# NTSB CEN21LA379: Diamond Aircraft Industries DA-42, N215BN, Bellefontaine, OH, August 17, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: August 17, 2021, 17:15 local (21:15 UTC) - Place: Bellefontaine, OH - Coordinates: 40.372278, -83.81925 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3723&lon=-83.8192&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration; CMH FSDO - NTSB case key (mKey): 103740 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA379 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103740/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103740 - Page: https://openairdocs.org/ntsb/CEN21LA379 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel pump](https://openairdocs.org/ntsb-findings/01057314): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-findings/01057314/cases.md?model=2990104), [All aircraft, 34 cases](https://openairdocs.org/ntsb-findings/01057314/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Diamond Aircraft Ind DA 42, 3 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2990104), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Failure; cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=2990104), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2990104), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=2990104), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-climb to cruise: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Diamond Aircraft Ind DA 42, 2 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2990104), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Enroute-climb to cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2990104), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Diamond Aircraft Ind DA 42, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=2990104), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N215BN), registered now, S/N 42.AC055, built 2007 (OpenAirDocs) - Reported make and model: DIAMOND AIRCRAFT INDUSTRIES DA-42 - Registry model: [Diamond Aircraft Ind DA 42](https://openairdocs.org/model/diamond-aircraft-ind-da-42) (registry code 2990104) (OpenAirDocs) - Registry engine: [Thielert TAE-125-01](https://openairdocs.org/engine/thielert-tae-125-01) (registry code 59300, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 42.AC055 - Year built: 2007 - Engines: Technify Motors GmbH TAE 125 02-99 reciprocating; Technify Motors GmbH 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 37; injuries: none; 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 - Student pilot; age 60; injuries: none; 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 ## 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 20210817022609A](https://openairdocs.org/incident/20210817022609A), Aug 17, 2021: Diamond Aircraft Ind Inc DA 42, Bellefontaine R, OH, Substantial damage. Immediately on takeoff the right hand engine lost power followed quickly by the other one. Power was approximately 30 per cent and resulted in the aircraft… ## Docket (15 files) The files NTSB released with the investigation on December 8, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103740. 55.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13726781&FileExtension=pdf&FileName=6120%20Master_Redacted-Rel.pdf - Flight instructor and pilot statements (item 2, PDF, 2 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13726340&FileExtension=pdf&FileName=Statements_Redacted-Rel.pdf - Video of accident takeoff (item 3, 3GP, 875 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13746806&FileExtension=3gp&FileName=RPReplay_10021-Rel.3gp - Left engine ecu message download of accident (item 4, PDF, 4 pages, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13786139&FileExtension=pdf&FileName=Left%20Engine%20ECU%20Excerpt%20for%20Accident-Rel.pdf - Right engine ecu message accident download (item 5, PDF, 2 pages, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13787007&FileExtension=pdf&FileName=Right%20Engine%20ECU%20Excerpt%20Accident-Rel.pdf - Record of correspondence - engine manufacturer (item 6, PDF, 1 page, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14053830&FileExtension=pdf&FileName=RECORD%20OF%20CORRESPONDENCE%20-%20CONTINENTAL%20AEROSPACE-Rel.pdf - Photo log (item 7, PDF, 1 page, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14174106&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - FAA inspector's statement of engine run (item 8, PDF, 2 pages, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13746513&FileExtension=pdf&FileName=N215BN%20Engine%20Run%20Report%2003-14-2022%20Master-Rel.pdf - Left engine control unit download - March 8, 2022 (item 9, XLSX, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13729018&FileExtension=xlsx&FileName=Left%20Engine%20Ser%20No%2002-02-03560-Rel.xlsx - Right engine control unit download - March 8, 2022 (item 10, XLSX, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13728819&FileExtension=xlsx&FileName=Right%20Engine%20Ser%20No%2002-02-03575-Rel.xlsx - Left engine logbooks (item 11, PDF, 26 pages, 8.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14173524&FileExtension=pdf&FileName=N215BN%20LH%20Engine%20Logs_Redacted-Rel.pdf - Right engine logbook (item 12, PDF, 25 pages, 36.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13745063&FileExtension=pdf&FileName=N215BN%20RH%20Engine%20Logs_Redacted-Rel.pdf - Email fuel feed pump bolt (item 13, PDF, 3 pages, 973 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14802502&FileExtension=pdf&FileName=Email%20Fuel%20Feed%20Pump%20Screw%20FW_%20TAE%20125%2002-99_Redacted-Rel.pdf - Email from engine manufacturer (item 14, PDF, 7 pages, 507 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14803098&FileExtension=pdf&FileName=Email%20from%20Engine%20Manufacturer_Redacted-Rel.pdf - Record of conversation - aircraft test run (item 15, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14803426&FileExtension=pdf&FileName=Memo%20of%20Coversation%20-%20Aircraft%20Test%20Run-Rel.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.