnetos.
On May 9, 2018, a representative of the NTSB traveled to AVStar Fuel Systems, Inc. to witness operational testing of the fuel injection servo.
The fuel inlet strainer was removed and when tapped on white paper some debris was noted. Some debris was also noted inside the strainer. Oil/dirt was noted on the exterior of the fuel servo. The mixture screw assembly was centered.
Fuel Servo
The fuel servo was placed on the test bench as received. The throttle valve was set at 0.007 inch (production units are set to 0.006 inch). The fuel servo was subjected to bench testing at calibration and service limits consisting of 4 Test Points. The fuel servo was flowed onto white paper; no contaminants or water was noted during the first fluid coming from the unit. During testing at Test Point 1, the regulator was "hanging up" at 80 pounds-per-hour (PPH), when it should have been between 22.0 and 28.0 PPH. This was likely due to air trapped inside the fuel servo. The fuel servo was then manipulated on the test bench in an effort to remove trapped air. The fuel servo was then subjected to Test Point 4, and flowed within limits. Additionally, the travel and hysteresis checks were satisfactory. The unit was then subjected to Test Point 1 and tested satisfactory. At Test Point 2 which is the idle cutoff check, 2 drops were noted in 1 minute (maximum leakage is 5 CC's in 1 minute. At Test Points 3 and 4, the unit flowed within limits and the pressure sensitivity checks at each of those test points were satisfactory. The idle fuel flow with the throttle valve where found (0.007 inch) flowed 11.0 PPH. The throttle valve was adjusted to 0.006 inch and the fuel flow was 6.5 PPH (the idle fuel flow specification is 6.0 to 7.0 PPH). The pressure sensitivity test at idle fuel flow was satisfactory.
Disassembly examination of the fuel servo revealed the regulator self-locking nut was in-place. When attempting to remove only the regulator cover, the air diaphragm, center body, fuel diaphragm and regulator cover separated from the fuel servo body. The air diaphragm and air side of the regulator were clean. A slight amount of fine residue (dust) was noted on the fuel diaphragm, but that did not affect the operation of the fuel servo. Slight contamination was noted on the fuel side of the center body, and also in the servo body regulator section. The fuel diaphragm stem was intact. The passages of the air venturi were clean but slight oily residue was noted on areas of the exterior surface.
The closest official weather observation station is St. Petersburg Airport (KPIE), St. Petersburg, Florida, which is located about 6 miles southeast of the accident site. At 0953, a METAR was reporting, in part, wind 230° at 11 knots; visibility 10 statute miles; clouds and ceiling clear; temperature 79° F; dew point 64° F; altimeter 29.95 inches of Mercury.
Pilot Information
Certificate: Private
Age: 61, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 06/01/2016
Occupational Pilot: No
Last Flight Review or Equivalent: 11/15/2017
Flight Time: 450 hours (Total, all aircraft), 245 hours (Total, this make and model), 450 hours (Pilot In Command, all aircraft), 25 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: ROCKWELL INTERNATIONAL
Registration: N1401J
Model/Series: 112A
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 401
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 03/04/2017, Annual
Certified Max Gross Wt.: 2950 lbs
Time Since Last Inspection: 30 Hours
Engines: 1 Reciprocating
Airframe Total Time: 2176 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: Installed, not activated
Engine Model/Series: IO360 SER
Registered Owner: On file
Rated Power: 200 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: KPIE, 11 ft msl
Distance from Accident Site: 6 Nautical Miles
Observation Time: 1453 UTC
Direction from Accident Site: 137°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 230°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.95 inches Hg
Temperature/Dew Point: 26°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: ZEPHYRHILLS, FL (ZPH)
Type of Flight Plan Filed: None
Destination: Clearwater, FL (CLW)
Type of Clearance: None
Departure Time: 1008 EST
Type of Airspace: Class E
Airport Information
Airport: CLEARWATER AIR PARK (CLW)
Runway Surface Type: Asphalt
Airport Elevation: 71 ft
Runway Surface Condition: Dry
Runway Used: 16
IFR Approach: None
Runway Length/Width: 4108 ft / 75 ft
VFR Approach/Landing: Forced Landing
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: 27.983056, -82.763056 (est)
The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office;
Miramar, Florida
Textron Aviation; Wichita, Kansas
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/N6102R
Location: Opa Locka, FL
Accident Number: ANC18LA009
Date & Time: 11/15/2017, 2007 EST
Registration: N6102R
Aircraft: CESSNA 172RG
Aircraft Damage: Substantial
Defining Event: Electrical system malf/failure
