Aviation Accident Summaries

Aviation Accident Summary NYC03FA131

Jeannette, PA, USA

Aircraft #1

N124A

Cessna 205

Analysis

Witnesses observed the airplane depart to the north, and experience a partial loss of power during the takeoff climb. The airplane then began a turn to the left, and initiated what appeared to be a right base entry for a landing on runway 20. The airplane continued the turn, past 270 degrees, and as it flew beyond the end of the runway, the engine appeared to regain power and the airplane began a climb. The airplane then banked sharply and impacted trees. Examination of the engine cylinders revealed heavy black combustion deposits, on the number 3 and number 6 cylinder chambers, exhibiting signatures of operation with a foreign material. Additionally, two pieces of aluminum material were found in the combustion chamber of the number 6 cylinder. The aluminum pieces were identified to be the same material as the air filter mount frame from the airframe induction system. The number 5 top compression ring was also broken and severely worn. According to the Continental Report, "The ingestion of foreign material in cylinder combustion chambers can affect proper valve operation/timing and produce a combustion miss, thereby diminishing the engine power output."

Factual Information

HISTORY OF FLIGHT On June 15, 2003, at 1315 eastern daylight time, a Cessna 205, N124A, was substantially damaged when it collided with terrain during a forced landing after takeoff from the Greensburg Jeannette Regional Airport (5G8), Jeannette, Pennsylvania. The certificated commercial pilot and three (skydiver) passengers were fatally injured. Another (skydiver) passenger was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the parachute drop flight conducted under 14 CFR Part 91. A witness, who was sitting on his motorcycle on the airport ramp, observed the airplane taxi from the grass on the southwest corner of the airport, to runway 02. The airplane immediately departed to the north, and during the initial climb, about 1/4-mile from the runway, the airplane's engine began to sputter. The airplane then began a turn to the left, and initiated what appeared to be a right base entry for a landing on runway 20. The airplane continued the turn, past 270 degrees and the end of runway 20, and headed east, perpendicular to it. As the airplane continued past the runway, it appeared that the engine had regained power, and the airplane began a climb. The witness then lost sight of the airplane behind a trailer, but immediately heard the engine stop producing power, then heard the sound of an impact with trees. The witness also noted that when the airplane initially turned back, it had sufficient altitude and airspeed to reach runway 20. A second witness was sitting on his porch about 1 mile northwest of the airport, when he heard a "reduction in speed and/or power" coming from the airplane's engine. The airplane climbed, then began a left turn, towards the south, parallel to the runway, but "considerably west and north of [it], and 100 feet off the ground." As the airplane approached the end of a level, grassy field, it banked sharply to the left, then abruptly to the right, towards the northern end of the runway. At that time, it appeared that the airplane would not be able to reach the end of the runway, which was at an elevation above the airplane's altitude. One of the airplane's wings then dropped, "either due to a stall or impact with a tree," and separated from the fuselage, before the airplane impacted the ground. The witness could not recall if the airplane's engine stopped prior to the impact. However, he reported that the engine sounded as if it was "changing speed to try to gain altitude." A third witness observed the airplane during the takeoff, and reported that as it tried to gain altitude, the engine was "struggling, as if the fuel mixture was too rich, or the choke was pulled out." The airplane performed a left turn back towards the airport, during which the engine "appeared to be struggling more." The airplane straightened its flight path, and then initiated a steep right bank, during which the engine "cut out completely." The witness lost sight of the airplane, and then heard its impact with the trees. A skydiver, who flew on the accident airplane just prior to the accident flight, was interviewed by telephone. He stated that he thought the accident flight was the airplane's third flight of the day. He reported that two skydivers took a flight prior to his flight, and the accident flight occurred just after his. The skydiver stated that just prior to his flight, the pilot added 2 quarts of oil to the engine, and opened the cowl flaps "for cooling." The pilot then attempted to start the engine twice before