Morton, WA, USA
N224GS
CIRRUS DESIGN CORP SR22
The airplane was in cruise flight when the engine lost power. The pilot attempted to reach the nearest airport, but the airplane collided with trees about 2.5 miles short of the runway. Non-volatile memory from the cockpit instruments revealed that the engine power decreased to 1,200 and 1,750 rpms, while the fuel flow reached 30 gallons per hour (the maximum range of the fuel flow sensor). Examination of the airframe and engine revealed no evidence of preimpact mechanical anomalies except for the fitting cap on the throttle and metering assembly inlet, which was not installed. The cap was found resting on the cylinder baffle, and there was light blue staining on the crankcase indicating fuel leakage. During a postaccident engine run, the engine operated normally with a substitute cap installed finger tight. An annual inspection was completed about 11 flight hours prior to the accident, during which three engine cylinders were replaced. Following the cylinder replacement, the fuel system pressures were checked with instrumentation that was plumbed into the system at the throttle and metering assembly. Following the pressure tests, the line where the instrumentation was connected should have been secured with the fitting cap that was found not installed. The manufacturer’s maintenance procedure requires that after the pressure tests are completed the cap be torqued and that a leak check be performed. Metallurgical examination of the cap showed that if it had been properly torqued it would have remained secure. Therefore, it is likely that the cap was installed finger tight and was not properly torqued when it was reinstalled. During the accident flight, the cap loosened and came off, resulting in a loss of engine power due to fuel starvation. There was no logbook entry for the most recent annual inspection, nor had the final items on the annual inspection checklist been completed. The Director of Maintenance for the facility had signed off the work order and returned the airplane to service. The assigned mechanic with inspection authorization indicated that he had not completed the annual inspection on the airplane and that the last maintenance he performed was that noted on the work order and annual inspection checklist. If the final checks had been completed, it is likely that the improperly secured cap would have been found because the fuel leakage would have been evident.
HISTORY OF FLIGHT On March 19, 2010, about 1910 Pacific daylight time, a Cirrus SR22, N224GS, collided with trees and terrain during a forced landing following a loss of engine power near Morton, Washington. The private pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The airplane was substantially damaged. The pilot was killed and the passenger sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed from Buchanan Field Airport, Concord, California, about 1540, and was destined for Renton Municipal Airport, Renton, Washington. The Safety Board investigator-in-charge interviewed the passenger on Wednesday, March 24, 2010. The passenger indicated that she and the pilot were returning from a business trip. After fueling the airplane, they departed and began the flight home. The passenger stated that while the airplane was in cruise flight, the pilot suddenly placed his hands on the controls, told her that the engine had lost power, and they were going to land at a nearby airport. He entered a steep right turn toward the airport. The passenger could not recall hearing anything unusual at the time of the event. The pilot remained calm throughout the approach to the airport and reassured the passenger during the descent that they would land safely. The pilot also declared a MAYDAY message and spoke on the radio. The passenger sent a text message to a friend at 1909 indicating that they were not going to make it to the airport. She did not recall anything after this point. The passenger indicated that the pilot had discussed the Cirrus Airframe Parachute System (CAPS) with her prior to the trip and showed her how to activate it in the event of an emergency. The passenger reported that the pilot did not attempt to activate the CAPS during the flight. Audio obtained from Prescott AFSS indicated at 1906:51, N224GS transmitted "MAYDAY, MAYDAY, Cirrus N4GS" on frequency 121.5. Part of the audio was unintelligible. Another aircraft, N999VK responded immediately to the MAYDAY call with “Cirrus on guard this is N999VK”, then a Seattle Radio controller responded with “Aircraft calling MAYDAY on 121.5, Seattle Radio." N999VK said “Standby center, 9VK is copying a MAYDAY”, and then asked N224GS to go ahead. N224GS said “I’m west of Strom airport, trying to make the field." N999VK