Injuries: 2 None
Flight Conducted Under: Part 91: General Aviation - Instructional
On November 15, 2017, about 2007 eastern standard time, a Cessna 172RG retractable gear airplane, N6102R, sustained substantial damage during landing at Miami-Opa Locka Executive Airport (KOPF), Miami, Florida. The airplane was registered to South Florida Aviation Group, LLC and operated by the pilot as a visual flight rules flight under the provisions of 14 Code of Federal Regulations Part 91 when the accident occurred. The certificated commercial pilot and safety pilot were not injured. Dark night, visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot reported that the purpose of the night flight was to practice instrument approaches for an upcoming Certified Flight Instructor Instrument check ride. Just prior to intercepting the glideslope for the ILS 9L approach into KOPF she moved the landing gear selector to the down position, verified that the landing gear position indicator light was illuminated green, set the flaps to 20 degrees, and completed the before landing checklist. About 500 feet above ground level (AGL), the GPS blinked, and all electrical power and radio communications were lost. The safety pilot set the transponder to squawk 7600. About 150 feet AGL the lights on the airplane's instrument panel blinked and remained illuminated. The pilot then selected flaps to 30 degrees and configured the airplane for landing, while the safety pilot attempted to contact the ATC tower. The pilot stated that she then moved the landing light switch to the on position, and immediately lost all electrical power. After receiving a green light gun signal from the tower, the pilot continued the approach and visually verified that the main landing gear was extended. Upon touchdown the right main landing gear collapsed, and the airplane departed the runway and sustained substantial damage to the right horizontal stabilizer. The pilot stated that no electrical or landing gear warning lights were illuminated for the duration of the flight.
The safety pilot reported that they were inbound on the ILS 9L approach into KOPF. About 1 to 2 miles before the final approach fix they selected gear down and completed the before landing checklist. The GPS then began blinking on and off; however, she still had power to the airplane's radios. She set the transponder to squawk 7600 and attempted to contact the tower on the number two radio but was unable to establish communications. Shortly thereafter the GPS came back on, and she once again unsuccessfully attempted to contact the tower. She said the pilot then moved the landing light switch to the on position, and all electrical power was lost. She felt the airplane touch on the landing gear, and then the airplane began to sink and drift to the right. She stated that the landing gear was down, and it had been verified with the illumination of the landing gear position indicator light.
According to the pilot operating handbook (POH) the landing gear extension, retraction, and main gear down lock release operation is accomplished by hydraulic actuators powered by an electrically-driven hydraulic power pack. A normal operating pressure of 1000 PSI to 1500 PSI is automatically maintained in the landing gear system. The nose gear and main gear incorporate positive mechanical down locks. Two position indicator lights are provided to show landing gear position. The landing gear system is also equipped with a nose gear safety (squat) switch, an emergency extension hand pump, and a gear-up warning system.
A postaccident examination revealed that the airplane's battery had been depleted. Further examination revealed no anomalies with the landing gear system or its actuators. However, when the landing gear position indicator light was pressed or the gear was in transit, the landing gear unsafe horn did not produce an audible warning. The engine, while still mounted on the airplane, was operated under the direction of the NTSB IIC. The engine started normally without hesitation or stumbling in the observed rpm. While the aircraft was at idle rpm the ammeter indicated a slight discharge. However, the low voltage warning light did not illuminate. The engine rpm was then increased to about 1700 and the ammeter indicated a charge. An electrical load was then place on the system by turning on the landing light, strobe lights and rotating beacon, and the ammeter continued to indicate a charge. An examination of the low voltage warning light revealed that one of the wire's conductors that transit the instrument panel was completely severed but no evidence of burning or arcing was present.
The closest weather reporting facility was Miami-Opa Locka Executive Airport (KOPF), Miami, Florida. At 1953, an METAR from KOPF was reporting, in part: wind from 020 °at 5 knots; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 75 °F; dew point 70° F; altimeter, 29.93 inches of mercury.
