ANC06LA021

NTSB accident investigation · Piper PA-32R-300 · Winslow, AZ · March 4, 2006

Accident · Minor injuriesLimited investigationFinal report
Date
March 4, 2006, 14:45 local (21:45 UTC)
Place
Winslow, AZ
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8322CPiper PA-32R-300
Weather
Visual (VMC) · Day
Status
Completed · report April 25, 2007
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Textron Lycoming, Federal Aviation Administration
FAA report
20060304030959A
Case key
63302

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The presence of a foreign material/substance in the fuel system, which partially blocked the fuel flow divider, and resulted in a loss of engine power during takeoff-initial climb, and an emergency landing. A factor associated with the accident was unsuitable terrain for a forced landing.

Analysis

The certificated private pilot, with one passenger, was on a cross-country personal flight under Title 14, CFR Part 91. Just after takeoff, when the airplane was about 200 feet above the ground, the engine began to run rough and lose power. Emergency procedures did not restore power, and the airplane collided with a barbwire fence during an off-airport forced landing, sustaining substantial damage to the wings, fuselage, and empennage. The airplane was equipped with a recently installed factory-remanufactured Textron Lycoming IO-540 engine. Postaccident investigation revealed a grayish, soft, rubbery material partially blocking the ports of the fuel flow divider's metering pin. There was no debris discovered in the interior of the fuel injector servo, or in the fuel injector's inlet screen. According to a representative of Textron Lycoming, fuel system components on factory-remanufactured engines are shipped separately. It is the responsibility of the receiving maintenance technician to install the fuel system components on the engine, and ensure that no debris enters the fuel line or fuel flow divider during the installation process. A Safety Board senior metallurgist who examined the gray foreign material was unable to identify the source, but reported it consisted of agglomerations of smaller particles, consistent with a Teflon-like material. The Safety Board metallurgist also reported that the rubbery material was not consistent with fuel supply line material, and no additional debris was found inside the fuel line or within the fuel injector servo.

Factual narrative

The factual narrative733 words

On March 4, 2006, about 1445 mountain standard time, a Piper PA-32R-300 airplane, N8322C, sustained substantial damage following a loss of engine power and subsequent forced landing, about 2 miles south of the Winslow-Lindbergh Regional Airport, Winslow, Arizona. The airplane was being operated as a visual flight rules (VFR) cross-country personal flight under Title 14, CFR Part 91, when the accident occurred. The certificated private pilot and the sole passenger sustained minor injuries. Visual meteorological conditions prevailed, and a VFR flight plan was in effect. The intended routing of the flight was from Lincoln, Nebraska, to Palm Springs California, with a fuel stop in Winslow. The accident flight originated at the Winslow-Lindbergh Regional Airport, Winslow, about 1445.

During a telephone conversation with the National Transportation Safety Board investigator-in-charge on March 4, the pilot reported that after completing the uneventful flight between Lincoln and Winslow, he purchased about 50 gallons of fuel, and then departed on the final flight leg to Palm Springs. He said that just after takeoff, when the airplane was about 200 feet above the ground, the engine began to run rough, and lose power. The pilot said that after performing the engine emergency procedures, he was unable to restore sufficient engine power to sustain flight, and he selected a forced landing area among rolling hills. He stated that during the emergency descent, just before touch down, all engine power was lost. During the forced landing roll, the airplane struck a barbwire fence, pivoted to the left, and collapsed the main landing gear. The airplane sustained substantial damage to the wings, fuselage, and empennage.

According to the pilot/owner, the airplane was equipped with a recently installed factory-remanufactured Textron Lycoming IO-540 engine. The pilot's maintenance provider located in Lincoln preformed the engine installation, about 20 hours before the accident.

The airplane was retrieved from the accident site and transported to Phoenix, Arizona.

On March 24, 2006, a Federal Aviation Administration (FAA) airworthiness inspector from the Scottsdale Flight Standards District Office, along with an air safety investigator from Textron Lycoming, conducted an engine exam and test run of the accident engine. The FAA inspector reported that the engine remained attached to the airframe, and once the engine was started, it ran rough and would not produce full power. A subsequent internal inspection of the engine's fuel flow divider revealed a grayish, soft, rubbery material partially blocking the ports of the flow divider's metering pin.

The recovered material, along with the fuel flow divider, fuel injector servo, and a portion of fuel line that connected the fuel injector servo to the fuel flow divider fuel supply line, was sent to the National Transportation Safety Board's Materials Laboratory for examination. A Safety Board senior metallurgist reported that the grayish-colored rubbery material consisted of agglomerations of smaller particles, consistent with Teflon like material, showing a significant fluorine elemental peak. Each mass measured less than 0.06 inches in maximum dimension with individual particles estimated to be a few thousands of an inch in size, which would break apart into smaller clumps when probed. The metallurgist reported that the rubbery material was not consistent with the fuel supply line material, and no additional debris was found inside the fuel line or within the fuel injector servo. There was no debris discovered in the interior of the fuel injector servo, or in the fuel injector's inlet screen.

A senior manager for Textron Lycoming's materials laboratory reported to the NTSB that when factory-remanufactured engines are shipped, the fuel injector servo assembly is not installed on the engine. He said that once the engine has been test-run at the factory, and before the engine is shipped to the customer, or to the customer's maintenance provider, the fuel injector servo is removed from the engine, and placed inside the engine-shipping crate. He stated that the fuel flow divider assembly remains attached to the engine, and that the fuel line which connects the fuel flow divider and the fuel injector servo, remains connected to the fuel flow divider. The other end of the fuel line is then capped-off during shipment. It is the responsibility of the maintenance technician to install the fuel control servo on the engine, connect the fuel line, and ensure that no debris enters the fuel line or fuel flow divider during the process.

The Safety Board released the fuel system components to the owner's representatives on November 13, 2006.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - nonmechanicalTakeoff - initial climb
Fuel system,fuel flow divider/distributor - blocked(partial)Cause
Fuel system - foreign material/substanceCause
Forced landingEmergency landing after takeoff
Terrain condition - none suitableFactor
On ground/water collision with objectEmergency landing
Object - fence

Aircraft

Registration
N8322C
Reported as
Piper PA-32R-300
Category
Airplane
Serial number
32R-7680093
Airframe hours
6,679
Engine
Lycoming IO-540-KIA5D, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Ronald D. Craig
Registered owner
Ronald D. Craig, Trustee, Bruce A. Miller
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 1, 2006 · 20 hours before
Departed
KINW · Winslow, AZ
Destination
KPSP · Palm Springs, CA
Flight plan
VFR
Airport
KINW · Winslow-Lindbergh Regional, runway 22, 7,499 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 1, 2004
Seat
Left
Flight hours
2,839 total · 1,900 in this make and model · 2,464 as pilot in command · 24 in the last 90 days · 11 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 15 knots
Visibility
10 statute miles
Lowest ceiling
None

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N8322C · 1

Matched to the same aircraft by N-number and date.