Aviation Accident Summaries

Aviation Accident Summary LAX03FA067

Palm Springs, CA, USA

Aircraft #1

N127WW

Cessna 414

Analysis

The certificated flight instructor (CFI) was providing multiengine training to one of the two owner/pilots aboard during an IFR cross-country flight. Upon reaching cruise altitude, both left and right engine fuel selectors were turned from the main fuel tanks to the auxiliary tanks. Shortly after selecting the auxiliary tanks, the left engine lost power. Power was restored after the fuel selector was returned to the main tank, and the CFI elected to continue the flight. During approach to land at the destination airport, the CFI simulated a left engine failure by reducing power on that engine to "zero thrust." The left propeller was intentionally not feathered. While on the base leg, about to turn final, the left engine began to surge, pulling the airplane away from the airport. The CFI stated that he took the controls, and increased power on both engines, but the airplane continued to move away from the runway. He stated that the left engine continued to surge, and the right engine began to lose power. He indicated that he turned the boost pumps for both engines from the low to "ON" (high) position without any noticeable difference in power. He did not feather either propeller, and made a forced landing off airport in a sandy ravine. All pilots indicated that there was ample fuel aboard the airplane at the time of the engine problems, and that the fuel tank selectors were on the main tanks. Postaccident inspection disclosed that the left main and auxiliary fuel tanks had been breached during the accident. The right main and auxiliary tanks were intact, with a usable quantity of fuel remaining in the right main. The left engine had damage that precluded a test run. It was disassembled, and no evidence of any preimpact mechanical anomaly was discovered. The left engine driven fuel pump was not tested. The left engine's fuel boost pump ran noisily for a short period, and then overheated. The right engine was successfully run on a test stand. An inspection of the right engine's spark plugs prior to the engine run revealed that the engine had operated in an overly rich state just prior to the accident. The right engine's fuel boost pump functioned normally. The airplane's flight manual cautions that if the boost pump switch is moved to the high position while the engine driven fuel pump is operating, an overly rich condition may result in a total loss of engine power.