Pilot Information
Certificate: Commercial
Age: 36, Female
Airplane Rating(s): Multi-engine Land; 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 Multi-engine; Airplane Single-engine
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 11/19/2017
Flight Time: 774 hours (Total, all aircraft), 29 hours (Total, this make and model), 465 hours (Pilot In Command, all aircraft), 174 hours (Last 90 days, all aircraft), 20 hours (Last 30 days, all aircraft), 1.7 hours (Last 24 hours, all aircraft)
Other Flight Crew Information
Certificate: Flight Instructor; Commercial
Age: 33, Female
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s):
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 06/21/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent: 07/17/2017
Flight Time: 860 hours (Total, all aircraft), 6.8 hours (Total, this make and model)
Aircraft and Owner/Operator Information
Aircraft Make: CESSNA
Registration: N6102R
Model/Series: 172RG
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 172RG0084
Landing Gear Type: Retractable - Tricycle
Seats:
Date/Type of Last Inspection: 10/20/2017, 100 Hour
Certified Max Gross Wt.: 2650 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 7304.8 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C91A installed, not activated
Engine Model/Series: O-360F1A6
Registered Owner: On file
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: Night
Observation Facility, Elevation: KOPF
Distance from Accident Site:
Observation Time: 0053 UTC
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 20°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.93 inches Hg
Temperature/Dew Point: 24°C / 21°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Opa Locka, FL (OPF)
Type of Flight Plan Filed: None
Destination: Opa Locka, FL (OPF)
Type of Clearance: Unknown
Departure Time: EST
Type of Airspace: Class D
Airport Information
Airport: MIAMI-OPA LOCKA EXECUTIVE (OPF)
Runway Surface Type: Asphalt
Airport Elevation: 8 ft
Runway Surface Condition: Dry
Runway Used: 09L
IFR Approach: ILS
Runway Length/Width: 8002 ft / 150 ft
VFR Approach/Landing: Full Stop; Precautionary 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: 25.907500, -80.278333 (est)
The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; DuPage, Illinois
Continental Motors; Mobile, Alabama
Hartzell Engine Technologies; Piqua, Ohio
Vitatoe Aviation; Chillicothe, Ohio
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/N5300A
Location: Grayslake, IL
Accident Number: CEN18LA031
Date & Time: 11/12/2017, 1730 CST
Registration: N5300A
Aircraft: CESSNA T210N
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Business
On November 12, 2017, about 1730 central standard time, a Cessna T210N airplane, N5300A, experienced a loss of engine power and landed short of runway 9 at Campbell Airport (C81), Grayslake, Illinois. The commercial rated pilot, who was the sole occupant, was not injured, and the airplane sustained substantial damage. The airplane was registered to and operated by Runzel Brothers Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a business flight. Night instrument meteorological conditions prevailed at the time of the accident, and the flight was operated on an instrument flight rules (IFR) flight plan. The airplane departed Pierre Regional Airport, Pierre, South Dakota, about 1435, and was en route to Chicago Executive Airport (PWK), Wheeling, Illinois.
The pilot reported that during the en route portion of the IFR flight, the engine indications were all normal. About 1715, he noticed the oil pressure had decreased into the yellow arc, but all other instruments were still showing normal indications. Shortly after ,the air traffic controller instructed the pilot to descend to 2,500 ft mean sea level (msl). When the airplane reached 2,500 ft, the pilot heard a "loud bang" from the engine, and the cockpit filled with smoke. He declared an emergency and requested vectors to the nearest airport, C81. About 700 ft above ground level (agl), he descended out of the cloud layer and identified the runway lights. The pilot was very familiar with C81 and planned to land in a wetland area short of runway 9 since he could not glide the airplane all the way to the runway. He left the landing gear retracted and landed in the wetland area, slid across a flat wooden bridge as seen in figure 1, and came to rest on runway 9.
