Aviation Accident Summaries

Aviation Accident Summary LAX99LA188

ORLAND, CA, USA

Aircraft #1

N8153Q

Cessna 414

Analysis

The pilot refueled the auxiliary tanks of the airplane at a different airport 1 month prior to the accident, and had not flown on the auxiliary tanks since that time. He was repositioning the airplane back to home base after a series of revenue flights when the accident occurred. About 20 minutes after takeoff he positioned the left and right engines to their respective auxiliary fuel tanks, and then returned to the mains 30 minutes later. The right engine began to surge and subsequently stopped running. Turning on the fuel boost pump restarted the engine. Five minutes later the engine quit and he secured it after unsuccessful restart attempts. Then the left engine began to surge and was developing only partial power. He diverted to an alternate airport with decaying altitude and power in the remaining engine. Crossing the airport, he saw he was too high to land with a tailwind so he circled to land into the wind. On the base leg he made the decision to land straight ahead in a field due to power lines in his path, rapidly decaying altitude, and power. During the landing roll, the airplane collided with a ditch. The left and right main fuel filters contained a foreign substance, which upon laboratory examination, was found to be a polyacrylamide. This is a manmade synthetic polymer that is used as an agricultural soil amendment that aids in reducing soil erosion. Distribution of the polymer is typically not done by aircraft. Inspection of the fueling facility revealed that the employees who do refueling did not have any formal or on-the-job training. There was no record that the delivery system filters had been examined or changed. The maintenance to the truck, delivery system, and storage facility are done by the employees on an as needed, time permitted basis. The fuel truck was found to be improperly labeled, and the fuel nozzle was lying in a compartment amid dirt, gravel, and other contaminates with no caps or covers for protection.

Factual Information

On May 21, 1999, at 1725 hours Pacific daylight time, a Cessna 414, N8153Q, made a forced landing in an open field due to the complete loss of power in one engine and the partial loss of power in the other engine near the Orland, California, airport. During the landing rollout, the airplane collided with a ditch. The airplane, operated by The Hangar, Inc., of Redding, California, under 14 CFR Part 91 as a positioning flight, sustained substantial damage. The airline transport pilot/owner, the sole occupant, received minor injuries. Visual meteorological conditions existed for the flight and no flight plan was filed. The flight originated from the Redding airport at 0800, flew several revenue segments to various airports, and had departed from San Jose, California, at 1600 for the positioning flight return to Redding. The pilot stated that on the morning of the accident he departed from Redding and flew to San Jose. He refueled the airplane, and picked up passengers for a revenue flight under 14 CFR Part 135. He flew the passengers to a meeting at the Paradise Skypark Airport, Paradise, California, and then flew them back to San Jose. He stated that he was repositioning from San Jose to Redding when the airplane experienced engine problems. Approximately 20 minutes after departing San Jose, he switched the right engine to the right auxiliary fuel tank, and 5 minutes later switched the left engine to the left auxiliary fuel tank. About 30 minutes later, he switched the right engine back to the right main at the "first sign that it [the right auxiliary fuel tank] was dry." Five minutes later, he returned the left engine to the left main from the left auxiliary fuel tank. He reported that he was approaching Orland airport when the right engine began to surge and subsequently stopped running. He turned on the right auxiliary fuel boost pump and the engine restarted. It ran for another 5 minutes and then stopped again. He reported that attempts to troubleshoot the problem were unsuccessful, so he secured the engine and feathered it. Simultaneous to the feathering of the right engine, the left engine began to surge. He proceeded to the Orland airport for an emergency landing with about 50 percent power on the left engine and a "high rate of descent." After crossing the north end of the airport at 2,000 feet above ground level (agl), he felt he was too high land to the south with a 25-knot crosswind. At the base leg he was about 500 feet agl, with the power decaying, and power lines in his flight path, and he made a decision to land straight ahead in a field on the southeast corner of the airport. The pilot stated that he lowered the landing gear and put in 30 degrees of flaps while maintaining single engine best rate of climb airspeed. On the landing rollout, the nose gear sheared off after colliding with a ditch. The airplane began to skid to the right and the left main landing gear collapsed. The left main fuel tank and about 1/4 of the field was consumed by a postimpact fire. The pilot estimated that he had 20 gallons of fuel remaining in the left main tank. In the pilot's written statement, he stated he believes he received contaminated fuel from Paradise Skypark Airport. He stated that the fuel remained in his auxiliary fuel tanks from April 27, 1999, when he last refueled, until the date of the mishap. The airplane was inspected on-scene by a Federal Aviation Administration (FAA) inspector. He found that the left and right main fuel filters retained a foreign substance. The filters and the foreign substance were sent to the Safety Board investigator who then sent them to the Safety Board's metallurgical laboratory for examination. A sample of the substance was then sent to Artech Testing LLC for a Fourier Transform Infrared Spectroscopic (FTIR) analysis, and an x-ray dispersive (EDS) spectra analysis. They identified the substance as a polyacrylamide, carboxyl modified, high carboxyl content. It is a long chain manmade synthetic polymer that is used as an agricultural soil erosion control method and can be purchased in liquid, granular or solid forms. The EDS analysis of the substance also found potassium and the presence of lead, aluminum, sulfur, iron, and copper. The synthetic polymer is not hazardous and is also not regulated. According to the products' manufacturer, the common use for the substance is to assist in the reduction of soil erosion by bonding soil particles together. General application is through a field irrigation system, and not by airplane. The polyacrylamide is soluble in water and alcohol; however, no data was available for fuel solubility. FAA inspectors traveled to Paradise Skypark Airport to perform an inspection of the fueling facility. The airport and the fueling facilities are owned by a local construction company, who will sell fuel to itinerate airplanes if requested by the pilots. The FAA inspector stated "there is no scheduled person to operate the truck or maintain the truck or fuel storage facility." The FAA inspector further reported the maintenance to the truck, fuel delivery system, and fuel storage facility are performed by employees of the construction company on an as needed, time permitted basis. The fuel truck was found to be labeled "80 octane," but the FAA inspector was told that it was in fact 100 low lead. No records were kept regarding the last delivery system filter change. The truck sumps and filters are not checked on any regular basis for contamination. It was also found that the fuel delivery nozzle was lying in its compartment amid dirt, gravel, and other contaminates. There were no protective caps or covers found on the nozzle. He also found that the employees that fuel the airplanes have not had any formal or on-the-job training.

Probable Cause and Findings

A loss of engine power in both engines due to fuel contamination, which resulted from the fueling facilities improper quality control procedures.

 

Source: NTSB Aviation Accident Database

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