# NTSB CHI01LA158: Packwood Packwood 1, N2402F, Pierce City, MO, June 9, 2001 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 9, 2001, 10:00 local (15:00 UTC) - Place: Pierce City, MO - Coordinates: 36.906112, -94.012779 - Nearby events: https://openairdocs.org/map.md?lat=36.9061&lon=-94.0128&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report August 26, 2003 - Report: Approved by Office Director - Parties: Federal Avaiation Administration - NTSB case key (mKey): 52489 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI01LA158 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52489/pdf - Page: https://openairdocs.org/ntsb/CHI01LA158 ## Probable cause an engine failure during initial climbout and the fence struck during the runway overrun. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - fuel injection control/system - failure (cause) - maintenance - inadequate, owner/builder (cause) - Forced landing, emergency landing after takeoff - In flight collision with object, emergency landing after takeoff - object - fence (cause) ## Analysis An amateur built airplane sustained substantial damage on impact with a fence and terrain during a forced landing after takeoff following a loss of engine power encountered on initial climbout. about 300 feet above ground level. The throttle body injector (TBI) was shipped back to the manufacturer to be re-built. That unit was recalled 12 years earlier. The pilot was not aware of the recall at the time of the accident. The TBI manufacturer stated that "during the bench check of its regulator cracking pressure and idle setting, it was determined that the inlet control valve was stuck in the closed position, a condition not unusual for a unit which had been run on automotive fuel, or one that has been stored for a period of time with standing fuel inside. Additionally the idle needle valve was found to be fully closed. When the regulator cover was removed to free the inlet control ball, water stains were observed over a large sector of the control diaphragm. Removal of the inlet fuel screen revealed that it too had experienced substantial long term water contamination some time in its past." The TBI was reassembled and test run. The manufacturer stated, "Data readings of fuel flow and airflow obtained during this test were plotted to reveal a metering curve indistinguishable from a new EFS-2." ## Factual narrative On June 9, 2001, about 1000 central daylight time, a Packwood Packwood 1, N2402F, piloted by a private pilot, sustained substantial damage on impact with a fence and terrain during a forced landing after takeoff following an in-flight loss of engine power encountered on climbout from runway 18 at the Monett Municipal Airport (M58), near Pierce City, Missouri. The personal flight was operating under 14 CFR Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot sustained no injuries. The local flight was originating from M58 at the time of the accident. During a telephone interview, the pilot stated "...the engine was running great during the takeoff. The engine quit about 300 ft AGL. He had tress ahead and performed a forced landing on the remaining runway. He went off the end of the runway and impacted fencing. He initially thought that the fuel pump had failed. He said that he did not have time to activate a back up fuel pump. After the accident he tested both fuel pumps and they both checked out ok. He shipped the Ellison throttle back to the manufacturer, Ellison, to be re-built. He said that Ellison indicated to him the unit was recalled 12 years earlier. He was not aware of the recall at the time of the accident." The TBI manufacturer stated: At your request we have completed our standard preshipping acceptance test on Throttle Body Injector Model EFS-2, S/N 1039. Our pretest inspection of the unit revealed that the regulator seal had been removed and the EFS-2 had been completely disassembled and reassembled by someone who lacked training in the correct procedure for installing lock wire. During the bench check of its regulator cracking pressure and idle setting, it was determined that the inlet control valve was stuck in the closed position, a condition not unusual for a unit which had been run on automotive fuel, or one that has been stored for a period of time with standing fuel inside. Additionally the idle needle valve was found to be fully closed. When the regulator cover was removed to free in inlet control ball, water stains were observed over a large sector of the control diaphragm. Removal of the inlet fuel screen revealed that it too had experienced substantial long term water contamination some time in its past. Following reassembly, the subject EFS-2 was installed on our 1835 CC Volkswagen test