Factual Information

HISTORY OF FLIGHT On January 14, 2003, at 1359 Pacific standard time, a Cessna 414, N127WW, lost engine power and made an off airport forced landing at Palm Springs, California. The owner operated the airplane under the provisions of 14 CFR Part 91. The airplane sustained substantial damage. The commercial multiengine pilot undergoing instruction (PUI) was located in the left seat, and received serious injuries. The certified flight instructor (CFI) in the right seat, and a pilot rated passenger in the passenger compartment had minor injuries. Visual meteorological conditions prevailed for the cross-country flight. An instrument flight rules (IFR) flight plan had been filed. The flight departed Zamperini Field (TOA), Torrance, California, at 1145. The flight was destined for Palm Springs International Airport (PSP). The wreckage was at a global positioning system (GPS) coordinates of 33 degrees 51 minutes north latitude and 116 degrees 29 minutes west longitude. Responding Palm Springs Police Department officers interviewed the pilots after the accident. The CFI reported that as they turned towards final, the left engine began to surge and the airplane yawed to the right. He went through the emergency procedures but the airplane continued to lose airspeed and altitude. While maneuvering to the landing spot, the CFI noted that the fuel selectors were positioned to the MAIN fuel tanks, and the gauges showed 25 gallons in each wing. The responding officers verified that the master switch and the magnetos were in the OFF positions, the landing gear handle was in the retracted position, and the flaps were retracted. They also noted that the fuel boost pump switches were "fully on." The fuel selector handles were in the OFF position. The officers inspected the fuel tanks and noted that the left side fuel tanks were empty, with the odor of fuel present under the damaged wing. The two outer right wing fuel tanks each had fuel remaining in them. CFI Statement (seated in the right seat) The CFI reported that on the day prior to the accident, during the preflight inspection, he noted that the left alternator circuit breaker had been tripped to the OPEN position, and he reset it. They started the engines and cross-fed fuel from the opposite main fuel tanks priming the engine via the emergency fuel pump ON position. Normal fuel flow was established and the engines were operating normally. They tested the airplane system per the BEFORE TAKEOFF checklist, with no discrepancies noted. As they taxied to the fueling area there was a discussion about the left alternator, which had recently been replaced. They did not know if it was on line or not. The PUI had informed him that during the ferry flight to reposition the airplane from Palomar Airport, Carlsbad, California, to TOA, the pilot noted that the left alternator was inoperative. However, during the taxi, no discrepancies were noted with the left alternator. The airplane was fueled to capacity; 100 gallons in the main fuel tanks, and 40 gallons each in the auxiliary and nacelle locker fuel tanks for a total of 80 gallons. The airplane was taxied to the hangar where they adjourned to start the ground school portion of the training. They spent the next 6 hours reviewing airplane systems. They met the next day to complete the ground school instruction. The pilots again performed the preflight inspection, which included sampling the fuel sumps, where about 1 quart of water was removed from the right wings' innermost rear sump. The water was not "clean; it was cloudy and contained sediment." They continued to sample the fuel until "clear fuel was detected." The airplane was started normally and they received an IFR flight plan to PSP via Thermal, California, and Blythe, California, reaching an altitude of 25,000 feet (flight level - FL250) to conduct high altitude operations. After reaching FL250, the airplane was configured for 65-percent power and the air-to-fuel mixture was adjusted to the recommend values. At that point, the CFI switched from the main fuel tanks to the auxiliary fuel tanks. Moments later, the left engine "dropped off line," and no fuel flow was evident on the fuel gauge. He then moved the left fuel selector back to the left main fuel tank. He advised Southern California Air Route Traffic Control Center (SoCal ARTCC) of the situation, and initiated a slow right circling descent towards Blythe airport. The left engine did not immediately come back on line, and it took a few minutes before the engine regained power. The CFI reported that they stabilized the airplane's altitude at 15,000 feet and elected to continue on towards Thermal. At that point both engines were operating normally. He stated that the left fuel selector was positioned to the MAIN fuel tank, and the right fuel selector was positioned to the AUXILIARY fuel tank. The CFI reported that because the engines were operating normally, he moved the left fuel selector from the MAIN fuel tank back to the AUXILIARY fuel tank. The left engine continued to operate normally. He stated that they performed flight maneuvers that included medium and steep bank turns, unusual attitudes, and various simulated emergency conditions. During the airwork, the fuel selectors were both positioned to the MAIN fuel tanks, and they initiated the fuel transfer process from the nacelle locker tanks to the main fuel tanks. The CFI stated that the engines were operating normally, and they continued the flight towards PSP, their original destination so they could refuel and switch pilots. At 