Aviation Accident Summaries

Aviation Accident Summary ERA16LA152

Bayport, NY, USA

Aircraft #1

N95118

PIPER PA 28-140

Analysis

The private pilot reported that, shortly after takeoff, the airplane's engine experienced a total loss of power. The pilot attempted to return to land at the airport, but the airplane was too low and struck trees and power lines; a postimpact fire ensued. Postaccident examination of the airplane revealed that the fuel selector valve was loose and did not fit securely into its respective detents. The valve was removed and exhibited blue-colored staining consistent with a fuel leak. The valve was disassembled, and numerous tool marks were observed on the valve cap, consistent with it having been disassembled many times. Removal of the valve's internal components revealed that they were not installed in the order outlined in the airplane's service manual. Additionally, the valve's components were worn; the position washer, which keeps the valve from rotating beyond the detents, was worn on both sides and appeared to have been inverted and reused rather than being replaced. According to the airplane's service manual, the fuel selector is to be inspected every 400 hours. The inspection requires the valve cap and the internal components to be removed and inspected, including the position washer, for signs of extreme wear. If the position washer exhibits such wear, it should be replaced. The valve was examined about 98.1 hours before the accident, at which time only an O-ring was replaced; at a minimum, the valve components' wear should have been evident at that time. The condition of the fuel selector and its internal components, particularly the position washer, is consistent with improper installation and maintenance, which allowed the fuel selector valve to be placed in a position between detents and resulted in fuel starvation to the engine.

Factual Information

On April 10, 2016, at 1907 eastern daylight time, a Piper PA-28-140, N95118, sustained substantial damage shortly after takeoff from Bayport Aerodrome (23N), Bayport, New York. The private pilot and the passenger were seriously injured. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight operated under Title 14 Code of Federal Regulations Part 91. The flight was originating at the time of the accident and destined for Orange County Airport (MGJ), Montgomery, New York.The pilot stated that the preflight inspection, engine run-up, and takeoff were normal. He said that when the airplane was about 300 ft mean sea level, he heard a "pop" and the engine sputtered before it completely stopped producing power. The pilot immediately checked the fuel selector valve, the magneto switch, the mixture control, and the carburetor heat, but they were all in their "proper positions." He then executed a forced landing to a road but collided with a set of power lines with the left wing. The airplane then impacted the ground and a postimpact fire ensued. The pilot estimated there were 37 gallons of fuel on board at the time he departed. According to eyewitnesses, the airplane's engine back-fired twice before it stopped producing power on takeoff. They watched as it then made a sweeping right turn, before it struck trees and power lines. The airplane came to rest in the middle of an intersection in a residential area. A post-impact fire ensued, and neighbors and responding rescue personnel assisted the pilot and passenger's egress from the burning airplane. The airplane sustained substantial damage to both wings, the firewall, the fuselage, and the tail section. A postaccident examination of the airplane revealed the flaps were in the fully retracted position. Flight control cable continuity was established from all major flight controls to the cockpit area. About 5-8 gallons of fuel were removed from the left-wing fuel tank and the right-wing fuel tank was breached. The engine crankshaft could not be rotated due to impact damage. Cylinder compression and valve train continuity could not be confirmed. Rather, the cylinders and pistons were removed, and mechanical continuity of the engine was established. The magnetos were removed from the engine. The ignition leads were removed due to thermal damage. Each magneto was spun and produced spark at all towers. The spark plugs were removed and compared to the Champion Check-A-Plug Chart. Each plug exhibited normal wear. The oil filler port sustained impact damage. A small amount of oil was drained from the oil suction screen area and some non-metallic debris was noted on the screen. The oil filter was removed and opened. The filter element was absent of debris. The carburetor remained on the engine but sustained impact and thermal damage. The butterfly valve in the heat box was open, consistent with the carburetor-heat being turned off. The carburetor was disassembled, and a small amount of fuel was in the bowl. The fuel was negative for water. The fuel inlet screen was removed and absent of debris. The engine-driven fuel pump was removed. When manually rotated, fuel was observed exiting the outlet of the pump and suction was confirmed at the inlet. A small amount of fuel was observed in the gascolator bowl and the screen was absent of debris. The electric fuel pump filter was removed. It was wet with fuel and absent of debris. Examination of the fuel selector valve appeared to be set to the "left" tank, but the cover had been damaged and partially torn away from the valve during impact. The pilot said the valve was set to the right tank when he took off. When the selector handle was moved, it was loose and the detents for the left and right tanks could not be easily felt. Blue-colored staining was also observed around the valve, consistent with a fuel leak. The valve was then tested in place by blowing shop air through the main fuel line from the engine. Air blew freely through the system on both the left and right tank positions. The fuel selector valve was removed and examined at the NTSB Materials Laboratory, Washington D.C. Numerous tool marks were observed on the valve cap consistent with it having been disassembled numerous times. The valve's internal components were removed and found to not be installed in the order outlined in the airplane's service manual. The valve's components were worn and the position-washer, which keeps the valve from rotating beyond the detents, was worn on both sides and appeared to have been inverted and reused. According to the airplane's service manual, the fuel selector valve was to be inspected every 400-hours. The inspection required the valve cap and the internal components to be removed and inspected, including the position washer for signs of extreme wear. If so, the washer should be replaced. A review of the airplane's maintenance logbook revealed that the last inspection of the fuel selector valve was made on June 22, 2013, at an airframe total time of 11,966.14 hours. At that time, only a new "O-ring" was replaced in the fuel selector valve. A review of the airplane and engine maintenance manuals revealed the last annual inspection was completed on November 9, 2015. At the time of the accident, the airplane had accrued a total of 12,064.24 hours and the engine had accrued about 2,020 hours. The pilot held a private pilot certificate with a rating for airplane single-engine land. He reported a total of 85 hours, of which, 25 hours were in the same make/model airplane as the accident airplane. His last Federal Aviation Administration (FAA) third-class medical was issued on April 30, 2012. Toxicological testing of the pilot's initial blood draw taken upon his admission to the hospital and tested by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified 0.0123 ug/ml of tetrahydrocannabinol carboxylic acid (THC-COOH), the primary inactive metabolite of THC, the main psychoactive component in marijuana. However, no THC was identified. This finding is consistent with the pilot having used marijuana at some point preceding the accident but was no longer being impaired by its effects when the accident occurred. At 1856, weather at Long Island McArthur Airport (ISP), New York, New York, about 3 miles west of the accident site, was reported as wind from 180 degrees at 12 knots, visibility 10 miles, few clouds at 15,000 ft, broken clouds at 26,000 ft, temperature 43° F, dewpoint 25° F, and an altimeter setting of 30.30 inHg. The carburetor icing probability chart from the FAA Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, June 30, 2009, shows a probability of icing at cruise/glide power at the temperature and dew point reported at the time of the accident.

Probable Cause and Findings

Maintenance personnel’s improper installation and maintenance of the fuel selector valve, which resulted in a total loss of engine power due to fuel starvation.

 

Source: NTSB Aviation Accident Database

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