CEN21LA379

NTSB accident investigation · Diamond Aircraft Industries DA-42 · Bellefontaine, OH · August 17, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
August 17, 2021, 17:15 local (21:15 UTC)
Place
Bellefontaine, OH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N215BNDiamond Aircraft Industries DA-42
Defining event
Enroute-climb to cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration; CMH FSDO
FAA report
20210817022609A
Case key
103740

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 improper position of the right engine’s fuel feed pump bolt, which led to a total loss of power on the right engine, and the left engine's partial loss of engine power for reasons that could not be determined based on the available evidence.

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 pumpAircraft › Aircraft power plant · Not specifiedDiamond Aircraft Ind DA 42: 1 caseAll aircraft: 34 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedDiamond Aircraft Ind DA 42: 3 casesAll aircraft: 2,247 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

During an instructional flight, the airplane experienced a total loss of engine power of the right engine during climb followed by a partial loss of power on the left engine. The flight instructor performed a forced landing on a field that was off the runway departure end. The airplane sustained substantial damage during the forced landing. Before the accident flight, the airplane had undergone maintenance to replace the time-limited engine fuel feed pump (FFP) on both engines, and no maintenance check flight was required to be performed before flight. Postaccident examination of the right engine revealed that the right engine fuel feed pump bolt was not seated and thus might have resulted in inadequate fuel pressure for proper engine operation. The available evidence for this investigation did not allow a determination of the reason that the bolt was not properly seated. Maintenance personnel stated that they did not change the position of the right engine’s FFP bolt when the FPP was installed onto the engine. Both engines were tested with engine exhaust pipes that were found not in compliance with an airworthiness directive for fractured exhaust pipes that could result in an uncommanded engine shutdown. Postaccident testing of the left engine was unable to duplicate any power loss. As a result, the reason for the left engine’s power reduction during the accident flight could not be determined based on the available evidence. The right engine operated normally after its fuel feed pump bolt was moved to its seated position.

Factual narrative

On August 17, 2021, about 1715 eastern daylight time, a Diamond Aircraft Industries DA-42, N215BN, was substantially damaged when it was involved in an accident near Bellefontaine, Ohio. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor was conducting a short-field takeoff from runway 7 with the student pilot. During the climb after takeoff, the right engine lost all power, which was followed by the left engine losing partial power (about 30% of available power remained). The flight instructor performed a forced landing onto a grass field near the departure end of the runway. The airplane sustained substantial damage to the wing spar and landing gear. Logbook records showed that the left and right engine fuel feed pumps (FFP) were installed on the day of the accident with an airplane tachometer time and total time of 3,138 hours. The FFPs were replaced as part of a 600-hour time-limited component change. The operator did not perform, and was not required to perform, a test flight upon completion of this maintenance. Engine control unit (ECU) data for the left engine on the day of the accident recorded 14 canceled engine start messages during a period of about 57 minutes. About 3 hours later, four canceled engine start messages were recorded during a period of about 1 hour, which were followed by another canceled engine start message about 3 hours later. The right engine ECU recorded 16 canceled engine start messages during a similar period, which were followed by two low rail pressure messages, which were the last two messages recorded. According to the airplane manufacturer’s service representative, the numerous engine starts were consistent with air in the system from the maintenance that was performed on the fuel system. Postaccident examination of the airplane revealed that the left and right engine exhaust pipes failed the testing protocol included in Federal Aviation Administration airworthiness directive (AD) 2018-CE-002, which affected Diamond Aircraft Industries airplanes. The AD described “the unsafe condition [of] uncommanded engine shutdown during flight due to failure of the propeller-regulating valve caused by hot exhaust gases coming from fractured engine exhaust pipes.” The operator did not and was not required to perform a maintenance test flight upon completion of maintenance. In preparation for an engine test run, the operator replaced both airplane propellers, repaired the damaged landing gear, and reinstalled the engine exhaust pipes from the accident engines . After the accident, the left engine FFP bolt was found seated, and the right engine FFP bolt was found not seated. Several start attempts of the left and right engine were made, all of which were unsuccessful. The left and right engines were then primed, but only the left engine started and operated normally. After the right engine FFP boltwas seated, the right engine started and operated normally. The operator’s maintenance personnel stated that they did not change the position of the right engine’s FFP bolt when the FFP was installed onto the right engine on the day of the accident. The FFP bolts were not manufactured with retaining hardware to prevent the bolts from backing off from their seat. The FFP bolts did not have any labeling indicating that in-service adjustment of the bolt was not permitted. According to the engine manufacturer, the FFP bolt is torqued to 12 nanometers during manufacture. The bolt sets the unit’s pressure reducing valve, and, if the bolt is not completely seated, air can enter and/or fuel can escape from the unit. The engine manufacturer also stated that the FFP bolt should not be removed during any maintenance or bleeding action and that the repair manual describes the process for bleeding the fuel system and measuring pressure. The engine manufacturer further stated that it had not tested an FFP with a bolt in a similar position as that found on the accident airplane’s right engine, but, if fuel leaked through the bolt threads, there might not be enough fuel to the high-pressure pump, which would affect rail pressure.

Aircraft

Registration
N215BN
Reported as
Diamond Aircraft Industries DA-42
Category
Airplane
Serial number
42.AC055
Built
2007
Engines
Technify Motors TAE 125 02-99, reciprocatingTechnify Motors TAE 125 02-99, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Midwest Corporate Air Inc
Registered owner
Midwest Corporate Air Inc
Airworthiness certificate
Standard, Normal
Last inspection
August 17, 2021 · 3,138.4 hours before
Destination
Same as departure
Airport
KEDJ · Bellefontaine Regional Airport, runway 7, 5,000 × 100 ft, asphalt
Equipment
Stall warning system, Auto-pilot

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
37
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
April 18, 2021
Seat
Right
Restraint
3-point
Role
Student pilot
Age
60
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 72 °F
Altimeter
30.05 inHg
Observed at
EDJ

Docket · 15

The files NTSB released with the investigation on December 8, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 55.3 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.