# NTSB CHI05LA233: North American Navion A (L-17B), N8828H, Zeeland, MI, August 13, 2005 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 13, 2005, 11:00 local (15:00 UTC) - Place: Zeeland, MI - Coordinates: 42.817222, -85.928054 - Nearby events: https://openairdocs.org/map.md?lat=42.8172&lon=-85.9281&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report August 29, 2006 - Report: Approved by Office Director - Parties: Sierra Hotel Aero, Inc., Teledyne Continental Motors, Federal Aviation Administration - SAIBs cited in the narratives: [SAIB CE-06-11](https://openairdocs.org/saib/CE-06-11) (OpenAirDocs) - NTSB case key (mKey): 62293 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI05LA233 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62293/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=62293 - Page: https://openairdocs.org/ntsb/CHI05LA233 ## Probable cause The loss of engine power after takeoff due to a fuel selector valve leak and low altitude and low airspeed at the time of power loss. A factor was the recommended maintenance service for the fuel selector not performed by the airplane owner/pilot. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, takeoff - fuel system,selector/valve - leak (cause) - Forced landing, emergency landing after takeoff - In flight collision with terrain/water, emergency descent/landing - terrain condition - ground - altitude - low (cause) - airspeed - low (cause) - maintenance,overhaul,major - not performed, pilot in command - maintenance,service of aircraft/equipment - not performed, pilot in command (contributing factor) ## Analysis The airplane impacted terrain following a total loss of engine power after takeoff. Examination of the airplane revealed internal and external leakage of the fuel selector. The airplane manufacturer issued a service bulletin about 13 months before the accident calling for the removal and replacement of fuel selectors which encompassed the accident airplane. This service bulletin was not complied with by the airplane owner who was also the pilot-in-command of the airplane. An engine test run was performed and no anomalies that precluded normal operation were noted. The engine exceeded the engine manufacturer recommend time between overhaul of twelve years. The airplane was not certified and not equipped with shoulder harnesses. The pilot and passenger sustained serious injuries. ## Factual narrative On August 13, 2005, at 1100 eastern daylight time, a North American Navion A (L-17B), N8828H, owned and piloted by a private pilot, received substantial damage on impact with terrain following a total loss of engine power after takeoff from Ottawa Executive Airport, Zeeland, Michigan. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 personal flight was not operating on a flight plan. The pilot and passenger sustained serious injuries. The flight was originating at the time of the accident and was en route to Grand Haven, Michigan. The pilot departed from runway 02 (3,800 feet by 60 feet, asphalt) and about 100-150 feet above ground level the airplane experienced a total loss of engine power. The pilot then "pushed the nose over and moved to the right on grass, landed very hard on [the] grass next to [the] runway." The North American Navion A (L-17B), serial number NAV-4-828, was registered to the pilot on May 10, 2004. The airplane was manufactured in 1947 and certified under Civil Air Regulations Part 3. Type certificate data sheet information indicated that the airplane was originally certified with a Continental E-185-3 or -9, or an optional IO-470-H engine, and a fuel capacity of 39.5 gallons. Airplane records show that Brittain Industries 20-gallon wing tip tanks, through supplemental type certificate SA4-915, were installed on June 29, 1992, at a tachometer time of 312 hours. The tachometer was changed during the history of the airplane. The last logbook entry noting the fuel selector dated October 27, 2003, states that the fuel selector O-ring was replaced at a tachometer time of 235 hours. The engine was last inspected during an annual inspection dated July 5, 2005, at a total time of 5,188.6 hours and a time since major overhaul of 872.55 hours. Inspection of the airplane by the Federal Aviation Administration (FAA) and representatives from Sierra Hotel Aero, revealed that 18 gallons of 100 low lead aviation fuel was drained from the main fuel tank, the left fuel tip tank had a few gallons of fuel and the right tip tank was empty. The fuel selector was then removed and upon removal fuel began to pour out from the left tip tank line. Fuel did not pour out of the right tip tank. The fuel strainer was half full of fuel and had grass packed into the drain valve handle. Fuel was puddled under the gascolator. CAR