CEN22LA128

NTSB accident investigation · Ryan L17 · Livingston, IL · February 20, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
February 20, 2022, 11:15 local (17:15 UTC)
Place
Livingston, IL · Open field
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5042KRyan L17
Defining event
Enroute-cruise: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA St. Louis FSDO
FAA report
20220220002369A
Case key
104674

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

A total loss of engine power due to fuel injection system contamination from an unknown source.

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.

Engine fuel and controlAircraft › Aircraft power plant · Damaged/degradedNavion NAVION A: 1 caseAll aircraft: 49 casesProbable cause
Engine fuel and controlAircraft › Aircraft power plant · Unknown/Not determinedNavion NAVION A: 1 caseAll aircraft: 49 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · FailureNavion NAVION A: 1 caseAll aircraft: 497 casesProbable cause
Engine fuel and controlAircraft › Aircraft power plant · MalfunctionNavion NAVION A: 1 caseAll aircraft: 49 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedNavion NAVION A: 2 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

The pilot receiving instruction reported that the purpose of the instructional flight was to practice various flight maneuvers, which were successfully performed. About halfway back to the departure airport, the pilot noticed the engine was “running rough.” The pilot proceeded to lean the airplane’s fuel mixture to correct the problem and noticed that the fuel flow gauge was “pegged.” The pilot continued to lean the mixture and adjusted the throttle, but no response was received from his inputs. The airplane began to lose altitude, and the pilot receiving instruction performed a forced landing to a flat muddy field. During the landing rollout, the nosewheel turned left in the mud, the airplane spun around, both wings and the propeller impacted the ground, and the airplane came to rest upright. The airplane sustained substantial damage to both wings. The flight instructor, who was also a mechanic, reported that, when the engine was running roughly, he tried to lean the mixture with no response. The flight instructor also reported that the fuel flow gauge needle had advanced into the manifold pressure side of the gauge and that the throttle had no response. The flight instructor assumed that the fuel control unit had a mechanical issue. Postaccident examination of the airplane found no anomalies that would have precluded normal operation. Testing of the fuel injection system found internal damage to the fuel control valve. The internal damage was likely consistent with fuel injection system contamination. In addition, the interior of the fuel pump had a dark deposit that was firmly adhered to the surface and could not be removed. When viewed under magnification, the deposit was found to be consistent with corrosion of the surface material. Thus, corrosion was likely present in the contamination. The engine manufacturer’s guidance stated that fuel injection system contamination may lead to “component damage, erratic engine operation, loss of power, or engine shutdown.” Although the source of the contamination could not be determined based on the available evidence, the contamination likely caused the fuel control system to fail, which led to the total loss of engine power during the accident flight.

Factual narrative

On February 20, 2022, about 1115 central daylight time, a Ryan L-17B airplane, N5042K, was substantially damaged when it was involved in an accident near Livingston, Illinois. The pilot receiving instruction, the flight instructor, and the passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot receiving instruction reported that the purpose of the flight was to practice various flight maneuvers. The airplane departed about 0943, and the training was successfully performed. About halfway back to the departure airport, the pilot noticed that the engine was “running rough.” The pilot proceeded to lean the airplane’s fuel mixture to correct the problem, and he then noticed that the fuel flow gauge was “pegged.” The pilot continued to lean the mixture and adjusted the throttle, but the airplane did not respond to these inputs. The airplane began to lose altitude, and the pilot receiving instruction performed a forced landing to a flat muddy field. During the landing rollout, the nosewheel turned left in the mud, the airplane spun around, both wings and the propeller impacted the ground, and the airplane came to rest upright. The airplane sustained substantial damage to both wings. The flight instructor, who was also a mechanic, reported that, when the engine was running roughly, he tried to lean the mixture with no engine response. He also reported that the fuel flow gauge needle had advanced into the manifold pressure side of the gauge and that the throttle had no response. The flight instructor assumed that the fuel control unit had a mechanical issue. Postaccident examination of the airplane found no mechanical anomalies with the airframe and engine. Fuel injection system testing was conducted. During the fuel pump testing, the fuel pressure was 4.5 pounds per square inch (psi); the standard is between 9 and 11 psi. The fuel control valve was found leaking through the screw to the metering insert. The fuel flow level would not stay set during the testing. The fuel control valve was disassembled, and the shafts and metering valve were found to have internal damage. The manifold valve was found leaking fuel to the air side of the diaphragm. The interior of the fuel pump had a dark deposit. The fuel pump was provided to the NTSB’s Materials Laboratory, which found that the deposit was firmly adhered to the surface and could not be removed. The deposit was viewed under magnification and found to be consistent with corrosion/oxidation of the surface material. Continental Motors released Service Bulletin SB-04A, Fuel Injection System Contamination (issued in March 2008 and revised in July 2016). This document provided guidance for maintenance personnel to prevent contamination of fuel injection systems during installation and maintenance work. This document states in part the following: o All caution must be exercised during reassembly of the fuel system to NOT allow anycontaminants to enter the components, lines and fittings during installation. o All surfaces surrounding the area where components are to be installed must be clean and free of all forms of contaminant before and during installation. o All hose assemblies must be flushed and verified to be free of contamination prior to installation. o All fuel system component and lines must be capped and remain capped until flushed and ready for installation. o The engine, tools and environment must be clean to minimize any potential for fuel system contamination. o All fuel system components, regardless of their source, must be purged at time of installation. SB-04A concluded with a warning that stated, “Fuel system contamination may lead to fuel system component damage, erratic engine operation, loss of power, or engine shutdown.” A review of maintenance records showed that the engine and its fuel system were overhauled in November 2017 and that the engine was installed in the accident airplane that same month. The maintenance records showed no further work for the engine fuel system. The maintenance records also did not indicate compliance with Continental Motors Service Bulletin SB-04A during the overhaul work performed in November 2017. The Federal Aviation Administration does not mandate compliance with service bulletins for 14 CFR Part 91 operations.

Aircraft

Registration
N5042K
Reported as
Ryan L17 (B)
Category
Airplane
Serial number
NAV-4-1654
Built
1948
Airframe hours
3,805.02
Engine
Continental Motors IO-520B, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 2021
Departed
ALN · Bethalto, IL
Equipment
Stall warning system, Satellite tracking device, Electronic flight bag or handheld device, ADS-B

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
Pilot
Age
62
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
February 20, 2022
Seat
Left
Restraint
Lap only
Flight hours
279 total · 10 in this make and model · 279 as pilot in command · 11 in the last 90 days · 4 in the last 30 days
Role
Flight instructor
Age
79
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
BasicMed, Without waivers/limitations
Last flight review
May 15, 2020
Seat
Right
Restraint
Lap only
Flight hours
14,740 total · 12 in this make and model · 13,965 as pilot in command · 32 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 22 knots, gusting 27
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 32 °F
Altimeter
30.04 inHg
Observed at
KALN, 13 nm away
METAR
KALN 201715Z 19022G27KT 10SM CLR 12/00 A3004 RMK ACFT MSHP

Docket · 5

The files NTSB released with the investigation on June 14, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.8 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.

Other investigations on N5042K · 1

Matched to the same aircraft by N-number and date.