8,500 feet, he radioed the PSP approach controller with a request to circle PSP airport, and simulate single engine operations (an engine out condition). The PSP controller acknowledged and approved their request. The flight proceeded direct to PSP at 3,500 feet and was instructed to contact tower personnel; a tower controller cleared them to land on runway 31L. The CFI then simulated a left engine failure by reducing the power with the throttle. The PUI initiated the emergency procedures by increasing mixture to rich, propellers to high rpm (revolutions per minute), and right throttle full forward. The PUI performed a "drag check" to ensure the landing gear and wing flaps were retracted. The PUI then identified the left engine as inoperative and verified by closing the left throttle. When the PUI went to feather the left propeller the CFI blocked him, and then set power on the left engine to simulate "zero thrust and trimmed for that condition." The PUI circled the airplane to the right, towards the operating engine, and during the descent, the power on the right engine was reduced to 29.5 inches manifold pressure (MAP) and 2,400 rpm. The CFI reported that they orbited the airplane a couple of times before establishing the airplane on the right downwind leg for runway 31L. As they turned from base to final, left wing high, the left engine started to "surge wildly, rotating the [airplane] clockwise 180 degrees from our previous heading and outbound perpendicular from the runway." They arrested the turn by leveling the wings, lowering the pitch attitude, and "bringing power up on both throttles." The CFI reported at that point he took over the flight controls. The power increased on the left engine, which continued to surge "with a higher frequency," and power on the right engine began to drop off progressively. They attempted to stabilize the power situation on the left engine and restore power to the right engine by placing the auxiliary fuel pump switches from the LOW position to the ON position. However, there was not a noticeable change in either engine. The airplane yawed to the right towards a housing development with surface streets and power lines in their route of flight. The airplane continued to lose altitude. He had the PUI inform PSP tower that they had an actual emergency condition. The CFI was able to regain directional control of the airplane by banking towards the left engine, but "felt the power dropping off there also." He reported that his main priority was clearing the housing development and obstacles in the area. He was able to maintain a minimal descent rate by reducing the airspeed. After the airplane cleared the obstacles, he then "gave up my altitude to preserve lift over the wings." He could feel the wings were just above a stall and pushed the nose down to maintain airplane control. The CFI stated that he made a forced landing in a sand covered ravine just west of the housing development. After landing hard, he had the PUI switch off the magnetos, alternators, and battery. The CFI selected both fuel selectors to the OFF position. The CFI further reported that fuel was pouring out of the left main fuel tank, which had broken away from its attachment point. PUI Statement (seated in the left seat) The pilot reported that after completing their morning ground session, they conducted a preflight of the airplane in accordance with the manufacturer's pilot operating handbook (POH). All six fuel tanks had been "topped" off with 100 low-lead octane aviation fuel by the local fixed base operator (FBO), totaling 180 gallons of useable fuel. He drained fuel sampled from all 12 fuel valve drains. Water was evident from the innermost fuel valve under the right wing. He drained about 2 cups of water from the fuel valve drain. After starting the airplane, he obtained Torrance's current Automatic Terminal Information Service (ATIS) information and taxied to the run-up area for runway 29R. In the run-up area he obtained the IFR clearance to PSP, with a requested altitude of FL 250. After takeoff, SoCal cleared them to the Seal Beach Very High Frequency Omni-directional Range (SLI VOR), where they began a series of climbs to FL250. The PUI indicated that the climbs were done using the cruise climb settings called out on the RAM series VI engine chart. The PUI reported that all systems were operating normally. Once they reached FL250, he configured the airplane at a cruise power setting of 65 percent. Shortly after the CFI switched to the auxiliary fuel tanks the power for the left engine "dropped off," and the CFI switched back to the left main fuel tank. He notified SoCal of situation, and initiated a descent towards the Blythe airport. During the descent, the left engine came back online, and they elected to proceed towards Thermal. The pilot reported that the flight from Blythe to Thermal was normal, and the left engine was supplied fuel from the left main fuel tank and the right engine was supplied fuel from the right auxiliary fuel tank. While en route to Thermal, the fuel selectors were placed on the main fuel tanks for both engines, and a fuel transfer from the nacelle locker tanks to the main fuel tanks was initiated. The pilot reported that 25 minutes later the fuel transfer was complete. He noted that the fuel quantities in the main and auxiliary tanks agreed with their planned fuel consumption calculations. During that portion of the flight, they performed airwork, which included medium and steep bank turns, and recovery from unusual attitudes. At that point, they