Figure 1 – Ground scars in the dirt and across a bridge
Pilot Information
Certificate: Flight Instructor; Commercial
Age: 29, 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): Airplane Single-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 With Waivers/Limitations
Last FAA Medical Exam: 06/16/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 11/07/2017
Flight Time: 1544 hours (Total, all aircraft), 42 hours (Total, this make and model), 1464 hours (Pilot In Command, all aircraft), 213 hours (Last 90 days, all aircraft)
Aircraft and Owner/Operator Information
Aircraft Make: CESSNA
Registration: N5300A
Model/Series: T210N
Aircraft Category: Airplane
Year of Manufacture: 1979
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 21063356
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 11/01/2016, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 3996 Hours as of last inspection
Engine Manufacturer: Continental Motors
ELT: Installed, not activated
Engine Model/Series: IO-550-P
Registered Owner: RUNZEL BROTHERS AVIATION LLC
Rated Power: 310 hp
Operator: RUNZEL BROTHERS AVIATION LLC
Operating Certificate(s) Held: None
The airplane was powered by a six-cylinder Continental Motors IO-550-P6B engine, serial number 1005420. The engine was modified via Vitatoe Supplemental Type Certificate (STC) SA02918CH, which converted the engine to a turbo-normalized induction system. According to the maintenance records, the modified engine was installed on the accident airplane on April 2, 2012.
The last maintenance logbook entry was on noted on July 27, 2017, at a tachometer time of 1,010.1 hours. The entry indicated compliance with airworthiness directive AD 71-09-07R1, which was an exhaust system inspection. The entry also noted a new fuel injector and a new cylinder head temperature probe were installed. The last oil change was performed on June 29, 2017, at a tachometer time of 1,001.73. The last 100-hour engine inspection was performed on November 1, 2016, at the same time the engine was reinstalled after a top overhaul.
The pilot stated that he couldn't remember the exact oil level and didn't recall anything out of the ordinary during the preflight inspection. He also did not recall any oil on the ramp underneath the airplane or any white smoke upon engine start up.
Meteorological Information and Flight Plan
Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: KPWK, 646 ft msl
Distance from Accident Site: 15 Nautical Miles
Observation Time: 1752 CST
Direction from Accident Site: 147°
Lowest Cloud Condition:
Visibility: 3 Miles
Lowest Ceiling: Broken / 600 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 320°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.38 inches Hg
Temperature/Dew Point: 3°C / 3°C
Precipitation and Obscuration: Moderate - Mist
Departure Point: PIERRE, SD (PIR)
Type of Flight Plan Filed: IFR
Destination: CHICAGO/PROSPECT HEIGHTS/WHEELING, IL (PWK)
Type of Clearance: IFR
Departure Time: 1435 CST
Type of Airspace: Class E
Airport Information
Airport: CAMPBELL (C81)
Runway Surface Type: Asphalt
Airport Elevation: 788 ft
Runway Surface Condition: Soft; Vegetation; Wet
Runway Used: 09
IFR Approach: None
Runway Length/Width: 3270 ft / 40 ft
VFR Approach/Landing: Forced Landing
Wreckage and Impact Information
Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 42.324167, -88.080278 (est)
The airplane landed in a field about 300 ft west of the runway 9 threshold. During the landing, the airplane sustained damage to the fuselage and elevator.
The pilot stated that after the accident he recalled oil covering the bottom fuselage and on the runway where the airplane came to rest.
After the accident, the engine was removed from the airframe and shipped to the manufacturer's facility for a detailed examination, which was conducted under the supervision of a National Transportation Safety Board investigator. The examination revealed no evidence of ground impact or fire damage. The crankcase exhibited two large holes; one was located near the No. 4 cylinder and the other was in between the Nos. 3 and 5 cylinders. All six cylinders remained attached to the crankcase with the No. 4 cylinder displaying mechanical damage to the cylinder skirt and two of the attachment studs had broken free from the crankcase. The inside of both the crankcase halves displayed mechanical damage with the most damage concentrated near the two holes. The No. 4 connecting rod had separated from the crankshaft and displayed thermal damage signatures. All of the connecting rod bearings exhibited smear type signatures on the bearing surfaces; the No. 4 bearings were significantly damaged as seen in figure 2.
