CEN17LA009

NTSB accident investigation · Aero Smart Solutions Lancair Evolution · Iola, KS · October 1, 2016

Accident · Minor injuriesLimited investigationFinal report
Date
October 1, 2016, 17:35 local (22:35 UTC)
Place
Iola, KS
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N38DMAero Smart Solutions Lancair Evolution
Defining event
Enroute-climb to cruise: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed · report August 3, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20161001021179A
Case key
94133

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

Water contamination of the fuel due to the pilot’s inadequate preflight inspection, which led to a total loss of engine power. Contributing to the accident was the pilot’s failure to complete the engine-out checklist, which resulted in an excessive loss of altitude and the inability to glide to the intended airport.

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.

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 was flying the airplane in cruise flight at 11,000 ft when the engine lost power. He attempted to restart the engine by switching fuel tanks, turning on the igniters, and holding down the start button but was unsuccessful. He elected to turn back toward the departure airport and feathered the propeller. During the descent, the pilot decided he was unable to make it back to the airport and conducted a forced landing on a dirt road. During the landing rollout, both wings struck trees, which resulted in substantial damage. Examination of the flight controls, engine, and fuel systems revealed no mechanical malfunctions or failures that would have precluded normal operation. However, fuel samples recovered from the airplane tested positive for water. Data recovered from the engine monitor showed an abrupt power loss that coincided with a loss of fuel flow. The flight instructor who completed transition training with the pilot reported the pilot did not sump the fuel before every flight. Thus, it is likely that the pilot did not perform an adequate preflight inspection and water remained in the fuel system, which led to a total loss of engine power. The pilot's operating handbook (POH) recommended that the configuration for a forced landing is landing gear up, flaps up, propeller feathered, and airspeed at 110 knots to achieve maximum glide performance. This configuration provides a maximum glide performance of about 500 ft per minute (fpm) descent and about 3.5 nautical miles glide distance per 1,000 ft of altitude lost. Data from the engine monitoring system revealed that, about 3 minutes after the fuel flow stopped and about 2-3 minutes before the accident, the flaps were extended to takeoff position, the airplane achieved 110 kts, and the propeller was feathered. During this time, the rate of descent exceeded 1,000 fpm and was, at times, in excess of 4,000 fpm. The pilot did not mention of the use of an emergency engine-out checklist or consultation of the POH during the event. The pilot's failure to accomplish all of the steps in the emergency engine-out checklist promptly after the loss of engine power led to an accelerated loss of altitude and the subsequent inability to glide to the airport.

