Reno, NV, USA
N4027W
PIPER PA 32-300
The private pilot, who owned the airplane and also partially owned the maintenance facility, arrived at the maintenance facility with his flight instructor on the day of the accident for a cross-country instructional flight to accomplish an insurance checkout requirement. He removed the airplane from the hangar without discussing it with the maintenance team. The pilot and flight instructor did not observe any anomalies during the engine run-up; they then departed with the pilot flying. During the initial climb, the engine experienced a total loss of power, at which point the instructor took control of the airplane to return to the airport. The pilot subsequently reclaimed the controls after he observed the stall warning light. He then lowered the nose and flared when the airplane was over a gravel area. The airplane impacted the ground, slid, and came to rest between two taxiways. Examination of the fuel sump revealed several ounces of fuel that resembled low lead aviation-grade gasoline that did not contain any water contamination or debris. During the postaccident engine examination, the engine was tested and started normally. The throttle was advanced to three separate power settings and, when the fuel pump was engaged, an excessive quantity of fuel was expelled from the engine-driven fuel pump hose. The engine-driven fuel pump was examined and tested. The examination revealed wear on the drive shaft and pinion. Further, the unit failed the external leakage and seal leakage tests, as flow testing showed that the seal behind the drive pinion leaked profusely. While the pump failed two discharge pressure tests, it functioned during each test and failed by a margin of 3%. A photograph revealed that the fuel pump inlet line was disconnected from the fuel pump. The mechanic who was responsible for the disconnected inlet line reported that he had been asked to install an engine monitor on the accident airplane but did not have the required equipment to complete the installation of the fuel flow sending unit the day before the accident; he chose to secure the inlet line fitting to the pump without applying the required torque until he could complete the work. Although the mechanic subsequently misinformed the director of maintenance (DOM) that the fuel line had been tightened, the DOM had not returned the airplane to service when the pilot came to retrieve the airplane. The pilot never asked the mechanic if the airplane had been returned to service or was ready to fly. The examination did not reveal any other mechanical malfunctions or failures that would have precluded normal operation. Thus, the loss of engine power was most likely due to fuel starvation as a result of fuel being expelled from the unsecured fuel pump inlet line.
HISTORY OF FLIGHTOn January 17, 2018, about 1520 Pacific standard time, a Piper PA-32-300 airplane, N4027W, was substantially damaged when it impacted the ground shortly after takeoff from Reno/Tahoe International Airport (RNO), Reno, Nevada. The private pilot and flight instructor were not injured. The airplane was registered to and operated by the private pilot under the provision of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed, and no flight plan was filed for the cross-country flight which was originating at the time of the accident. The flight was destined for Hawthorne Industrial Airport (HTH), Hawthorne, Nevada. According to the flight instructor, who was the pilot-in-command (PIC) at the time of the accident, he was providing instruction to the pilot to satisfy a checkout requirement imposed by his insurance company. Prior to takeoff, a weight and balance computation were performed, the fuel quantity was visually inspected, the oil quantity was verified, and a walk-around inspection of the airplane's control surfaces was accomplished. Both main fuel tanks had been filled to their capacity and some residual fuel remained in the auxiliary tanks. After an uneventful engine start, the instructor contacted ground control who directed him to taxi to runway 16L. The instructor reported that he followed the airplane's "before takeoff" checklist and performed an engine run-up to 2,000 rpm, at which time he leaned the fuel/air mixture about 50° rich of peak to accommodate a departure from a high field elevation. The instructor and pilot observed a drop of about 100 rpm when they selected each magneto. During this time, the analog fuel pressure gauge was normal, and the JP Instruments, Inc. engine monitor appeared to be operational. The instructor then set 10° of wing flaps, verified the fuel selector was on the left main fuel tank and turned the auxiliary fuel pump on. The pilot, who occupied the left seat, performed the takeoff and initial climb, which were uneventful; however, when the airplane reached an altitude about 300 ft above ground level, a total loss of engine power occurred. According to the instructor, the engine stopped firing rapidly with no pre-indication. The pilot then transferred the controls to the instructor and declared an emergency to air traffic control, who cleared them to land on runway 16R. The instructor started a turn to the right over runway 16R, but quickly determined the airplane would not be able to land on the remaining runway and continued the turn. Despite their previous agreement that the instructor would control the airplane in an emergency, the pilot took the controls back from the instructor after the airplane's stall warning light appeared during the descent. The flight instructor did not recall any details beyond the illumination of the stall warning light. The pilot subsequently lowered the nose and flared when the airplane was over a gravel surface. During touchdown, the airplane impacted the gravel, slid, and came to rest between taxiways "A" and "B." PERSONNEL INFORMATIONThe 67-year-old flight instructor held a flight instructor certificate with ratings for single-engine land and instrument airplane. The instructor's most recent second-class medical certificate was issued on July 18, 2016, which included the limitation, "must wear glasses." According to the instructor he had accumulated 916 hours of total flight time in all aircraft, of which 38 hours was in the accident airplane make and model. The 44-year-old private pilot held a private pilot certificate with a rating for single-engine land. His most recent third-class medical certificate was issued on February 27, 2017, which did not include any limitations. According to the pilot, he had accumulated a total of 110 hours of flight time in all aircraft, and no time logged in the accident airplane make and model. AIRCRAFT INFORMATIONThe airplane was powered by a Lycoming IO-540-K1G5D, a normally-aspirated, direct-drive, air-cooled, 300-horsepower engine. Aircraft logbooks furnished by the pilot showed that the airplane's most recent annual inspection was completed on December 1, 2017, at which time the airplane had accumulated 5,979 total flight hours. The entry listed a tachometer time of 747.1 flight