# NTSB CEN22LA128: Ryan L17, N5042K, Livingston, IL, February 20, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: February 20, 2022, 11:15 local (17:15 UTC) - Place: Livingston, IL · Open field. - Coordinates: 38.963365, -89.802281 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.9634&lon=-89.8023&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA St. Louis FSDO - NTSB case key (mKey): 104674 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104674/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104674 - Page: https://openairdocs.org/ntsb/CEN22LA128 ## Probable cause A total loss of engine power due to fuel injection system contamination from an unknown source. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control](https://openairdocs.org/ntsb-findings/01057300): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-findings/01057300/cases.md?model=6150104), [All aircraft, 49 cases](https://openairdocs.org/ntsb-findings/01057300/cases.md) - [Engine fuel and control](https://openairdocs.org/ntsb-findings/01057300): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-findings/01057300/cases.md?model=6150104), [All aircraft, 49 cases](https://openairdocs.org/ntsb-findings/01057300/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=6150104), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Engine fuel and control](https://openairdocs.org/ntsb-findings/01057300): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-findings/01057300/cases.md?model=6150104), [All aircraft, 49 cases](https://openairdocs.org/ntsb-findings/01057300/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Navion NAVION A, 2 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=6150104), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=6150104), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Navion NAVION A, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=6150104), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Navion NAVION A, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=6150104), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/aircraft/N5042K), registered now, S/N NAV-4-1654 (OpenAirDocs) - Reported make and model: RYAN L17 (B) - Registry model: [Navion NAVION A](https://openairdocs.org/model/navion-navion-a) (registry code 6150104) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-1654 - Year built: 1948 - Airframe hours: 3805.02 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; 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 - Flight instructor; age 79; injuries: none; 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 ## 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 20220220002369A](https://openairdocs.org/incident/20220220002369A), Feb 20, 2022: Navion NAVION A, Staunton, IL, Substantial damage. On February 20, 2022, N5042K Navion L-17B had to make an emergency landing in a soft field just west of 8437 Illinois state route 4 Staunton, IL, due to engine… ## Other investigations on N5042K (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 NYC72DNC48](https://openairdocs.org/ntsb/NYC72DNC48), May 7, 1972: Navion L-17B (N5042K), Manchester, NH, substantial damage ## Docket (5 files) The files NTSB released with the investigation on June 14, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104674. 5.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14558082&FileExtension=pdf&FileName=NTSB%20Form%206120_1%20Redacted-Rel.pdf - Accident photographs (item 2, PDF, 3 pages, 328 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557847&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf - Examination reports and Continental motors service bulletin (item 3, PDF, 9 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14562382&FileExtension=pdf&FileName=Examination%20Reports%20and%20Continental%20Motors%20Service%20Bulletin%20Redacted-Rel.pdf - Additional statements (item 4, PDF, 4 pages, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14558092&FileExtension=pdf&FileName=Additional%20Statements%20Redacted-Rel.pdf - Maintenance records (item 5, PDF, 9 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14557176&FileExtension=pdf&FileName=Maintenance%20Records%20Redacted-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.