Factual narrative

According to the POH, the recommended configuration for a forced landing is landing gear up, flaps up, propeller feathered, and airspeed at 110 knots. This configuration provides a maximum glide performance of about 500 fpm descent, an 18:1 glide ratio, and about 3.5 nm glide distance per 1,000 ft of altitude lost. Pratt & Whitney Service Bulletin 12144, Turboprop Engine Fuels and Additives - Requirements and Approved Listing, states, "Fuel shall consist solely of hydrocarbon compounds except as otherwise specified herein. It shall be free from water, sediment, and suspended matter, and shall be suitable for use in aircraft turbine engines." The Lancair Evolution Pilot Operating Handbook (POH) highlights the importance of sumping fuel and checking fuel quality on preflight and after refueling. The POH states, "The fuel system feeds fuel to the engine through a fuel screen pickup, fuel selector, gascolator/fuel filter, electric boost pump ad finally a fuel control unit. The fuel tanks should be sumped at regular intervals." Fuel sumping is also called for in the preflight inspection checklist contained in the POH. On October 1, 2016, about 1735 central daylight time, an Aero Smart Solutions Lancair Evolution airplane, N38DM, experienced a total loss of engine power during cruise flight. The pilot made a forced landing onto a roadway near Iola, Kansas. The private pilot was not injured and the passenger suffered minor injuries. The airplane was registered to, and operated by, Aero Smart Solutions, Inc. under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, and an instrument flight rules flight plan was filed. The pilot stated he had just departed after stopping to refuel at Allen County Airport (K88) in Iola, Kansas. Shortly after departure, air traffic control (ATC) cleared the pilot to his destination of Ogden-Hinckley Airport (OGD) in Ogden, Utah. The pilot reported he switched from the left fuel tank to the right fuel tank, he did not recall when he made the switch. Around 11,000 ft, the pilot heard the pitch of the engine "drastically change." Immediately following that, the pilot heard an alarm from the engine monitoring instrument which showed the oil pressure had decreased to "0." The pilot did not notice any instrument indications before the engine lost power. The pilot pushed the nose over, and switched fuel tanks from the right to the left. He turned on the igniters and held the start button down but there were no changes to the engine power. The pilot called ATC and declared an emergency. He used his GPS to return directly back to K88, and the controller also provided a vector. The pilot feathered the propeller and it completely stopped rotating; the pilot noticed a billow of smoke out of the right exhaust pipe. At that time, the airplane was about 6,500 ft and 8-9 miles from the airport. About 6 miles from the airport, the pilot decided hewas unable to make it back to the airport. He saw an open dirt road and decided to conduct a forced landing on the road. During the landing rollout, the roadway became tree-lined and both wings were substantially damaged due to impact with trees. The raw, unsmoothed data from the engine monitoring system indicated normal flight parameters until 17:29:35 when the fuel flow abruptly dropped to zero. The flaps were extended at 17:32:33 to about 16°, or takeoff position, and remained at 16° until the end of the flight. The airplane achieved 110 knots, best glide speed, at 17:32:35. The propeller was feathered at 17:33:10. Figure 1 depicts these events during the flight. From 17:29:48 until 17:33:18 the rate of descent exceeded 1,000 ft per minute (fpm) and was, at times, in excess of 4,000 fpm. During that 3.5-minute period, the airplane descended from about 11,900 ft to about 3,560 ft, an average descent rate of nearly 2,300 ft per minute. In multiple statements provided by the pilot, there was no mention of the use of an emergency engine out checklist or consultation of the pilot operating handbook (POH) during the event. Figure 1: Plot of Flight Track with Control Inputs Depicted The pilot's flight instructor who completed transition training with the pilot stated the pilot did not sump the fuel before every flight. The instructor also explained that he advised his students that the engine can tolerate some water. The instructor did not mention addressing the pilot's lack of a proper preflight inspection or advise the pilot that sumping the fuel was necessary. The airplane came to rest on the side of a tree-lined dirt roadway with substantial damage to both wings, the engine, and the empennage from tree strikes. The left wingtip separated about 9 ft outboard of the fuselage. The right wingtip separated just outboard of the fuel cap. The engine mounts were separated from the firewall, and the propeller blades had separated from the hub. The main and nose landing gear were separated. Fuel samples were collected from 4 locations within the fuel system: the fuel control unit, fuel/oil heat exchanger, fuel lines to/from the fuel pump, and the fuel filter. Federal aviation Administration (FAA) inspectors performed testing on the fuel samples collected from the fuel control and fuel filter using a Kolor Kut water finding paste. All 4 samples tested positive for water contamination. The fuel control unit (FCU) and fuel pump were examined and tested by the engine manufacturer. The FCU test results were consistent with typical field adjustment for operation. Corrosion was noted on the fuel pump; however, it performed satisfactorily during testing. An examination revealed no preimpact anomalies with the flight controls, engine, or fuel system that would have precluded normal operation.

Aircraft

Registration
N38DM
Reported as
Aero Smart Solutions Lancair Evolution (NO SERIES)
Category
Airplane, amateur-built
Serial number
EVO-0047
Built
2013
Airframe hours
442
Engine
P&W Canada PT6A-42, 850 horsepower, turbo prop
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Aero Smart Solutions Inc
Registered owner
Aero Smart Solutions Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 24, 2016
Departed
K88 · Iola, KS
Destination
OGD · Ogden, UT
Flight plan
IFR
Equipment
ADS-B, Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Stall warning system

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
40
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
October 17, 2015
Seat
Left
Restraint
3-point
Flight hours
1,660 total · 359 in this make and model · 1,660 as pilot in command · 95 in the last 90 days · 37 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
73 °F, dew point 48 °F
Altimeter
30.04 inHg
Observed at
K88

Docket · 15

The files NTSB released with the investigation on June 2, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.8 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.