Figure 2 – Damaged No. 4 connecting rod and bearings
There were no signs of fretting on the bearing supports or evidence of a bearing shift. The oil galleys did not reveal any blockages. The oil sump and the oil pickup tube and screen all remained intact, undamaged, and contained a significant amount of metallic debris. The oil pump remained intact, undamaged, and internally contained a few metallic flakes and a small amount of gouging along the oil pump housing. The oil filter remained attached to the oil filter adapter with no anomalies noted. The oil filter pleats contained a significant amount of metallic debris. The oil cooler remained intact with no signs of an oil leak and no anomalies noted. There were no blockages noted in any of the oil lines. Since the oil lines had been removed for shipping, the b-nuts could not be checked for tightness.
The turbocharger oil scavenge check valve spring was found broken, and the flapper valve would not close automatically.
No other anomalies were noted with the engine.
Additional Information
Engine Data
An AuRACLE CRM 2100 engine monitor was installed on the airplane. The extracted data revealed that the oil pressure remained steady for about the first 2 hours of the flight; after 2 hours, the oil pressure began to decrease. The oil pressure decreased steadily from 51 psi to a low of about 13 psi over the course of about 42 minutes. When the oil pressure decreased below 30 psi, the oil temperature began to increase steadily until the total loss of engine power.
Turbocharger Oil Scavenge Check Valve
According to the STC owner and the turbocharger manufacturer, the broken check valve spring that wouldn't allow the flapper valve close automatically, would allow oil to enter the turbo after engine shutdown. The oil could leak into the compressor/induction and turbine/exhaust areas and small batches would get consumed during each subsequent engine start. Typical signs of this issue include oil leaking from the exhaust pipe and pooling under the airplane and white smoke during engine start. The broken spring would not have caused a restriction from oil going from the turbo to the scavenge pump.
According to the engine manufacturer, usually when a scavenge check valve isn't closing properly, while the airplane is sitting on the ground, the oil that is in the line is allowed to pool in the turbocharger. This would be a small amount of oil that gets lost while the airplane is sitting. However, during engine operation, an open check valve would not have any effect on oil consumption.
The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Fresno, California
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/N88MV
Location: Selma, CA
Accident Number: WPR18LA021
Date & Time: 10/30/2017, 1416 PDT
Registration: N88MV
Aircraft: METCALFE ROBERT B VANS RV 6
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal
On October 30, 2017, about 1416 Pacific daylight time, a Vans Aircraft experimental, amateur built RV-6 airplane, N88MV, impacted a fence in a vineyard during a forced off-airport landing near Selma, California. The airline transport pilot was uninjured. The wings and fuselage incurred substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight originated from Fresno Chandler Executive Airport (FCH), Fresno, California about 1346.
According to the pilot, after takeoff, he proceeded west to climb above the Fresno Yosemite International Airport (FAT), Fresno, California and verified his transponder operation with Fresno Approach. He then headed towards the west/southwest. About 15 to 20 minutes later, the pilot began a descent to get below the FAT Class C airspace, and return to FCH. At an altitude of about 4,000 ft, the pilot noticed that the airplane batteries, located in the cockpit near his right foot, were getting hot. The pilot switched the engine monitor display to check the electrical system values, and saw that the indicated voltage was 15.5 volts, and that the indicated current was just above 30 amperes. At that point, the engine suddenly lost all power, but the propeller continued to windmill.
The pilot made some abbreviated and unsuccessful attempts to restore power, but then turned his attention to landing the airplane. He determined that the nearest airport was Selma Airport (0Q4), Selma, California which was about 10 miles away, and he began a gliding descent towards that airport. He communicated his situation and plans to a Fresno Approach controller. When the airplane altitude was about 1,000 ft, the pilot determined that he would not be able to reach 0Q4, and selected a road as his intended off-airport landing site. At that time, the only traffic on that road was an oncoming truck, but as the pilot continued the descent, he became uncertain whether the airplane would have sufficient altitude to clear the truck. The pilot then offset his flight path to the side of the road, in order to ensure that he would clear the truck. The truck passed the airplane, and the pilot then turned left and underflew some powerlines in an attempt to line up with, and land on, the road. That effort was unsuccessful, and the airplane touched down in a vineyard on the other side of the road. The airplane nosed over, and came to rest inverted. The pilot escaped the airplane by breaking the canopy. Although there was fuel leaking from the airplane, there was no fire. Federal Aviation Administration (FAA) inspectors examined the airplane at the site, and the airplane was recovered and transported to a secure facility for further examination.
