CEN15LA226

NTSB accident investigation · Air Tractor AT 502B · Dighton, KS · May 10, 2015

Accident · No injuriesLimited investigationFinal report
Date
May 10, 2015, 09:11 local (14:11 UTC)
Place
Dighton, KS
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N879JAAir Tractor AT 502B
Defining event
Initial climb: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration - Wichita FSDO
FAA report
20150510006669A
Case key
91152

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

On this page

Probable cause

The pilot's failure to follow the Preflight checklist and his inadequate preflight inspection, during which he failed to detect the water contamination of the fuel, which resulted in a partial loss of engine power during initial climb.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionAir Tractor AT-502B: 4 casesAll aircraft: 1,695 casesProbable cause
Fuel systemAircraft › Aircraft systems · Inadequate inspectionAir Tractor AT-502B: 2 casesAll aircraft: 181 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotAir Tractor AT-502B: 1 caseAll aircraft: 551 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotAir Tractor AT-502B: 2 casesAll aircraft: 336 casesProbable cause
Terrain: wet/muddy terrainEnvironmental issues › Physical environment · Contributed to outcomeAir Tractor AT-502B: 1 caseAll aircraft: 110 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot stated that he did not observe any anomalies during his preflight inspection or during his before-takeoff engine run-up. The pilot was departing on a positioning flight when the engine lost partial power during initial climb. The pilot's corrective actions did not restore full engine power, so he made a forced landing to a nearby muddy field. The pilot reported that, after the accident, the engine continued to run with a gas generator speed of about 35% and that he cut fuel flow to the engine to shut it down. Postaccident engine examination revealed no evidence of a mechanical malfunction that would have precluded normal operation; however, an examination of the fuel system revealed water contamination in multiple tanks and filters. Laboratory testing showed that the observed water contamination exceeded the allowable limits for aviation turbine fuel. Given the amount of water contamination observed after the accident, it is likely the pilot did not adequately check the fuel condition at both wing fuel tanks, header fuel tank sump, and the fuel valve sump as required by the airplane flight manual's Preflight checklist.

Factual narrative

On May 10, 2015, about 0911 central daylight time, an Air Tractor AT-502 airplane, N879JA, collided with terrain during a forced landing following a partial loss of engine power shortly after takeoff from Dighton Airport, Dighton, Kansas. The commercial pilot was not injured, and the airplane was substantially damaged. The airplane was registered to and operated by Jordan Air Inc. under the provisions of Title 14 Code of Federal Regulations Part 91 as a positioning flight without a flight plan. Day visual meteorological conditions prevailed for the cross-country flight that had an intended destination of Dodge City Regional Airport, Dodge City, Kansas.The pilot reported that he observed no anomalies during his preflight inspection of the airplane or during his before-takeoff engine runup. The airplane was last fueled (topped-off) a couple of days earlier at another airport and was not refueled before the accident flight. The pilot stated that the engine produced full torque and speed during the takeoff from runway 35, and that he made a left turn shortly after liftoff to avoid a powerline located about 400 yards north of the runway. The pilot stated that the airplane experienced a partial loss of engine power shortly after he made an initial power reduction during initial climb. His corrective actions did not restore full engine power, so he made a forced landing to a nearby muddy field. The pilot reported that the engine continued to run after the accident with a gas generator speed of about 35%. The pilot stopped the engine by turning off the electric fuel pump, repositioning the fuel valve to OFF, and moving the condition lever to the fuel cutoff position. On May 11, 2015, a Federal Aviation Administration (FAA) maintenance inspector with the Wichita Flight Standards District Office examined the wreckage. The wreckage had been recovered to the departure airport before the examination. The FAA inspector reported that the right wing, aft fuselage, and tail were substantially damaged during the forced landing. A fuel sample obtained from the fuel control unit inlet filter revealed evidence of water contamination. Additional fuel samples were obtained from both wing fuel tanks and the firewall-mounted primary fuel filter. These additional samples initially appeared to be free of any water contamination on the day of the examination; however, over the next two days the fuel samples became opaque with a yellow tint. The FAA Inspector noted that the airplane was in an abnormal attitude when the wing tanks were drained and, as such, the samples were not likely representative of the fuel found at the lowest point of each wing fuel tank in a normal ramp attitude. On May 13, 2015, the wreckage salvage company reported that after moving the airplane they observed contaminated fuel with an orange/red color in both wing tanks and the firewall-mounted primary fuel filter. An engine examination revealed no evidence of a mechanical malfunction that would haveprecluded normal operation. At the request of the National Transportation Safety Board (NTSB) investigator, the wreckage salvage company obtained fuel samples from the header tank and the fuselage-mounted primary fuel filter. These fuel samples were submitted to the National Institute of Standards and Technology's Applied Chemicals and Materials Division, Boulder, Colorado, for laboratory testing. A visual examination of the fuel samples revealed two immiscible liquid phases in their respective containers; the top phase was consistent with a hydrocarbon while the bottom phase appeared to be aqueous. The top and bottom layers of the header tank sample were clear and colorless. The top layer of the primary fuel filter sample was clear and colorless, and the bottom layer was a pale brown or orange color with similarly colored fine precipitate on the bottom of the container. The initial boiling temperature for the bottom layer of each sample was consistent with water. The initial boiling temperatures for the top layer of each sample was consistent with aviation turbine fuel. Volatility measurements using the advanced distillation curve (ADC) method confirmed that the top hydrocarbon layer of each sample was consistent with aviation turbine fuel. The water concentration was about 162 parts per million (ppm) and 160 ppm for the hydrocarbon layer of the primary fuel filter sample and header tank sample, respectively. The specified limit for water concentration in aviation turbine fuel is 30 ppm. Volatility measurements for the lower aqueous layer of each sample was consistent with water, and the water concentration was about 93% and 100% for the aqueous layer of the primary fuel filter sample and header tank sample, respectively. The Air Tractor AT-502B Airplane Flight Manual specifies that during a preflight inspection a pilot should obtain a fuel sample from both wing fuel tank sumps, header fuel tank sump, and the fuel valve sump.

Aircraft

Registration
N879JA
Reported as
Air Tractor AT 502B
Category
Airplane
Serial number
502B-2879
Built
2013
Engine
Pratt & Whitney Canada PT6A-34AG, 750 horsepower, turbo prop
Damage
Substantial damage
Flight
Positioning · Part 91
Operator
Jordan Air, Inc.
Registered owner
Jordan Air, Inc.
Airworthiness certificate
Special, Restricted (Special)
Departed
K65 · Dighton, KS
Destination
DDC · Dodge City, KS
Airport
K65 · Dighton Airport

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
48
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 15, 2014
Seat
Center
Restraint
5-point
Flight hours
11,525 total · 500 in this make and model · 11,242 as pilot in command · 200 in the last 90 days · 150 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 23 knots, gusting 28
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 34 °F
Altimeter
29.87 inHg
Observed at
GCK, 36 nm away

Docket · 6

The files NTSB released with the investigation on October 2, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.7 MB in all.

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 N879JA · 1

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