Panama City, FL, USA
N8891N
PIPER PA-28-140B
Before the accident flight, the airplane had been started and taxied, but not flown in several years, and had been stored outdoors during that time. The pilot was aware of the condition and history of the airplane and conducted a cockpit orientation and cursory review of the onboard paperwork with the airplane’s owner. The pilot subsequently checked the fuel and oil to assure that they were at the proper levels and that no water or debris was indicated by samples from the drain ports. The pilot and the mechanic (who had performed the only recorded maintenance and inspection on the airplane in the previous 5 years) planned to take a short flight in the general vicinity of the airfield and then land. The weight and balance were within limits, and there was about 25 gallons of fuel on board. Ground operations were unremarkable. All the electrical gauges were within limits and the battery indicated that it was charged. The engine ran smooth, and all indications were within limits. The pilot stated that before takeoff, he decided to perform the pre-takeoff checks twice - each followed by a high-speed taxi down the runway to rotation speed. “The aircraft performed flawlessly” and he then then did a final runup and magneto check, lined up, advanced to full throttle, and began the takeoff roll. The airplane accelerated and became airborne as expected, but as they approached the departure end of the runway the engine rpm suddenly decreased to about 2,400 rpm and airspeed began to decrease. He ensured the mixture was full rich and the throttle was full in. He believed that the engine was running fine, but at reduced rpm. The engine rpm then decreased to 2,100 rpm. He then checked that the throttle was full in, the mixture was rich, the primer was in, and the fuel pump was on, as he lowered the nose to maintain airspeed. However, engine rpm began to decrease as if he was slowly pulling the throttle to idle. The engine was not running rough, just slowly decreasing uncommanded to idle (and at this point the propeller was likely windmilling). As they approached a highway, they were in a descent below best glide speed. He realized he would not be able to turn and try to land on the highway without stalling. They were descending at such a rate that they could not make it to a nearby road or some small clearings just south of it, so he aimed between pine trees and tried to align the airplane’s flight path with the planted pattern of the trees and prepared for a forced landing. Just above the treetops, he slowed to stall speed and attempted to use rudder to keep the wings level as the wings impacted the trees to slow them down before the airplane came to rest. During the impact sequence, the airplane was substantially damaged. Postaccident examination revealed that the engine displayed numerous areas of corrosion, missing paint, and a wasp nest was adhered to the accessory case. Water was discovered in the gascolator and boost pump, which upon further examination was determined to not be an approved boost pump. Corrosion was present in the engine-driven fuel pump, and the carburetor fuel inlet screen displayed several areas where corrosion and debris were adhering to the screen. Further examination also revealed water in the carburetor float bowl. Based on this information it is likely the engine sustained a complete loss of engine power due to fuel contamination. The airplane Owner’s Handbook stated under “PREFLIGHT” that the airplane should be given a thorough visual inspection before each flight, including visually checking the fuel supply, securing the fuel caps, draining the fuel tank sumps, checking that the fuel system vents were open, checking for obvious fuel and oil leaks, and checking that the required papers were in order and in the airplane. Under “GROUND CHECK” (which occurs after the engine is started), it also required that the pilot check the magnetos, vacuum indicator, oil temperature, oil pressure, and carburetor heat, as well as turning the electric fuel pump off momentarily to determine that the engine-driven fuel pump was functional. Just before takeoff, it required that the pilot check that the fuel was on the proper tank, the electric fuel pump was “ON,” the engine gauges were checked, the carburetor heat was “OFF,” the mixture was “RICH,” the quadrant friction knob was set, the wing flaps were set, the trim was set, the controls were free, the door was latched, and the belts/harnesses were fastened. The pilot purportedly accomplished all these checks twice—each followed by a high-speed taxi down the runway to rotation speed—and then performed a final runup and magneto check before takeoff. However, examination of the tachometer hour meter indicated that the time from engine start to the loss of power was only about 2 tenths of an hour (approximately 12 minutes at cruise rpm). Examination of airplane maintenance records revealed that the mechanic inspected and serviced the airplane about 4 days before the accident. The entry in the airplane maintenance records made no mention of an annual inspection. Further examination revealed that an annual inspection had occurred about 6 years prior. During that inspection, 19 discrepancies were discovered and the “airframe was determined to be UNAIRWORTHY.” About 14 months later, a document was produced by a mechanic that listed the 19 discrepancies found during the annual inspection, and that they had been remediated. However, the document did not state that an annual inspection had been completed. No other maintenance entries were found in the airplane maintenance records after the document was produced from about 5 years until the entry that occurred 4 days before the accident, and a review of the engine maintenance records revealed that the most recent engine overhaul was completed more than 50 years before the accident. Review of the manufacturer’s published guidance for 100 hour/annual inspections indicated that approximately 174 checklist items were required to be checked/inspected during a 100 hour/annual inspection. About 18 of the checklist items had to do with inspection of the fuel system, including checking the wing tanks and fuel lines, the gascolator, boost pump, engine-driven fuel pump, carburetor inlet screen, and carburetor. Additional review of the “GENERAL” section also revealed that one checklist item stated, “Appropriate entries made in the Aircraft and Engine Logbooks” and another stated, “Airworthiness & Registration Certificates in the aircraft and properly displayed.” The pilot had accrued about 3,870 total hours of flying experience, 3,182 hours of which was as pilot in command. However, most of the pilot’s total flight hours were in several turbojet powered airplanes, and, at the time of the accident, he had no flight hours in the accident airplane make and model. Although he was transitioning to an unfamiliar airplane, he did not seek specific training in the new airplane’s systems and operating characteristics to include normal, abnormal, and emergency procedures. Thus, the evidence indicates that the mechanic should have been familiar with the scope and details to be included in annual and 100-hour inspections, and should have been familiar with the general items to be checked during inspections, but due to the airplane’s maintenance history and his inadequate inspection the contamination in the fuel system was not detected. Also, the pilot, who was the last barrier in preventing the accident and was aware of his lack of experience in the airplane, did not seek specific training, was either unaware of or ignored the risks inherent in flying an airplane that had not flown in many years, and either rushed or performed an incomplete preflight inspection and runup, which resulted in him failing to detect the contaminated fuel.