engine which was instrumented for measuring both fuel flow and air flow, following which the test engine started and idled normally. After a suitable warm up period the engine was operated through its full range of throttle openings with ten data points taken ranging from idle to full throttle. Data readings of fuel flow and airflow obtained during this test were plotted to reveal a metering curve indistinguishable from a new EFS-2. (See appended performance chart) At 0953, the reported temperature and dew point at Joplin, Missouri, were 24 degrees Celsius and 19 degrees Celsius respectively. The temperature and dew point were plotted on a Transport Canada carburetor-icing chart. Their intersection fell in the moderate icing-cruise power or serious icing-descent power area. (See appended icing chart) An excerpt from the TBI manufacturer's web site stated: Contrary to common belief, the ELLISON TBI can accumulate ice! Additionally, engines with cold induction manifolds such as the four cylinder Continental engines, the Continental O-470, and all Volkswagen derivative engines are especially susceptible to the formation of manifold ice. FOR THESE REASONS, ALL TBI INSTALLATIONS MUST INCLUDE AN INDUCTION HEATING SYSTEM capable of providing an inlet air temperature rise of 90 degrees F. Follow engine or airframe manufacturer's recommendations for use of induction heat. ... The Ellison Throttle body Injector (TBI) requires clean fuel for proper operation. A 70 micron filter is required to keep contaminates out of the TBI. The TBI does have a last chance fuel strainer installed on the fuel inlet fitting. This strainer is there only to trap large particles in the event of a primary filter failure. The strainer is fine enough to reduce the possibility of particles plugging the fuel metering tube but particles which can pass through the fuel inlet screen can keep the valve in the fuel regulator from closing completely. This can result in an erratic idle and fuel leakage after engine shutdown. Many throttle body installations use a standard gascolater with screen before the fuel pumps to prevent large particles from damaging the fuel pumps and to provide a low point water drain, but then after the engine driven pump, a 70 micron filter or finer must be installed. This filter must be carefully selected. Some paper filters will not pass water and could cause fuel system blockage if filled with water. A drain must be provided and it must be drained before each flight. If this filter is installed on the pressure side of the boost pump it must have sufficient strength to handle pump pressure without bursting or leaking. The Glassair III uses a Fram HPG 1 with a low point water drain added which is a very good filter housing and perfectly capable of operating with pressurized fuel. As with all fuel system components, the filter must be located well away from sources of heat, preferably outside of the engine compartment. If located in the engine compartment it must be blast cooled to prevent vapor formation. Subsequent to the accident, the TBI manufacturer, Ellison, stated that "we will be including information on our website about the factory recall of early-model EFS-2's as well as copies of all service bulletins which have been issued on any of our products." ## Aircraft - Registration: [N2402F](https://openairdocs.org/deregistered/N2402F-2018-06-08), registration cancelled 2018-06-08, S/N 001, built 2000 (OpenAirDocs) - Reported make and model: Packwood Packwood 1 - Registry model: [Packwood Auburn L PACKWOOD 1](https://openairdocs.org/model/packwood-auburn-l-packwood-1) (registry code 05610AD) (OpenAirDocs) - Registry engine: [Revmaster 1800](https://openairdocs.org/engine/revmaster-1800) (registry code 52549, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1 - Airframe hours: 5 - Engines: Revmaster 2100D 75 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Auburn L. Packwood - Airworthiness certificate: Special, Experimental (Special) - Departed: M58, Pierce City, MO - Airport: M58, Monett Muni, runway 18, 5,000 × 75 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; last flight review April 28, 2001; seat: left; flight hours: 100 total ## Weather - Conditions: Visual (VMC), Day - Wind: 0° at 0 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 66 °F - Altimeter: 30.04 inHg - Observed at: JLN, 25 nm away ## 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 20010609011619A](https://openairdocs.org/incident/20010609011619A), Jun 9, 2001: Monett, MO, No damage. (-23)Pilot stated that on take off, the engine lost power at approximately 300 feet AGL, so he elected to attempt to land the airplane on the remaining runway,… 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.