were just west of Chiriaco Summit, California, at an altitude of 8,500 feet above ground level (agl). Both engines were operating normally and they continued the flight towards PSP. They picked up ATIS information and advised PSP approach of their intent to circle over the airport, and perform a simulated single engine operation culminating in a full stop landing. PSP controllers approved the request and advised them to contact PSP tower. The PUI initiated a descent to 3,500; simultaneously a PSP tower controller cleared them to land on runway 31L. At that point the CFI reduced the power on the left engine via the throttle. After recognizing the loss of power, he initiated the engine-out procedure by pushing the mixture levers forward to the rich position, propeller levers forward to high rpm, and right throttle full forward. He performed a "drag check" to ensure the flaps were UP and the gear was retracted. He then verified that the left engine was inoperative in response to my 'dead foot - dead engine' assessment. When he attempted to feather the left engine the propeller control was "blocked by the instructor." The CFI then configured power on the left engine for "zero thrust and we trimmed the aircraft for that condition." The PUI stated that he made right-hand circles over the airport, towards the good engine, and established the power setting of the right engine at 29.5 inches MAP and 2,400 rpm. After a couple of turns he established the airplane on the downwind leg east of the airport and completed the before landing checklist using the POH. While on the base leg, the left engine began to surge and the airplane yawed "violently clockwise taking us away from the airport." At that point the CFI took the flight controls. The CFI then leveled the wings, lowered the nose, and pushed the power levers full forward. The PUI declared an emergency with PSP tower and assisted the CFI with emergency procedures while scanning the instruments in an attempt to identify the problem. The PUI stated that he did not believe that either engine was developing power, and the airplane could not maintain its altitude. Passenger Statement According to the passenger, the preflight inspection was completed utilizing the POH for the airplane. The airplane had full fuel tanks - 180 gallons. The PUI sampled the fuel from all 12 fuel drains, and the passenger stated that the fuel was blue in color. The right side rear interior fuel valve had water in the sample, and the PUI continued to drain fuel (about 2 cups worth) from it until it was "clear and clean." The passenger reported that he sat behind the copilot seat to observe the flight. The PUI was in the left seat, and the CFI sat in the right seat. During climb out they checked the pressurization, heating, defrost, and air conditioning systems - with no discrepancies noted. After reaching their assigned altitude, the PUI set cruise power at 65 percent. The CFI switched both main tanks to the auxiliary fuel tanks. The passenger stated that shortly after switching tanks, the left engine began to lose power. The CFI switched back to the left main tank, and the engine regained power. The passenger stated that the pilots started to transfer fuel from the nacelle locker tanks to the main tanks. He saw the pilots switch both fuel transfer pumps to the ON position. The passenger stated that the PUI performed air work, which included steep and standard rate turns, and recovery from unusual attitudes. After about 25 minutes, he noticed the transfer pump annunciator lights on indicating the fuel transfer was complete. The right main tank gauge indicated nearly full, and the left main tank gauge showed about 40 gallons. The flight continued normally to PSP, and clearance was obtained to circle the airport with the intent to conduct a simulated engine-out landing at PSP. A descent to 3,500 feet was started, and the CFI reduced the power on the left engine to simulate an engine failure. The PUI identified and verified the inoperative left engine, and during his attempt to feather the propeller the CFI stopped him. The CFI then configured the left engine "for zero thrust." At that point they were circling the airport to the right and performed the landing checklist. The passenger reported that after turning right downwind to base for runway 31L at PSP, the left engine began to surge and the airplane yawed to the right. The CFI took the flight controls and attempted to identify the problem. The PUI contacted the tower and declared an emergency. The passenger noted that the CFI kept the airplane in controlled flight, but the airplane was drifting away from the airport, and was losing altitude, "it seemed we had very little power." From the passenger's position he was able to observe that the fuel selectors were selected to the main tanks, and the fuel gauges showed "an ample supply of fuel." He noted that the gear and flaps were in the UP positions. PERSONNEL INFORMATION Certified Flight In

Probable Cause and Findings

The flight instructor's improper selection of the high boost position for the operating right engine while on base leg to land, which resulted in a loss of engine power of the right engine. Factors associated with the accident are the left engine's loss of power for an undetermined reason, the flight instructor's failure to feather the propellers of the affected engines, and his failure to maintain directional control, which resulted in an off-airport forced landing.

 

Source: NTSB Aviation Accident Database

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