On April 18, 2022, about 1329 central daylight time, a Piper PA-28-140B, N8891N, was substantially damaged when it was involved in an accident near Panama City, Florida. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to the pilot, the airplane had been started and taxied over the past few years and he had been briefed about the condition and history of the airplane by the owner and a mechanic (who held a mechanic certificate with airframe and powerplant ratings as well as an inspection authorization). A Federal Aviation Administration (FAA) inspector noted that the airplane had not flown for several years and was stored outdoors during that time. The pilot reported that he conducted a cockpit orientation and cursory review of the onboard paperwork with the owner a few weeks before the accident flight. A pilot operating handbook and abbreviated checklist were onboard, which he used to study for the flight. The pilot believed that the weight and balance was in order, and a copy of an airworthiness certificate that had been printed on a copy machine on 8.5” x 11” paper was onboard. The registration that was onboard had expired on July 31, 2016. According to the pilot, the owner had applied for re-registration, and the owner briefed the pilot that it was valid for 90 days. The pilot met with the mechanic (who had performed the only recorded maintenance and inspection on the airplane since 2017) on the day of the accident flight for a briefing on the condition of the airplane to ensure he reduced any potential risks before the flight. They discussed all applicable airworthiness directives, that they were complete, and that the aircraft’s engine and flight controls had been inspected and met specifications. The mechanic answered all the pilot’s questions and the pilot offered to take him on the flight, which the mechanic accepted. The pilot planned to take a short flight in the general vicinity of the airfield and then land. The pilot reported that he checked the fuel and oil to ensure that they were at the proper levels. No water or debris was indicated by samples from the drain ports. He stated that the weight and balance were within limits, and there were about 25 gallons of fuel on board. The pilot stated that ground operations were unremarkable. The engine ran smoothly, and all indications were within limits. Before takeoff, the pilot decided to perform the pre-takeoff checks twice, followed each time by a high-speed taxi down the runway to rotation speed. The pilot stated that the airplane “performed flawlessly.” He then did a final runup and magneto check before he lined up, advanced to full throttle, and began the takeoff roll. The airplane accelerated and became airborne as expected at 60 to 65 mph with only slight back pressure. The initial climb rate was 300-500 fpm. The pilot let the airplane accelerate to 85 mph for best climb rate and ensured they would clear the pine trees just off the end of runway 27. He continued to let the airplane accelerate towards 100 mph for enroute climb and engine cooling, but as they approached the departure end of the runway the engine rpm suddenly decreased to about 2,400 rpm without any input, and airspeed began to decrease. The pilot then turned about 10° left to get away from the tallest trees in front of them and houses to the north of them. He ensured the mixture was full rich and the throttle was full in. The engine was running fine, but at reduced rpm. The engine rpm then decreased to 2,100 rpm. He then checked that the throttle was full in, the mixture was rich, the primer was in, and the fuel pump was on as he lowered the nose further to maintain airspeed. However, the engine rpm began to decrease as if he was slowly pulling the throttle to idle. The engine was not running rough, just slowly decreasing uncommanded to idle. As they approached a highway, they were in a descent with airspeed below best glide speed around 80 mph. He realized he would not be able to turn and could not land on the highway without stalling. They were descending at such a rate that they could not make it to a nearby road or some small clearings just south of it, so he aimed between pine trees and tried to align the airplane’s flight path with the planted pattern of the trees and prepared for a forced landing. Just above the treetops, he slowed to stall speed, and attempted to use rudder to keep the wings level as the wings impacted the trees and slowed them down. They experienced a very solid tree impact on the right wing just before impact. The airplane then impacted the ground and the windscreen shattered. The pilot was not sure if the engine was at idle or windmilling at time of impact. According to the pilot, he had accrued about 3,870 total hours of flying experience, 3,182 hours of which was as pilot in command. Most of the pilot’s total hours was in several turbojet powered airplanes. He did not have any prior experience in the accident airplane make and model. According to the Piper Aircraft PA-28-140B Owner’s Handbook, the fuel system was equipped with an auxiliary electric fuel pump (boost pump) for use in case of failure of the engine-driven fuel pump. The electric pump was required to be turned on for all takeoffs and landings and when switching fuel tanks. The airplane’s fuel strainer (gascolator) was equipped with a quick drain and was located on the front lower corner of the firewall. The manual stated that the strainer should be drained regularly