he was successful. The flight departed about 1145, and no engine abnormalities were noted during the flight, which lasted about 30 minutes. None of the witnesses observed the airplane being fueled. The skydiver who survived the accident was interviewed in the hospital. He had no memory of the accident flight. The accident occurred during the hours of daylight, at 40 degrees, 22.47 minutes north longitude, 79 degrees, 36.26 minutes west latitude, at an elevation of 1,168 feet. PERSONNEL INFORMATION The pilot held a commercial pilot certificate, issued on February 2, 2002, with ratings for single engine land and instrument airplane. His most recent FAA second class medical was issued on December 9, 2002, at which time he reported 785 hours of total flight experience. Examination of the pilot's logbook revealed 809 hours of total flight experience, 10 of which were in the same make and model as the accident airplane. AIRCRAFT INFORMATION A handwritten flight time log was found in the airplane, with entries noting the date, beginning and ending tach times, and the "amount of fuel at start." The last entry, noted on June 14, 2003, a beginning tach time of 467.8, and 62 gallons of fuel at start. The tach time at the accident site was 470.4. Examination of the airplane and engine logbooks revealed that the last two entries were for annual inspections performed on October 18, 2001, and October 4, 2002. The last inspection occurred at tach time 454.7 hours. No additional entries were noted between inspections, or following the last inspection. A handwritten log found in the airplane recorded oil changes since 1995. The last two entries were dated October 2002 and March 16, 2003. The comments following the entries were, "annual inspection, oil change, 454.7", and "oil change, no filter, 459.5," respectively. METEOROLOGICAL INFORMATION Weather reported at the Arnold Palmer Regional Airport (LBE), Latrobe, Pennsylvania, 11 miles to the southeast, at 1247 eastern daylight time, included calm winds, 10 miles visibility, a few clouds at 5,000 feet, scattered clouds at 7,000 feet, temperature 75 degrees Fahrenheit, dew point 59 degrees Fahrenheit, and a barometric pressure of 30.08 inches Hg. WRECKAGE AND IMPACT INFORMATION The accident site was located on airport property, in hilly, wooded terrain next to an access road. The site was 250 feet northeast of the approach end of runway 20, and 20 feet below the runway's elevation. The wreckage was examined at the site, and all major components of the airplane were accounted for at the scene. The initial impact point was at the top of a tree about 50 feet tall, in which a portion of the right horizontal stabilizer was observed. The wreckage path measured 150 feet from the tree to the main wreckage, and was oriented about 212 degrees magnetic. The left wing was located along the wreckage path, under a 14-inch-diameter, uprooted tree. Examination of the wing's leading edge, 2 feet outboard from the wing root, revealed a concave impression with brown transfer marks. Examination of the tree revealed white paint transfer marks, and imbedded in the tree, 30 feet up from the roots, was the boarding step from the left main landing gear. The left wing fuel cap was secured to the tank; however, the tank was breached. When the wing was positioned upright, a small amount of blue-colored fuel was drained into a container. Black particulate matter was subsequently observed at the bottom of the container, while white particulate matter was observed in suspension. Also located along the wreckage path were the left wing strut, cabin roof, left cabin wall and door, and the left main landing gear. The main wreckage came to rest on a heading of 172 degrees magnetic, partially inverted, on its right side. The cockpit area remained intact, and several instrument indications were noted. The throttle, mixture, and propeller controls were observed in the full forward position, and the electric fuel boost pump switch was observed in the "off" position. The flap selector indicated the flaps were in the "up" position, and the fuel selector indicated the right fuel tank was selected. The words, "Switch Tanks" were handwritten on the instrument paneling. The engine remained attached to the firewall, and the propeller remained attached to the engine at the propeller hub. Examination of both propeller blades revealed chordwise scratching. In addition, one propeller blade exhibited torsional bending, and one blade was bent aft. The right wing, which had remained partially attached to the fuselage, was subsequently cut away by rescue personnel. Examination of the right wing leading edge revealed concave dents, and the wingtip was crushed aft. The right fuel tank cap was secured to the tank; however, the fuel tank was