hours at the time of the inspection. At the time of the airplane's most recent service, the engine had accrued a total of 1,231.6 hours since major overhaul. The pilot reported that he purchased the accident airplane in December 2017, and on the day of the accident, he had planned to fly with his instructor and observe the performance of a recently installed engine monitor. An airframe and powerplant mechanic employed by Advanced Aviation Reno, Inc., the maintenance facility partially owned by the pilot of the accident airplane reported that he had been asked to install a JP Instruments engine monitor in the accident airplane. The day before the accident, the company received fittings for the fuel flow sending unit portion of the assembly; however, the fittings were not the correct size for the fuel pump inlet line. The mechanic informed his director of maintenance of the error and then reinstalled the fuel line with a stubby wrench and reported to the director of maintenance that the fuel line had been tightened. He did not re-torque the fitting, as he was under the impression that the installation would be completed before the airplane was returned to service. When the pilot came to retrieve the airplane, the mechanic was working on another aircraft and had assumed the pilot was not going to fly the airplane. According to the fitting manufacturer, the line must be torqued between 135 – 90 lb/in. The director of maintenance corroborated the mechanic's statement and further added that he didn't know the airplane had been returned to service or even left the hangar. According to JP Instrument, Inc's website, the installation of the JPI unit requires the completion of an FAA Form 337 major alteration/repair under Federal Regulations Part 43 appendix A. A major alteration requires the signature of a mechanic who holds inspection authorization (IA) in the aircraft logbook. According to the mechanic, the director of maintenance was the only IA mechanic at the time the service was completed, as the company's other IA had not been to work in at least a month. The pilot stated that he didn't know if the mechanic knew they had planned to fly the airplane. He never asked the mechanic if the airplane had been returned to service or was ready to fly. AIRPORT INFORMATIONThe airplane was powered by a Lycoming IO-540-K1G5D, a normally-aspirated, direct-drive, air-cooled, 300-horsepower engine. Aircraft logbooks furnished by the pilot showed that the airplane's most recent annual inspection was completed on December 1, 2017, at which time the airplane had accumulated 5,979 total flight hours. The entry listed a tachometer time of 747.1 flight hours at the time of the inspection. At the time of the airplane's most recent service, the engine had accrued a total of 1,231.6 hours since major overhaul. The pilot reported that he purchased the accident airplane in December 2017, and on the day of the accident, he had planned to fly with his instructor and observe the performance of a recently installed engine monitor. An airframe and powerplant mechanic employed by Advanced Aviation Reno, Inc., the maintenance facility partially owned by the pilot of the accident airplane reported that he had been asked to install a JP Instruments engine monitor in the accident airplane. The day before the accident, the company received fittings for the fuel flow sending unit portion of the assembly; however, the fittings were not the correct size for the fuel pump inlet line. The mechanic informed his director of maintenance of the error and then reinstalled the fuel line with a stubby wrench and reported to the director of maintenance that the fuel line had been tightened. He did not re-torque the fitting, as he was under the impression that the installation would be completed before the airplane was returned to service. When the pilot came to retrieve the airplane, the mechanic was working on another aircraft and had assumed the pilot was not going to fly the airplane. According to the fitting manufacturer, the line must be torqued between 135 – 90 lb/in. The director of maintenance corroborated the mechanic's statement and further added that he didn't know the airplane had been returned to service or even left the hangar. According to JP Instrument, Inc's website, the installation of the JPI unit requires the completion of an FAA Form 337 major alteration/repair under Federal Regulations Part 43 appendix A. A major alteration requires the signature of a mechanic who holds inspection authorization (IA) in the aircraft logbook. According to the mechanic, the director of maintenance was the only IA mechanic at the time the service was completed, as the company's other IA had not been to work in at least a month. The pilot stated that he didn't know if the mechanic knew they had planned to fly the airplane. He never asked the mechanic if the airplane had been returned to service or was ready to fly. ADDITIONAL INFORMATIONThe airplane was examined by representatives of the manufacturer with oversight from the NTSB Investigator-in-Charge. Examination of the fuel sump revealed several ounces of fuel that resembled 100 low lead aviation grade gasoline that did not contain any water contamination or debris. The fuel selector was moved through its detents and the auxiliary fuel pump motor was audible when the pump was engaged at the cockpit. The airplane was then moved to an open area outside of the owner's hangar and secured with wheel chocks and a tether to facilitate an engine run; the engine was run with its original propeller. Approximately three gallons of 100 low lead aviation grade gasoline was deposited into the left tip tank. The airplane started normally and was set at idle power (~1,000 rpm) for about one minute before the test began. The throttle was then advanced to three separate power settings: 1,600 rpm, 1,900 rpm, then 2,600 rpm. The fuel pump was engaged during engine runs at the first two power settings. During the test run, an excessive quantity of fuel was expelled from the engine driven fuel pump hose. However, the results showed that the engine could achieve a maximum power of 2,600 rpm. According to the airplane flight manual, the airplane's published maximum power is 2,700 rpm. The engine driven fuel pump, manufactured by Lear Romec, was examined and tested by the manufacturer under the supervision of the FAA. The examination revealed wear on the drive shaft and pinion. Further, the drive pinion rotated freely about 40°; a newly manufactured pump would rotate less than 10°. The unit failed the external leakage and seal leakage tests, as flow testing showed that the seal behind the drive pinion leaked profusely. While the pump failed two discharge pressure tests, it functioned during each test and failed by a margin of 3%.
A total loss of engine power due to fuel starvation. Contributing to the accident was the failure of the pilot/owner to ensure that the airplane was airworthy before flight.
Source: NTSB Aviation Accident Database
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