to check for water or sediment accumulation. To drain the lines from the fuel tanks, the tank selector valve must be switched to each tank in turn, with the electric pump on, and the gascolator drain valve opened. Each tank also had an individual quick drain located at the bottom, inboard, rear corner. The Owner’s Handbook further stated under “PREFLIGHT” that the airplane should be given a thorough visual inspection before each flight. Preflight checklist items involving the airplane fuel system included: visually checking the fuel supply, securing the caps, draining the fuel tank sumps, checking that the fuel system vents were open, and checking for obvious fuel and oil leaks. In addition, the Owner’s Handbook instructed the pilot to check that the required papers were in order and in the airplane. Under “GROUND CHECK”, which occurs after the engine is started, the Owner’s Handbook also required that the pilot check the magnetos, vacuum indicator, oil temperature, oil pressure, carburetor heat, and turn the electric fuel pump off momentarily to determine that the engine-driven fuel pump was functional. Just before takeoff, the Owner’s Handbook required that the pilot check that the fuel was on the proper tank, the electric fuel pump was “ON”, the engine gauges were checked, the carburetor heat was “OFF”, the mixture was “RICH”, the quadrant friction knob was set, the wing flaps were set, the trim was set, the controls were free, the door was latched, and the belts/harnesses were fastened. Postaccident examination of the airplane and engine revealed that, during the impact sequence, the right wing and right horizontal stabilator had separated from the airplane. The engine displayed numerous areas of corrosion, missing paint, and a wasp nest adhered to the accessory case. Water was discovered in the gascolator and boost pump, which upon further examination was determined to not be an FAA-approved boost pump. Corrosion was present in the engine-driven fuel pump, and the carburetor fuel inlet screen displayed several areas where corrosion and debris were adhering to the screen. Further examination also revealed the presence of water in the carburetor float bowl. The tachometer hour meter time at the time of the accident was 2,820.67. Examination of airplane maintenance records revealed that the mechanic inspected and serviced the airplane on February 14, 2022, at a tachometer hour meter time of 2820.48. The entry made no mention of an annual inspection. Further examination revealed that an annual inspection had occurred on July 10, 2016. The tachometer hour meter time noted in the entry was 2,816.28. During that inspection, 19 discrepancies were discovered and the “airframe was determined to be UNAIRWORTHY.” On November 30, 2017 (about 14 months later), a document was produced by an A&P that listed the 19 discrepancies found during the annual inspection on July 10, 2016, and stated, “Tach reading at completion of remediation” and listed the tachometer hour meter time as 2,819.3. However, the document did not state that an annual inspection had been completed. No entries were found in the airplane maintenance records for a time span of about 5 years, from November 30, 2017, until February 14, 2022. A review of the engine maintenance records revealed that the engine had accumulated 1,874.29 hours since major overhaul at the time of the accident. The most recent engine overhaul was completed on March 16, 1972, more than 50 years before the accident. According to Lycoming Service Instruction No. 1009BE, “All engine models are to be overhauled within twelve (12) calendar years of the date they first entered service or of last overhaul. This calendar year time period [time before overhaul] is to mitigate engine deterioration that occurs with age, including corrosion of metallic components and degradation of non-metallic components such as gaskets, seals, flexible hoses, and fuel pump diaphragms.” A review of Piper Aircraft Corporation Inspection Report (Part Number 230-207), which met the requirements of 14 CFR Part 43 (Maintenance, Preventive Maintenance, Rebuilding and Alteration), indicated that approximately 174 checklist items were required to be checked/inspected on a 100 hour/Annual inspection. These various checklist items were listed in the “PROPELLER GROUP,” “ENGINE GROUP,” “CABIN AND COCKPIT GROUP,” “FUSELAGE AND EMPENNAGE GROUP,” “WING GROUP,” “LANDING GEAR GROUP,” “FLOAT GROUP (IF INSTALLED),” “SPECIAL INSPECTIONS,” “OPERATIONAL INSPECTION,” and “GENERAL.” Further review also indicated about 18 of the checklist items involved inspection of the fuel system, including checking the wing tanks and fuel lines, gascolator, boost pump, engine-driven fuel pump, carburetor inlet screen, and carburetor. Additional review of the “GENERAL” section also revealed that one checklist item stated, “Appropriate entries made in the Aircraft and Engine Logbooks” and another stated, “Airworthiness & Registration Certificates in the aircraft and properly displayed.” According to an FAA inspector, this was the first time that the mechanic had signed off an annual inspection.
A total loss of engine power due to fuel contamination. Contributing to the accident was the inadequate maintenance and inspection of the airplane and engine by maintenance personnel, and the pilot’s inadequate preflight inspection and runup.
Source: NTSB Aviation Accident Database
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