CEN17LA202

NTSB accident investigation · Piper PA36 · El Campo, TX · May 28, 2017

Accident · Serious injuriesLimited investigationFinal report
Date
May 28, 2017, 09:10 local (14:10 UTC)
Place
El Campo, TX
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N3711EPiper PA36
Defining event
Maneuvering-low-alt flying: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed · report June 5, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Lycoming Engines, Precision Airmotive LLC
FAA report
20170528007859A
Case key
95258

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

Foam contamination in the fuel injector nozzles from deteriorated foam baffles and water in the fuel flow divider, the combination of which resulted in the loss of engine power.

Findings · 2

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 (reciprocating)Aircraft › Aircraft power plant · InoperativePiper PA-36-300: 2 casesAll aircraft: 497 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid conditionPiper PA-36-300: 1 caseAll aircraft: 1,695 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 commercial pilot was conducting an agricultural application flight when the airplane experienced a loss of engine power. The airplane subsequently impacted an adjacent field in a nose-low, left-wing-low attitude. Due to his injuries, the pilot did not recall the details of the accident flight, loss of engine power, or impact sequence. The location of the wreckage, the debris field, and the damage to the airplane are consistent with the airplane being in a turn at the time of the accident. An examination of the engine revealed no evidence of any preimpact mechanical anomalies that would have precluded normal operation. An examination of the fuel system revealed that the internal foam baffles in both fuel tanks were discolored and deteriorated, and they disintegrated into very fine particles when touched. According to the owner/operator, during routine maintenance 5 days before the accident, a mechanic found blue foam, which he identified as coming from the foam baffles, in the fuel filter at the engine. Subsequent periodic inspections of the screen revealed no contaminants. The postaccident examination of three fuel injector nozzles revealed that they were plugged with an unknown substance. In addition, evidence of water was found in the fuel flow divider. It is likely that, given the condition of the foam baffles and the owner's previous identification of foam in the fuel system, that the particles found in the fuel injector nozzles were from the foam baffles. This contamination, in combination with the water found in the fuel flow divider, likely resulted in the loss of engine power.

Factual narrative

HISTORY OF FLIGHT On May 28, 2017, about 0910 central daylight time, a Piper PA36-300 airplane, N3711E, was substantially damaged when it impacted a cotton field near El Campo, Texas. The commercial-rated pilot sustained serious injuries. The airplane was owned and operated, by Trade Wind Ag Service Inc., under the provisions of Title 14 Code of Federal Regulations Part 137. Visual meteorological conditions prevailed and no Federal Aviation Administration (FAA) flight plan had been filed for the flight. The aerial application flight departed a private field about 0900. The owner of the accident airplane was conducting agricultural flight operations in another airplane, over a nearby field, and had not seen the accident airplane for a while. He flew to check on the pilot and spotted the airplane wreckage about 0920. Two witnesses in the area reported seeing or hearing the airplane flying just prior to the accident and could hear popping noises or loud shot gun-type popping sounds. According to the FAA inspector who responded to the accident, the airplane hit the ground in a nose low, left wing low attitude. The airplane wreckage was in the field adjacent to where the pilot was conducting aerial applications. Debris extended for about 60 feet from the initial impact point to the main wreckage. The engine and propeller assembly, and both main landing gear separated from the airframe. The right wing separated partially from the fuselage and the left wing was crushed aft and buckled. Months following the accident, the pilot could not recall details of the accident. He did recall losing altitude and trying to level the wings. He also recalled trying to egress from the airplane window. Prior to the accident flight, he recalled having a difficult time starting the engine – once the engine started there was a deep rumble with popping, but it eventually cleared, and the engine ran without issue or hesitation. WRECKAGE INFORMATION The wreckage was recovered to a secure storage facility and examined by a National Transportation Safety Board (NTSB) investigator and an investigator from Lycoming. The fuel selector valve was in the "On" position. The detents were definitive when tested and the fuel selector valve lever moved without hesitation or sticking. Both fuel tanks were compromised during the impact sequence and the wing skins exhibited hydraulic deformation, consistent with fuel being present at the time of impact. The internal foam baffles in both fuel tanks were discolored and deteriorated. When touched by hand, the baffles would disintegrate into very fine particles. The engine assembly was impact damaged and had dirt imbedded around the case and cylinders of the engine. The left magneto leads were impact damaged and could not be functionally tested. Both the left and right magneto produced a spark at the end of each lead when placed on a test bench and activated. The valve covers, the upper bank of spark plugs, and the injector nozzles were removedto facilitate the examination. Injector nozzle Nos. 1, 2, and 6 were obstructed with an unknown substance. The engine was rotated through by hand at the propeller. Valve movement was noted on all cylinders. Tactile compression was observed at all, but the No. 1, cylinder. The accessory gears at the rear of the engine rotated and confirmed valve train and crankshaft continuity. There was no evidence of fuel in the engine fuel lines; however, trace fuel was noted in the engine driven fuel pump and 5 to 10 ml of fuel was noted in the boost pump output line. The fuel filter, fuel screen, and the throttle body screen were free of visible contaminants. Liquid in the fuel flow divider tested positive for water when tested with a water-finding paste. The fuel injection servo was examined by an NTSB investigator and an investigator from Precision Airmotive LLC. The flange, mixture shaft, and multiple fittings on the fuel injection servo were impact damaged. The unit was placed on a field flow bench and stoddard solvent was used to test the unit for flow and pressure. A leak was noted at the mixture control shaft; however, it was attributed to impact damage to the unit. The pressures at varying simulated engine rpms were consistent with the mixture control valve in the idle or off position. This position was later confirmed during the disassembly of the unit. Both the drain jet and the venturi drain were plugged and partially plugged, respectively, with an unknown substance. According to Precision Airmotive LLC, both conditions would result in a rich mixture. ADDITIONAL INFORMATION According to the owner/operator of the airplane, they had purchased the airplane about a year prior to the accident. On occasion they had issues starting the engine and this was remedied by adjusting the gap on the spark plugs. During flight, the fuel pressure would decrease, and the low fuel pressure light would illuminate. If the pilot turned the fuel pump on, the light would go out, and the fuel pressure would increase. During routine maintenance, 5 days prior to the accident, a mechanic found blue foam, he identified as coming from the internal foam baffles in the fuel tanks, in the fuel filter at the engine. The filter was cleaned and then checked periodically after every flight without further findings. The internal foam baffles were not replaced at the time of the finding. Piper Service Bulletin 713, dated May 11, 1981, calls for the inspection and maintenance of the fuel cells due to the possibility of foam particles contaminating the fuel system, when they start to discolor and deteriorate.

Aircraft

Registration
N3711E
Reported as
Piper PA36 (300)
Category
Airplane
Serial number
36-7860044
Built
1978
Airframe hours
4,586.3
Engine
Lycoming IO-540-K1G5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
Trade Wind Ag Services Inc
Registered owner
Trade Wind Ag Services Inc
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · January 23, 2017
Departed
8TE8 · El Campo, TX
Destination
8TE8 · El Campo, TX
Equipment
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
19
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
September 13, 2016
Seat
Single
Restraint
4-point
Flight hours
405 total · 130 in this make and model · 300 as pilot in command · 50 in the last 90 days · 25 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 6 knots
Visibility
10 statute miles
Lowest ceiling
3,300 ft broken
Temperature
84 °F, dew point 73 °F
Altimeter
29.92 inHg
Observed at
KARM

Docket · 5

The files NTSB released with the investigation on March 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.