CEN15LA239

NTSB accident investigation · Ayres S2R G6 · Tivoli, TX · May 20, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
May 20, 2015, 14:40 local (19:40 UTC)
Place
Tivoli, TX
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N3300UAyres S2R G6
Defining event
Landing: Nose over/nose down
Weather
Visual (VMC) · Day
Status
Completed · report November 19, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA, Woodward Inc, Honeywell Aerospace
FAA report
20150520023629A
Case key
91209

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 failure of the fuel control unit due to the worn stub shaft spline, which resulted in an engine overspeed. Contributing to the accident was maintenance personnel's inadequate inspection of the fuel control unit.

Findings · 3

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.

Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Fatigue/wear/corrosionAyres S2R-G6: 2 casesAll aircraft: 59 casesProbable cause
Engine fuel and control: fuel controlling systemAircraft › Aircraft power plant · Inadequate inspectionAyres S2R-G6: 2 casesAll aircraft: 59 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelAyres S2R-G6: 1 caseAll aircraft: 320 casesProbable cause

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 pilot reported that, during the accident flight, which was the twelfth aerial application flight of the day, the engine made an uncommanded power acceleration. The pilot retarded the throttle lever, but the engine did not respond. The pilot subsequently made a forced landing into a field, and the airplane nosed over and then came to rest inverted. A postaccident examination of the airplane revealed no anomalies with the engine rigging. Examination of the fuel control unit revealed that the stub shaft spline was worn beyond the allowable limits. Such wear can allow the fuel control underspeed governor to be driven at a lower speed than the engine speed, which can increase fuel flow and engine speed and is consistent with the uncommanded power acceleration that occurred during the accident flight. A review of the airplane's maintenance records revealed that, 2 months before the accident flight, the fuel control unit was inspected for wear and damage in accordance with an airworthiness directive (AD). It is unlikely that the wear observed during the postaccident examination could have occurred between the time of the AD inspection and the accident. It is likely that the AD was either not accomplished as noted in the maintenance records or that maintenance personnel inadequately conducted the inspection.

Factual narrative

On May 20, 2015, about 1440 central daylight time, an Ayres Corporation S2R-G6 agricultural airplane, N3300U, made a forced landing into a field following a loss of engine power near Tivoli, Texas. The commercial pilot, who was the sole occupant, sustained minor injuries and the airplane was substantially damage. The airplane was registered to AT Rental Properties and operated by AT Ag Services, LLC, Tivoli, Texas, under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed. The local flight originated from a private strip near Tivoli, Texas. The pilot reported that the accident flight was the twelfth aerial application flight of the day. He was carrying a load of fertilizer to the destination field when the engine made an uncommanded power acceleration. He noticed the engine temperature increase so he retarded the power lever, but the engine did not respond. The pilot jettisoned the load of fertilizer and shut off the fuel supply to the engine. He then made a forced landing into a field; during the landing the airplane nosed over and came to rest inverted. A postaccident examination of the airplane was conducted by the responding Federal Aviation Administration (FAA) inspector and a representative from Honeywell Aerospace. The examination revealed no anomalies with the engine rigging, but the engine's fuel control unit stub shaft spline appeared to be worn. No other anomalies were noted. On June 9, 2015, the fuel control unit was examined by Woodward, Inc., Loves Park, Illinois, with representatives from the NTSB, FAA, and Honeywell Aerospace. The examination revealed that the stub shaft spline was worn beyond the allowable limits. The internal spline was also checked using a specific go/no-go gauge, which should not fit between the teeth of the spline; the gauge rotated freely. This wear can allow the fuel control underspeed governor to be driven at a speed which is lower than the engine speed and subsequently increase fuel flow and engine speed. On August 24, 2006, the FAA issued Airworthiness Directive (AD) 2006-15-08, for Honeywell TPE331 series turboprop engines. The AD stated in part, "The AD results from reports of loss of the fuel control drive, leading to engine overspeed, overtorque, overtemperature, uncontained rotor failure, and asymmetric thrust in multi-engine airplanes. We are issuing this AD to prevent destructive overspeed that could result in uncontained rotor failure, and damage to the airplane." The AD specifies that Honeywell Service Bulletin (SB) TPE331-A73-0262 be used to accomplish the maintenance work. An excerpt from the SB: Initial Inspection of Engines with Affected FCU Assemblies (f) At the next scheduled inspection of the fuel control drive, but within 1,000 hours-in-service after the effective date of this AD: (1) Perform an initial dimensional inspection of the fuel controldrive for wear or damage. Information on spline inspection can be found in Section 72-00-00 of the applicable maintenance manuals. (2) Repair or replace the fuel pump, if the spline fails the dimensional inspection, with any serviceable fuel pump. (3) Repair or replace the FCU assembly, if the splines fail the dimensional inspection, with a serviceable modified FCU assembly. Repetitive Inspections of Engines with Affected FCU Assemblies (g) Thereafter, within 1,000 hours since-last-inspection: (1) Perform repetitive dimensional inspections of the fuel control drive, for wear or damage. Information on spline inspection can be found in Section 72-00-00 of the applicable maintenance manuals. (2) Repair or replace the fuel pump, if the spline fails the dimensional inspection, with any serviceable fuel pump. (3) Repair or replace the FCU assembly if the splines fail the dimensional inspection, with a serviceable modified FCU assembly. A review of the aircraft maintenance records revealed that AD 2006-15-08 was accomplished on March 16, 2015. The records noted that the AD inspection was to be completed again in 1,000 hours.

Aircraft

Registration
N3300U
Reported as
Ayres S2R G6
Category
Airplane
Serial number
G6-139
Built
1996
Engine
AiResearch TPE 331-10, turbo prop
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
A T Ag Services, LLC
Registered owner
A T Rental Properties LLC
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Continuous airworthiness · March 16, 2015
Departed
Tivoli, TX
Destination
Tivoli, TX

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
58
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
May 18, 2015
Seat
Single
Restraint
3-point
Flight hours
300 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 9 knots
Visibility
10 statute miles
Lowest ceiling
5,000 ft broken
Temperature
84 °F, dew point 73 °F
Altimeter
29.95 inHg
Observed at
KPKV, 17 nm away

Docket · 7

The files NTSB released with the investigation on October 21, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 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.