breached at its inboard edge. A small amount of liquid was observed in a crevice of the fuel tank bladder. The empennage section remained attached to the fuselage, and all flight control surfaces remained attached to their respective airframe attachment points. Flight control continuity was confirmed from the cockpit to all flight control surfaces, and "broomstraw" fractures were observed on the cable breaks. A measurement of the flap actuator revealed that the flaps were fully retracted. The engine was removed from the airframe, and rotated manually via the propeller. Thumb compression and valve train continuity was obtained on all cylinders. The top spark plugs were removed; they were dark in color, and the numbers 1, 3, and 5 spark plugs were coated with oil. During rotation of the engine, spark was produced at each magneto ignition lead, with the exception of the number 5 top and bottom leads, due to impact damage to the harness. The harness was then manually cut at the terminals, the engine was rotated again, and spark was observed at both wires. The engine-driven fuel pump was removed and examined. The pump's drive coupling was intact, and the pump rotated freely. A small amount of blue fuel was observed. The fuel was sampled, and black particulate matter with white suspended contamination was noted. The fuel lines to and from the fuel-metering unit were disconnected and examined, as well as the fuel line from the electric fuel boost pump. The lines contained fuel with contamination similar to that found in the fuel pump. The electric boost pump was removed, and when power was applied to the pump, fuel flowed smoothly and continuously through it. The oil filter was removed and cut open to examine the filter element. The filter was full of dark, opaque oil. No metallic contamination of the filter element was observed. Examination of the air filter revealed it remained intact and attached to the engine. No anomalies were visible with the filter. The engine was disassembled and examined at the Teledyne Continental Motors Analytical Department under the supervision of the FAA. Examination of the cylinders revealed heavy black combustion deposits, with the number 3 and number 6 cylinders exhibiting signatures of operation with a foreign material. Additionally, two pieces of aluminum material were found in the combustion chamber of the number 6 cylinder. The aluminum pieces were identified by the Teledyne Metallurgical Lab to be the same material as the air filter mount frame from the airframe induction system. The number 5 top compression ring was also broken and severely worn. According to the Continental Report, "The ingestion of foreign material in cylinder combustion chambers can affect proper valve operation/timing and produce a combustion miss, thereby diminishing the engine power output." MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by personnel of the Office of the Chief Medical Examiner, Greensburg, Pennsylvania. Toxicological testing was conducted on the pilot at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. ADDITIONAL INFORMATION Aircraft fueling Examination of fuel receipts and a written statement provided by the fixed base operator (FBO) at the Mount Pleasant/Scottsdale Airport (P45), Mount Pleasant, Pennsylvania, revealed that the owner of the airplane purchased 40 gallons of 100 LL aviation fuel on April 26, 2003, and again on May 23, 2003. Both purchases were billed to "Skydive Boquet," and on both occasions, the fuel was purchased and transported in eight, 5-gallon "polyurethane" fuel containers. A portable trailer, from which "Skydive Boquet" had been conducting skydiving operations, was removed from the airport following the accident and prior to the Safety Board's arrival. On the day after the accident, a Federal Aviation Administration (FAA) inspector interviewed the airplane owner's wife, at her residence. He observed the "Skydive Boquet" portable trailer at the residence, and was given access to its contents. He observed three plastic "lawnmower" type fuel containers inside the trailer, which the owner's wife stated were used to fuel the airplane. One container had a 2 1/2-gallon capacity, and two containers had a 5-gallon capacity. All three containers were empty. The eight, 5-gallon polyurethane fuel containers were not located. Wreckage Release The airplane wreckage was released on June 23, 2003, to a representative of the owners insurance company.

Probable Cause and Findings

The loss of power caused by fragments of the air filter being ingested in the engine. A factor was the pilot's delayed decision to perform a forced landing after experiencing a partial loss of engine power.

 

Source: NTSB Aviation Accident Database

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