Aviation Accident Summaries

Aviation Accident Summary LAX97FA330

PACOIMA, CA, USA

Aircraft #1

N5241K

Ryan NAVION B

Analysis

The aircraft experienced a loss of engine power in the takeoff initial climb followed by a steep descent into two single-family residences located approximately 1/2 mile from the end of the departure runway. Evidence at the accident site, and interviews with the aircraft's mechanic and the student pilot's flight instructor, indicated that the auxiliary fuel tank may have been supplying the engine during the takeoff and initial climb. Because the 'OFF' nomenclature on the cockpit fuel tank selector was located on the aft side of the selector housing in this aircraft, it would be easy to infer that the long end of the selector handle should be pointed toward the desired fuel tank selection (which is incorrect), particularly if the small arrow head on the opposite end of the handle has been partially obliterated with age as was the case with this aircraft.

Factual Information

HISTORY OF FLIGHT On September 25, 1997, at 1817 hours Pacific daylight time, a Ryan Navion-B N5241K, collided with two houses in Pacoima, California, approximately 1/2 statute mile from the end of the runway following a loss of power in the takeoff initial climb. The flight departed the Whiteman Airport on a local instructional flight and no flight plan was filed. The aircraft was destroyed in the collision sequence and postimpact fire. The flight instructor sustained serious injuries, and a student pilot and one passenger received fatal injuries. Two residential dwellings were substantially damaged by impact and fire as a result of the accident. There were no injuries to ground personnel. Visual meteorological conditions prevailed for the personal flight. Witnesses stated that they heard the engine stop running then saw the airplane make an abrupt turn to the right, nose down, and descend at a steep angle to the ground. PERSONNEL INFORMATION The private pilot's partially destroyed logbook was recovered and it documented a total flight time of 252 hours with 10 hours in the last 90 days, of which 8 hours were in the Navion airplane. Of the 8 hours of Navion time, 5 hours were dual under the supervision of a flight instructor. The flight instructor stated in his report that his total flight time was 2,000 hours, of which 12 hours were in the Navion airplane. AIRCRAFT INFORMATION The aircraft A&P/IA stated that he had performed an annual inspection on the airplane on September 11, 1997, and at that time it had a total flight time of 3,245 hours with no outstanding airworthiness directives. Inspection of Navion Aircraft Specification No. A782 (attached to this report) indicated that this aircraft was equipped with two main fuel tanks with a useable capacity of 39.5 gallons, plus a 20 gallon auxiliary tank. This specification also contains a statement that the auxiliary fuel tank is not to be used for takeoff or landing. A sketch of the cockpit fuel tank selector used in this aircraft is included in this report. WRECKAGE AND IMPACT INFORMATION The airplane collided with two, single-family residential dwellings that were separated by a breezeway approximately 10 feet in width. The airplane engine, left wing, and fuselage were found imbedded in the rear portion of one house and the right wing in the other house. Both houses had impact holes in the roof and extensive fire damage. The fire consumed the airplane structure to the extent that the continuity of the flight control and fuel systems could not be established, however, the cockpit fuel tank selector was located and found to be in an intermediate position. The engine and attached propeller were buried in a pile of debris from both the airplane and the house, and were extensively burned. Two of the engine cylinders melted, as did the magnetos and ignition harness; however, external impact damage to the main engine structure was minimal. METEOROLOGICAL INFORMATION At the time of departure, the weather was reported as thin broken clouds at 6,000 feet agl, broken clouds at 15,000 feet agl, and 30 statute miles visibility. The temperature and dew point were 79 and 66 degrees Fahrenheit, respectively, and the wind was from 290 degrees at 8 knots. Daylight, visual meteorological conditions prevailed, and the altimeter setting was 29.73 inHg. MEDICAL AND PATHOLOGICAL INFORMATION The Los Angeles County Coroner's toxicological report indicated no evidence of alcohol, controlled substances, prescription drugs, or carbon monoxide in the samples available from the student pilot. ADDITIONAL INFORMATION On September 30, 1997, the aircraft engine was disassembled and inspected with no evidence of incorrect assembly, excessively worn parts, or internal failure. It was not possible to determine the state of the ignition or fuel systems due to fire damage. The A&P/IA who performed the most recent inspection of the aircraft stated that the aircraft owner had recently purchased the aircraft and was confused about how the fuel tank selector operated. He also stated that he had attempted to explain how to operate the system to the new owner, but he was not sure his instructions were completely understood. During postaccident interviews, the A&P/IA and the instructor pilot on the flight gave conflicting information as to how to use the cockpit fuel selector. The A&P/IA stated that the long (handle end) of the selector should be pointed toward the desired fuel tank selection, while the instructor pilot said that the little arrow head on the short end of the selector lever should be pointed toward the desired selection. (The Navion B pilot's handbook indicates that the little arrow should be pointed toward the desired selection.) See the attached sketch. The instructor pilot also stated during his interview that, although the aircraft had been fueled prior to takeoff, the auxiliary tank was not serviced at that time and he did not know how much fuel may have been in that tank. (The auxiliary fuel is gravity fed to the main fuel system so there is no cockpit quantity indicator.)

Probable Cause and Findings

the dual student's improper positioning of the fuel selector and the CFI's inadequate supervision, which led to a takeoff with the auxiliary fuel tank selected and resulted in fuel starvation. A contributing factor was the position of the nomenclature on the cockpit fuel tank selector.

 

Source: NTSB Aviation Accident Database

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