Pilot Information
Certificate: Airline Transport; Flight Instructor; Commercial
Age: 36, 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): Airplane Multi-engine; Instrument Airplane
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 10/04/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent: 10/02/2017
Flight Time: 2700 hours (Total, all aircraft), 300 hours (Total, this make and model), 2150 hours (Pilot In Command, all aircraft), 62 hours (Last 90 days, all aircraft), 21 hours (Last 30 days, all aircraft), 1 hours (Last 24 hours, all aircraft)
The pilot held commercial, airline transport, and flight instructor certificates, and airplane single- and multi-engine land and instrument ratings. He reported a total flight experience of 2,700 hours, including 300 hours in the accident airplane make and model. His most recent flight review was completed October 2017, and his most recent FAA first-class medical certificate was also issued in October 2017.
Aircraft and Owner/Operator Information
Aircraft Make: METCALFE ROBERT B
Registration: N88MV
Model/Series: VANS RV 6 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 2000
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 24874
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 10/25/2017, Condition
Certified Max Gross Wt.: 1600 lbs
Time Since Last Inspection: 1 Hours
Engines: 1 Reciprocating
Airframe Total Time: 1422 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: Installed, activated, aided in locating accident
Engine Model/Series: O-360-A3A
Registered Owner: On file
Rated Power: 180 hp
Operator: On file
Operating Certificate(s) Held: None
The airplane was constructed in 2000 by another individual, and that individual sold it to the accident pilot in February 2013. At the time of the pilot's purchase, the airplane was equipped with a Lycoming O-360 series engine, and a Hartzell 2-blade constant speed propeller. According to the pilot, when he acquired the airplane, the airframe and engine had each accumulated a total time (TT) in service of 1,100 hours. The pilot put about 300 hours more on the airplane, and then decided to modify it with some significant system and engine changes.
The pilot reported that the engine of the as-purchased airplane was equipped with a carburetor and a conventional magneto ignition system. He decided to change those systems to electronic versions for "performance and efficiency improvements." The pilot purchased a non-certificated kit that included an electronic fuel injection system, and replaced the magnetos with a fully electronic ignition system. The kit included the necessary wiring diagrams and instructions. The pilot performed the installations, and he reported that he had very few questions (of the manufacturers or vendors) regarding the installation details.
The pilot also reported that the as-purchased airplane had a "very basic visual flight rules (VFR) avionics package" that he replaced with an updated avionics suite. He purchased and installed a Garmin G3X system that presented flight instrumentation, position, navigation, communication, and other information using flat-panel color display(s). He purchased a pre-fabricated wiring harness to help expedite his G3X installation effort. He also installed two EARTHX-brand lithium-ion batteries as part of the modifications. None of these components met any FAA technical approvals such as Technical Standard Orders (TSO), nor were they required to do so.
About 5 weeks before the accident, the pilot had essentially completed the avionics and engine modifications, and then began ground runs of the engine and avionics in order to configure and test the new installations. Prior to the accident flight, he had put about 1.5 to 2 hours of ground run time on the engine, and had also conducted two uneventful but brief test flights. The accident flight was the third flight with the new systems, and the engine power loss occurred about 25 minutes into that flight.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: FCH, 280 ft msl
Distance from Accident Site: 10 Nautical Miles
Observation Time: 1415 PDT
Direction from Accident Site: 360°
Lowest Cloud Condition: Clear
Visibility: 9 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.77 inches Hg
Temperature/Dew Point: 23°C / 12°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Fresno, CA (FCH)
Type of Flight Plan Filed: None
Destination: Fresno, CA (FCH)
Type of Clearance: None
Departure Time: 1345 PDT
Type of Airspace: Unknown
The 1415 automated weather observation at FCH, located about 10 miles north of the accident location, included calm winds, visibility 9 miles, clear skies, temperature 23° C, dew point 12° C, and an altimeter setting of 29.77 inches of mercury.
Wreckage and Impact Information
Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 36.572500, -119.754722 (est)
The airplane came to rest inverted in a vineyard, about 6 miles west of 0Q4. The pilot was able to exit due to the resting attitude of the airplane, which allowed sufficient ground clearance beneath the canopy. The fuselage, wings and horizontal stabilizers sustained substantial damage.