asked N224GS how far he was from the field. No additional transmissions were received from N224GS. Prescott AFSS contacted the local sheriff's office. The wreckage was located immediately following the accident approximately 2.5 miles west-northwest of Strom Field Airport, Morton, Washington. PERSONNEL INFORMATION Pilot Information The pilot, age 39, held a private pilot certificate with an airplane single-engine land rating, and a third-class airman medical certificate issued May 29, 2007, with the limitation that he must wear corrective lenses. Copies of the pilot's logbook were obtained from his family. The last entry was dated February 21, 2010, and showed a total time logged of 219.8 hours. In a second earlier logbook provided by the pilot's family, the total time logged was 258.6 hours. Based on information obtained from the avionics onboard the airplane, the pilot had flown approximately 11 additional hours in the airplane, for a total flight time of 489.4 hours. He had flown 13 hours over the past 30 days and 14.9 hours over the past 90 days. His last flight review was on July 29, 2009. Maintenance Personnel Information Director of Maintenance The Director of Maintenance (DOM) for Auburn Flight Service, the facility that performed the most recent annual inspection on the airplane, was interviewed. He held an aviation maintenance technician certificate with airframe and powerplant (A & P) ratings and also held an inspection authorization (IA). He had worked as an A & P since 1989, and obtained his IA in October of 1999. He had served as the DOM at Auburn Flight Service since October of 2002. The DOM's normal work schedule consisted of a 40-hour work week, although he indicated that he was "juggling a lot" between work and personal life. He usually worked between 50 to 60 hours per week with 10 to 11-hour days. The number of employees he oversaw varied. During high employment periods, he oversaw five to six mechanics. In February of 2010, he employed three mechanics. Airframe and Powerplant Technician with Inspection Authorization The A & P/IA began his maintenance career in the military in 1991. Following the military, he worked in airline heavy line maintenance for seven years. He held employment as a flight engineer and first officer at a cargo company, and then returned to the Seattle area for family reasons. He began work with Auburn Flight Service where he worked for two years until leaving in February of 2010 for career advancement at a different company. The A & P/IA typically worked a 40-hour week with occasional overtime. He never felt like he was asked to do more than he was capable of doing. Airframe and Powerplant Technician The A & P held an aviation maintenance technician certificate with airframe and powerplant ratings. He began his maintenance career in the military in 1974 and obtained his A & P in 1986. He began working for Auburn Flight Service in April of 2007. The mechanic generally worked a 40-hour work week although his workload had recently increased due to more work and fewer employees. The mechanic felt that he had adequate time to perform his job duties. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear airplane, serial number (SN) 1326 was manufactured in 2005. It was powered by a Teledyne Continental IO-550-N engine and equipped with a Hartzell PHC-J3YF-1RF propeller. Maintenance The maintenance records were reviewed and the last annual inspection noted in the logbooks was October 17, 2008. The Safety Board investigator-in-charge contacted the maintenance facility that performed the annual inspection, Auburn Flight Service, and inquired whether or not a more recent annual inspection had been completed. According to the DOM for Auburn Flight Service, the last annual inspection was completed in February of 2010. He was uncertain why the annual inspection logbook entries were not in the logbooks. A work order dated January 8, 2010, contained a stamp dated February 5, 2010, and was signed by the DOM indicating that the airplane and engine had undergone an annual inspection. The DOM indicated that he did not perform the work on the airplane but had signed it off as airworthy. The work order for the airplane showed that cylinders 3, 5, and 6 needed to be replaced due to cracks. The cylinders were replaced on February 2, 2010. On February 3, the work order noted "perform gnd run and leak check…check engine specs per TCM MM Table 19-1/TCM SB M89-71R." Both items were initialed by the A & P. The last item noted on the work order was dated February 3, and stated that "during ground runs L/R mag drops rough." Spark plugs were cleaned, tested, and reinstalled. The A & P also initialed this item. The Cirrus maintenance checklist for the accident airplane was reviewed. The checklist noted the type of inspection as "annual." On page 17, the "Return to Service" checklist, five of the following six items were not initialed as being completed: 1. Close Access 2. Verify all Airworthiness Directives complied with (Initialed) 3. Fuel Injection System (The checklist noted "Functional inspection of fuel injection system in accordance with the manufacturer's approved instructions for continued airworthiness after engine installation, every 100 hours, at annual, or fuel system component replacement.") 