# NTSB CEN12LA348: Piper PA-22-135, N3431A, Bangor, MI, June 6, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 6, 2012, 10:15 local (14:15 UTC) - Place: Bangor, MI - Coordinates: 42.309505, -86.110992 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.3095&lon=-86.1110&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report September 5, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA - Grand Rapids FSDO - NTSB case key (mKey): 83893 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA348 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83893/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83893 - Page: https://openairdocs.org/ntsb/CEN12LA348 ## Probable cause The pilot’s failure to properly service the fuel system, and subsequent decision to conduct the flight with known fuel system deficiencies, which led to the total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel filter-strainer](https://openairdocs.org/ntsb-findings/01022821): Aircraft › Aircraft systems · Not serviced/maintained (probable cause); cases with it: [Piper PA-22-135, 1 case](https://openairdocs.org/ntsb-findings/01022821/cases.md?model=7102206), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/01022821/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-22-135, 9 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102206), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Not serviced/maintained (probable cause); cases with it: [Piper PA-22-135, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=7102206), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Maintenance](https://openairdocs.org/ntsb-findings/02062000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-22-135, 1 case](https://openairdocs.org/ntsb-findings/02062000/cases.md?model=7102206), [All aircraft, 143 cases](https://openairdocs.org/ntsb-findings/02062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-22-135, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102206), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Piper PA-22-135, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102206), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-22-135, 17 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102206), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis On the day before the accident, the owner/pilot made a forced landing to a field due to a loss of engine power. No damage was incurred during that event. Examination of the airplane after the off-airport landing revealed that the gascolator screen was almost completely plugged by a flaky, shellac-type material. The airplane had a history of automotive fuel use, and the inspector who examined the airplane told the pilot that he should have a local mechanic do a thorough fuel system evaluation and flushing before further flight. He reminded the pilot that there were screens in the fuel tanks, carburetor, and in the belly sump that should be checked and cleaned. On the day of the accident flight, the pilot and a local mechanic added fuel to the right fuel tank and performed fuel flow tests. The pilot then attempted to take off, and the engine stopped producing power. The airplane impacted the ground in a left turn and nosed over. Examination of the airplane after the accident revealed that the carburetor and gascolator screens were 50 percent obstructed. Neither the pilot nor the mechanic indicated in their postaccident statements that the gascolator, carburetor, or fuel tank screens were checked or that the fuel system was flushed to remove the residual fuel system contaminants. Based on the available evidence, it is likely that the engine power loss was due to the obstruction of the fuel system screens, which prevented adequate fuel flow to the engine. ## Factual narrative On June 6, 2012, about 1015 eastern daylight time, a Piper PA-22-135, N3431A received substantial damage when it impacted the ground and nosed over after it was unable to climb after takeoff from an unimproved field near Bangor, Michigan. The private pilot received serious injuries. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight was originating at the time of the accident and was destined for the South Haven Area Regional Airport (LWA), South Haven, Michigan. On the day prior to the accident, June 5, 2012, the pilot was flying the airplane to LWA when he experienced a loss of engine power and executed a forced landing into a field. The airplane was not damaged during the off-airport landing. On the day of the accident, the pilot was attempting to take off from the same field in order to continue to LWA. The pilot reported that after takeoff, the engine stopped producing power and he was attempting to return to the field. The airplane was in a left turn when it struck the ground. The pilot reported that he had added fuel to the right fuel tank and accomplished fuel flow tests on the ground prior to the accident. He stated that the fuel flow from the left tank was not adequate, but flow from the right tank was. He stated that he ran the engine for about 20 minutes on the right tank at high power settings before the attempted flight. A local mechanic who was a witness to the accident reported that the owner enlisted his help to rectify a fuel flow issue. He stated that on the morning of the accident, they added 10 gallons of fuel to the right fuel tank. They then removed the gascolator bowl and timed the fuel flow. The left tank took 7 minutes to flow one gallon of fuel and the right tank took 6 minutes to flow one gallon of fuel. They then performed a run-up to full power on both fuel tanks. He stated that the pilot then attempted to take-off. He said the airplane was slow to clear the ground and gain altitude. It then turned left and descended at which point the witnesses view was obstructed by terrain. A postaccident examination of the airplane after the landing in the field on June 5, 2012, confirmed that the airplane was not damaged. The gascolator screen was found to be almost completely plugged by a flaky shellac type material. The owner reported to the Federal Aviation Administration (FAA) inspector that the airplane had a long history of auto fuel use and that he had been getting the shellac type material from the fuel sumps on the airplane. The inspector and the owner discussed that the owner would get a local mechanic and do a thorough fuel system evaluation and flushing before further flight. The inspector reminded the pilot that there were screens in the fuel tanks, carburetor, and in the belly sump that should be checked andcleaned. A second examination of the airplane after the accident on June 6, 2012 revealed that the gascolator and the carburetor inlet screens were about 50 percent restricted. Neither the pilot nor the mechanics report made mention of having performed a flushing of the fuel system or checking/cleaning of the fuel tank screens in the fuel tanks, carburetor, or gascolator. ## Aircraft - Registration: [N3431A](https://openairdocs.org/deregistered/N3431A-2012-10-02), registration cancelled 2012-10-02, S/N 22-1700, built 1953 (OpenAirDocs) - Reported make and model: PIPER PA-22-135 - Registry model: [Piper PA-22-135](https://openairdocs.org/model/piper-pa-22-135) (registry code 7102206) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 22-1700 - Airframe hours: 3784 - Engines: LYCOMING 0-290 SERIES 135 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 6, 2011 - Departed: Bangor, MI - Destination: LWA, South Haven, MI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 15, 2012; seat: left; flight hours: 5,000 total, 1,500 in this make and model, 5,000 as pilot in command, 9 in the last 90 days, 9 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F, dew point 52 °F - Altimeter: 30.09 inHg - Observed at: LWA, 5 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20120606010599A](https://openairdocs.org/incident/20120606010599A), Jun 6, 2012: Piper PA-22-135, Bangor, MI, Substantial damage. Pilot had made a precautionary landing in a field the prior day due to a power loss. Examination revealed the gascolator screen was restricted with shellac… ## Docket (3 files) The files NTSB released with the investigation on June 26, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83893. 956 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 673 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394228&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement (item 2, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394229&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - FAA inspector's Statement (item 3, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40394230&FileExtension=.PDF&FileName=FAA%20inspector%27s%20Statement-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.