During the initial post-accident inspection by FAA personnel, no non-impact related damage was noted. The fuel tanks were not compromised, and they contained sufficient fuel for continued flight.
The alternator was an automotive model with an integral voltage regulator. The
nut and stud assembly that was used to attach the primary alternator ground cable to the alternator was found to be secure, and the cable terminal was securely attached to that stud. However, the swaging of the ground cable to that terminal was loose. Black residue, consistent with arcing and fretting, was present at the conductor-to-terminal junction. The appearance was consistent with that residue having been caused by the looseness of the crimp (swage), and as having been loose for an extended period prior to the accident.
The cockpit circuit breaker for the alternator was rated at 60 amperes. It was the flush-when-set type, without the tall head that would allow manual tripping (breaking the circuit) by the pilot. The circuit breaker was found in the non-tripped position.
No other pre-impact anomalies with the airplane or engine were observed. The G3X device was removed from the airplane and sent to the NTSB facilities in Washington DC for data download.
Additional Information
G3X Data
The G3X device was successfully downloaded by NTSB personnel. The resulting dataset contained 91 parameters, including date, time, flight information (position, speed, heading etc), autopilot information, and engine/system information. The data captured multiple airplane power-up sessions on 12 different days. The data began on September 26, 2017, and included all three flights reported by the pilot, including the accident flight on October 30, 2017.
Flight Summaries
The data indicated that the pilot conducted two separate flights on October 28, 2017, followed by the accident flight on October 30. The airborne segment of the first flight subsequent to the installation of the new engine systems lasted about 5 minutes. The second flight was initiated about 70 minutes later, and its airborne segment lasted for about 10 minutes. The accident flight was conducted 2 days later, and lasted about 30 minutes.
Engine Performance and Power Loss
Recorded system and engine parameters included voltage (V), current (A), exhaust gas temperature (EGT), cylinder head temperature (CHT), manifold, oil, and fuel pressure, fuel flow, RPM, and "power." Except for "power," which was a derived/calculated value, all other engine parameters were measured values. The exact locations in the electrical system where the voltage and current were measured was not determined by the investigation.
Aside from the voltage and current data streams, no anomalies were observed with any of the engine parameters prior to the power loss. As indicated by multiple parameters, the engine ceased operating at 1411:02, and the power loss was essentially instantaneous.
Review of all available voltage data indicated that nominal system voltage was about 13.1V to 13.5V for all ground and flight modes. Excluding the accident flight, the highest recorded voltage value was 13.5V. On the accident flight, the nominal voltage was about 13.8V. About 3 minutes before the engine stopped producing power, the voltage began to rise, and reached a peak value of 16.3V. The engine stopped producing power within a few seconds of that voltage peak, and the voltage decreased to 13.5V about 7 seconds later. The voltage then gradually decreased to 12.8V by the end of the flight, which was about 5 minutes later.
For all three flights, on takeoff, the current values rose rapidly to about 30A, remained near 30A for climbs and level flight, but then decreased to about 18A during descents. On the accident flight, the current initially fluctuated somewhat, but then remained very stable at about 30A for the 15 minute-period just prior to the time that the voltage began to rise. Once the voltage started to rise, the current also started to rise, and climbed to a peak value of 33A. The first data line that indicated that the engine had stopped also indicated that the current had simultaneously and instantaneously decreased to a value of 0A. The current remained at 0A for the remainder of the flight.
Electrical Provisions and Failure Modes
Electrical problems or failures can result in a complete loss of engine power in airplanes equipped with fully electronic ignition or fuel-control systems, but there are several hardware or system-architecture approaches to reduce the possibility of a complete engine power loss. These include equipment redundancy (eg dual batteries, dual alternators, etc), alerting systems/indicators, and circuitry isolation mechanisms.
The pilot reported that both of the lithium-ion batteries were equipped with non-pilot-controlled over-voltage protection circuitry, and his conclusion was that that protection had not activated on the accident flight. He based that determination on the fact that the LED lights on the batteries that indicated activation of the protection circuitry had not illuminated. This was not able to be independently verified during the investigation. The airplane was equipped with a single alternator with an integral voltage regulator, but the alternator's cockpit circuit breaker did not trip, and the pilot was unable to take the alternator off-line due to the circuit breaker design.
