# NTSB CEN20LA078: Navion Navion, N1011M, Fort Smith, AR, February 9, 2020 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: February 9, 2020, 15:00 local (21:00 UTC) - Place: Fort Smith, AR - Coordinates: 35.337054, -94.365393 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.3371&lon=-94.3654&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious, 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration - ADs cited in the narratives: [AD 2008-05-14](https://openairdocs.org/ad/2008-05-14) (OpenAirDocs) - NTSB case key (mKey): 100928 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100928/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100928 - Page: https://openairdocs.org/ntsb/CEN20LA078 ## Probable cause The inadequate inspection of the fuel selector valve, which was degraded, allowed fuel to leak, and resulted in fuel starvation and a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Navion NAVION G, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=6150120), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Fuel system: fuel selector/shutoff valve](https://openairdocs.org/ntsb-findings/01022823): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Navion NAVION G, 1 case](https://openairdocs.org/ntsb-findings/01022823/cases.md?model=6150120), [All aircraft, 176 cases](https://openairdocs.org/ntsb-findings/01022823/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Navion NAVION G, 3 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=6150120), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Navion NAVION G, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=6150120), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Navion NAVION G, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=6150120), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis Shortly after the pilot took off for a personal cross-country flight, about 300 ft above ground level, the engine lost partial power. The pilot lowered the airplane nose and the engine continued to operate, before losing total power. The pilot activated the electric fuel boost pump and engine power resumed for a few seconds. The pilot executed a forced landing to a grass area on airport property. During the forced landing, the airplane sustained substantial damage to both wings and the fuselage. Postaccident examination of the airplane revealed blue staining on and around the fuel selector valve area, consistent with a degraded valve. The valve failed leak checks during multiple vacuum tests to check external and internal leakage, which were called for in the manufacturer’s service bulletin 106 A and related airworthiness directive (AD) 2008-05-14. No fuel was found in any fuel lines or components from the firewall forward to the engine fuel components, and about 20 gallons of fuel was recovered from the airplane fuel tanks. It is likely the degraded fuel selector valve was leaking air, which resulted in fuel starvation to the engine. Aircraft records showed that the airplane and fuel selector valve were inspected and returned to service 2 days and about 18 flight hours before the accident. Based on the amount of fuel staining on and around the fuel selector valve and air leakage noted during the tests, the valve had likely become degraded before the last inspection. Given the valve’s degraded condition, it should have been tested and repaired or replaced during the last inspection in compliance with AD 2008-05-14. ## Factual narrative On February 9, 2020, about 1500 central standard time, a Navion G airplane, N1011M, impacted terrain during a forced landing near Fort Smith, Arkansas. The pilot, and two passengers sustained minor injuries, one passenger sustained serious injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, shortly after takeoff about 300 ft above ground level, the engine lost partial power. The pilot lowered the airplane nose and the engine continued to operate. Shortly thereafter, the engine lost total power. The pilot activated the electric fuel boost pump and engine power resumed; however, the engine lost power again within a few seconds. The pilot executed a forced landing to a grass area on airport property. During the forced landing, the airplane impacted terrain and sustained substantial damage to both wings and the fuselage. Postaccident examination of the airplane by a Federal Aviation Administration (FAA) inspector and a mechanic revealed that the fuel selector valve exhibited blue staining on and around the fuel selector valve area. The fuel selector valve was removed for further examination. No fuel was found in any fuel lines or components from the firewall forward to the engine. About 20 gallons of fuel were removed from the airplane fuel tanks during recovery. A review of the aircraft records showed that an annual inspection was completed and airworthiness directive (AD) 2008-05-14, an inspection of the airplane fuel system, was complied with on February 7, 2020, at a total tachometer time of 224.25 hours. The airplane had accumulated 18.2 hours since the inspections. The FAA inspector examined the fuel selector valve and performed vacuum tests on the valve, in accordance with Navion Service Bulletin (SB) No. 106 A, Fuel System - Inspection of the fuel system continued safe operation. Visual examination of the fuel selector valve showed blue staining, consistent with fuel, near the valve stem and inside the airplane were the fuel selector valve was mounted. Multiple vacuum tests, performed to check external and internal leakage, failed the required leak checks per the SB. The AD referred directly to the SB and stated that the fuel selector valve should be repaired or replaced if it failed the tests. ## Aircraft - Registration: [N1011M](https://openairdocs.org/deregistered/N1011M-2023-03-04), registration cancelled 2023-03-04, S/N NAV-4-2470, built 1962 (OpenAirDocs) - Reported make and model: Navion NAVION (G) - Registry model: [Navion NAVION G](https://openairdocs.org/model/navion-navion-g) (registry code 6150120) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-2470 - Year built: 1962 - Airframe hours: 3877 - Engines: Continental IO-550N2 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 7, 2020 - Departed: FSM, Fort Smith, AR - Destination: FSM, Fort Smith, AR - Airport: FSM, Fort Smith Regional Airport - Equipment: ADS-B, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; flight instructor, commercial, private; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review September 28, 2019; seat: left; restraint: lap only; flight hours: 3,302 total, 18 in this make and model, 3,091 as pilot in command, 74 in the last 90 days, 35 in the last 30 days, 18 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 3,500 ft overcast ## 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 20200209002719A](https://openairdocs.org/incident/20200209002719A), Feb 9, 2020: Navion NAVION G, Fort Smith, AR, Substantial damage. N1011M departed kfsm runway 7 to the east, veering towards the northeast for approximately four miles to conduct familiarization training on aircraft flight… ## Other investigations on N1011M (1) 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. - [NTSB LAX68D0103](https://openairdocs.org/ntsb/LAX68D0103), Aug 10, 1967: Navion G (N1011M), Avondale, AZ, substantial damage ## Docket (4 files) The files NTSB released with the investigation on March 25, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100928. 6.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481548&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Examination Report (item 2, .PDF, 615 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481549&FileExtension=.PDF&FileName=FAA%20Examination%20Report-Master.PDF - FAA Examination and Photos (item 3, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481550&FileExtension=.PDF&FileName=FAA%20Examination%20and%20Photos-Master.PDF - Excerpt of Records (item 4, .PDF, 625 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40481551&FileExtension=.PDF&FileName=Excerpt%20of%20Records-Master.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.