4. Perform an airplane run-up (The checklist noted "In accordance with operational/functional check in 5-30. After completing the operational check, perform a walk around to detect fluid leaks or other abnormalities.") 5. Install Engine Cowling 6. Verify airplane papers in proper order Director of Maintenance Interview In an interview with the DOM, he indicated that the normal process when an airplane is brought in for maintenance is that the airplane is dropped off by the owner, a work order is created by the DOM, squawks are noted, checklists are compiled, and the package is assigned to a mechanic. If the maintenance includes an annual inspection, then the inspection is assigned to an IA. Due to differences in work requirements, mechanics may shift to other projects throughout an annual inspection. When the work order for an annual inspection is completed, it is returned to the responsible IA, the operations checks and engine cylinder compression checks are completed, the endorsements are made, the checklists and work orders are initialed, and the work order is stamped completed by the responsible IA. According to the DOM, during an annual inspection of a Cirrus, the fuel system must be checked. Calibrated gauges are used to test metered and unmetered fuel pressure. A steel fuel cap is removed and the gauge is installed. At the completion of the test, the cap is reinstalled, and a leak check is performed. The DOM stated that the accident airplane had been maintained at Auburn Flight Service since it was new. The annual inspection was due in October of 2009 and in November the owner contacted him about the inspection. The owner brought the airplane to Auburn Flight Service in January of 2010. In addition to the annual inspection and two-year items being due, the inspection had identified three cracked cylinders. Another A & P/IA who worked at Auburn Flight Service was assigned to complete the inspection. Two additional A & Ps worked on the airplane during the maintenance as well. The DOM stated that following the accident, he asked the A & P/IA if he had signed off the annual inspection. The DOM stated that the IA was certain he had signed it off. A review of records showed that another Cirrus was in the shop at the same time and it also had to have three of its cylinders replaced. The DOM believes that the IA may have remembered completing the endorsement for the other airplane. A checklist was created during the annual inspection for the airplane and as noted previously, items on the checklist were not initialed. The DOM stated that the IA assigned to complete the job forgot to initial the checklist items, and to complete the endorsements. When asked how he knew the work was completed, the DOM said that he was aware of what was going on in the facility regarding airplanes currently being worked on through daily contact with his technicians, contact with aircraft owners, and through review of the work orders. The DOM indicated that the A & P/IA should have signed off the inspection and maintenance endorsement for the airplane logbooks but overlooked doing so. Aviation Maintenance Technician with Inspection Authorization Interview The A & P/IA said that the accident airplane had been in the facility for an annual inspection. He was assigned to perform the annual inspection. During the inspection, three cracked cylinders were identified and they had to be replaced. The annual inspection was completed as far as the maintenance personnel could work until the new parts arrived. Once the parts arrived, an A & P in the shop replaced the cylinders and the A & P/IA replaced a seal on the lower cowling. He could not recall doing any additional maintenance items on the airplane. The A & P/IA was asked about the throttle and metering assembly and when the fuel inlet cap on the line would be removed. He indicated that although he ran the engine before the annual inspection was conducted, he did not conduct any final checks. He said that in order to check the metered and unmetered fuel pressure, you would refer to a service bulletin and usually connect the gauge at the steel cap fitting. At the completion of the test, the cap is reinstalled and torqued. He indicated