The pilot purchased the ignition/fuel injection kit from Protek Performance, a vendor of aftermarket engine components for non FAA-certificated (experimental) aircraft and aircraft engines. The kit components were from manufacturers of aftermarket components for non FAA-certificated aircraft engines. The kit included dual SDS-brand engine control units (ECUs), an SDS Programmer, and an SDS crankshaft trigger for spark timing. The engine conversion retained the dual ignition system concept, which included two spark plugs per cylinder, with each spark plug powered by one of the two separate ECUs.
The pilot had equipped the airplane with a FlyEFII-brand "bus manager" which included an emergency power switch. FlyEFII-published information contained the following verbiage about the system:
"The Bus Manager was designed to provide a protected "essential power bus" for vehicles that rely upon critical electronic equipment for safe operation. This includes aircraft with electronic ignition or electronic fuel injection systems. The Bus Manager creates a protected 12 volt power source to ensure that these critical systems keep working during vehicle operation...The Bus Manager system, when fully implemented manages a two battery vehicle power system plus additional emergency power circuit paths to provide triple redundant protection of essential bus powered systems."
According to FlyEFII documentation, relevant functions of the Bus Manager include:
- Triple redundant Essential Bus protection.
- Built-in Essential Bus and Main Bus relays.
- Alternator charge isolation for two-battery system.
- Emergency Power Switch (pilot-actuated) function provides third level of Essential Bus protection.
FlyEFII published the following information regarding the operation of the Bus Manager overvoltage protection:
"If you have a voltage reading above 15.2V, your regulator has failed and your overvoltage protection in the plane will be activated if you have this safety feature. If your over voltage protection in the plane fails, the batteries over voltage protection will engage. In this scenario, the battery does not disconnect but instead blocks the excess current/voltage into the battery. If you see high voltage and amperage readings, you should immediately take your alternator off line to avoid damage to your electronics and possibly damage to the battery. The BMS protection has limitations and is designed to protect your battery, not your electronics."
Review of the manufacturer's wiring diagram for the bus manager indicated that with the alternator still on line (producing electricity, and circuit breaker not tripped) but with the batteries off line (due to their internal protective circuitry), selection of the emergency power switch to "ON" will provide alternator-produced DC power to the essential bus.
The arcing signatures on the loose alternator ground cable swage were consistent with transient power interruptions. Transient power interruptions can create the potential for spurious electrical power variations. Spurious power variations can exceed the design tolerance levels for the electrical equipment. Power interruptions and variations can adversely affect the operation of electronic components, with unknown results.
Pilot Actions
The investigation did not locate any applicable checklists or other procedural guidance to be used in the event of engine problems or a complete engine power loss in this airplane as configured for the accident flight.
The pilot reported that prior to the accident, when tested on the ground and in the air, the dual ECUs functioned correctly, both independently and jointly. During the accident flight, the engine was operating in the normal mode on both ECUs when the engine power loss occurred. After the engine power loss, the pilot selected each of the ECUs independently, but engine power was not restored.
The batteries powering the system could be pilot-selected either independently or jointly. The pilot reported that if "the battery overvoltage protection" would have triggered, it would have "shut that battery down and I would lose the avionics that didn't have a self-contained backup battery. I would [have had to] switch to the other battery to get [the avionics] back online." All the avionics continued to function normally after the engine power loss, with no battery switching by the pilot.
The pilot reported that the "bus manager blocks the voltage from going to the battery but it doesn't block the power from going to the ignition system (which is what failed). In the event that the bus manager fails the emergency power switch is used to bypass [the bus manager] and send power directly from the battery to the [electronic fuel injection and ignition] system."
The pilot reported that he did try the emergency power switch but that engine power was not restored. The pilot reported that "everything was wired per the drawings," but he could not specifically recall what other systems (in addition to fuel injection and ignition) were powered by the essential bus. The drawings referenced by the pilot were not obtained or examined by the investigators.
Finally, the pilot reported that he "wasn't really able to pinpoint a single point of failure in the system." He also reported that in communications with a Protek Performance representative, the representative stated that the fuel injection and ignition systems should not have been adversely affected by the observed voltage and current values.
Fuel Servo Debris 