that normally torque seal would be used to mark that the cap had been torqued. He indicated that the engine run noted on the work order on February 3, was for the cylinder work and not the return to service run. The A & P/IA stated that when he finished an annual inspection, he would sign the stamped page on the work order. In this case, the DOM, signed the front page. Additionally, the A & P/IA would have created logbook endorsements. The A & P/IA felt that the DOM may have been pressured to return the airplane to the owner. There was another Cirrus in the facility at the time and the workload was high. The A & P/IA provided a copy of a logbook page showing the airplanes that he had signed off as airworthy or unairworthy from January 2010 through February 2010. The accident airplane was not listed. Aviation Maintenance Technician Interview The A & P recalled the accident airplane being in the shop for an annual inspection. The A & P said that there was nothing out of the ordinary during the maintenance that he performed and that the annual inspection items must be checked and functionally checked by an IA. The A & P explained the fuel system pressure checks indicating that the line and cap are removed on the metering assembly, the fuel pressures are checked, and then the lines and cap are secured. This is followed by a leak check. The A & P stated that after the check is completed, everything is torque sealed. During the interview, he could not recall what color torque seal he might have used when securing the cap on the throttle and metering assembly. When the A & P reviewed the annual inspection checklist during the interview, he indicated that several items were not completed by the A & P/IA. During the interview, the A & P indicated that there should have been additional discrepancy items for the A & P/IA's check of the fuel system. The A & P stated that the fuel system check that he (the A & P) performed was required due to the cylinder change as well as annual inspection requirements, and was not the final check. Additionally, he stated that the checklist was not filled out entirely by the A & P/IA. The A & P indicated that once all of the work order discrepancies are accomplished, the A & P/IA takes the work order package, completes the logbook entry, and the airplane is released. The A & P did not recall seeing the A & P/IA doing the final items not initialed on the checklist. In later correspondence, the A & P stated that he misspoke during the interview and noted that he did not recall removing the test equipment. He reported the following: "On work order 7631 item #39, I did not sign off removal of equipment or a leak check. In addition on the Cirrus checklist 05-20 page 17 Item 3 was left blank, indicating that check was not completed by the inspector in accordance with FAR 43.15 (c.), (2.), (i.), (ii.), (iii.) and (iv.). Furthermore, on Cirrus Checklist 05-20 page 17, items 1., 4., 5., and 6., were left blank indicating a final inspection/return to service was not documented by the inspector." Teledyne Continental Motors Guidance According to Teledyne Continental Motors Service Information Directive (SID) 97-3E, Procedures and Specifics for Adjustment of Teledyne Continental Motors (TCM) Continuous Flow Fuel Injection Systems, after the fuel pressures are checked, the test gages are removed, and all fuel hoses and cap fittings are reinstalled to their original location. Under Section D(3), it states "ASSURE CAP ASSEMBLY 639494 IS CORRECTLY INSTALLED ON INLET TEE FITTING OF COMBINATION THROTTLE BODY/METERING UNITS. TORQUE TO 135-190 INCH POUNDS PER TABLE 1 SPECS. UNDER NO CIRCUMSTANCE ALLOW ANY CAP FITTING OTHER THAN 639494 TO BE INSTALLED DURING ENGINE OPERATION." Following the installation, a complete fuel system leak check must be performed in accordance with the aircraft manufacturer's instructions. METEOROLOGICAL INFORMATION The closest official aviation weather was reported 30 miles west of Strom Field at Chehalis-Centralia Airport, Chehalis, Washington, at 1915 PDT. The following weather conditions were reported: visibility 10 statute miles, sky condition clear, temperature 13 degrees Centigrade, dew point 2 degrees Centigrade, wind from 340 degrees
The failure of maintenance personnel to properly secure a fitting cap on the throttle and metering assembly inlet after conducting a fuel system pressure check, which resulted in a loss of engine power due to fuel starvation. Contributing to the accident was the decision by the Director of Maintenance to return the airplane to service without verifying with the assigned inspector that all annual inspection items had been completed.
Source: NTSB Aviation Accident Database
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