certification standards did not require the installation of shoulder harnesses in the airplane. The accident airplane was not equipped with shoulder harnesses. Service Bulletin No. 101, dated June 24, 2004, and Service Bulletin No. 101A, dated August 23, 2005, were issued by Sierra Hotel Aero, Inc. regarding the fuel system fuel selector valve, serial number NAV-4-002 thru NAV-4-2561. Both Service Bulletins called for the removal and replacement of the fuel selector. Service Bulletin No. 101A states: "Previous design has a history of wear, causing internal leakage, valve step air ingestion and improper valve selector positioning. Internal leakage of the valve is suspected in several cases resulting in inadvertent fuel transfer between main and auxiliary tanks. Improper valve selector positioning and air ingestion has been implicated in several crashes - some fatal. The improper position is more likely to occur as detents in the original body wear, making positive tank selection less obvious." A Special Airworthiness Information Bulletin, CE-06-11, dated November 29, 2005, was issued by the Federal Aviation Administration and recommends the inspection of the Navion fuel system selector valve for proper operation and make sure the valve cannot introduce air into the fuel line system. An appropriately rated mechanic or repair facility should inspect these units for binding, leakage, or improper operation and replace any defective fuel selector valves with a serviceable unit. There are no known FAA approved field instructions/procedures to repair these fuel selector assemblies. On August 26, 2005, the fuel selector valve was tested and examined at Sierra Hotel Aero, Inc. under supervision of the Federal Aviation Administration. Identifying information of the valve indicated that the valve was manufactured by Imperial Valve which was one of two valves manufactured by North American and Ryan. The valve was configured, with an STC part number added, with 3 inlet ports, one for the main tank, one for each left and right tips tank. Testing of the valve was not within the Sierra Hotel Aero, Inc.'s test specifications. The valve was then disassembled and was noted to exhibit rework. On October 13, 2005, an engine test run was performed at Teledyne Continental Motors under the supervision of the Federal Aviation Administration. The test was within Teledyne Continental Motors test specifications. The FAA, Sierra Hotel Aero, Inc., and Teledyne Continental Motors were parties to the investigation. ## Aircraft - Registration: [N8828H](https://openairdocs.org/deregistered/N8828H-2007-06-22), registration cancelled 2007-06-22, S/N NAV-4-828, built 1947 (OpenAirDocs) - Reported make and model: North American Navion A (L-17B) - Registry model: [North American NAVION A](https://openairdocs.org/model/north-american-navion-a) (registry code 6150132) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-828 - Engines: Continental IO-520-B6B 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Lambert Damstra - Airworthiness certificate: Standard, Utility; Standard, Normal - Departed: Z98, Zeeland, MI - Destination: Grand Haven, MI - Airport: Z98, Ottawa Executive, runway 02, 3,800 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3; last flight review November 1, 2004; seat: left; flight hours: 1,561 total, 1,326 in this make and model, 1,561 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 0° at 0 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 64 °F - Altimeter: 29.97 inHg - Observed at: BIV, 9 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 20050813024809A](https://openairdocs.org/incident/20050813024809A), Aug 13, 2005: Tmpson NAVIONA, Zeeland, MI, Destroyed. (-23) Aircraft experienced engine failure shortly after take off from Ottawa Executive Airport (Z98), MI. Aircraft descended from 200 feet and struck ground… ## Docket (9 files) The files NTSB released with the investigation on May 12, 2006, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=62293. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 308 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419979&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Weather Information (item 2, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260491&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Type Certificate Data Sheet (item 3, .PDF, 769 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260492&FileExtension=.PDF&FileName=Type%20Certificate%20Data%20Sheet-Master.PDF - Aircraft Log (item 4, .PDF, 452 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419980&FileExtension=.PDF&FileName=Aircraft%20Log-Redacted.PDF - Special Airworthiness Information Bulletin (item 5, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419981&FileExtension=.PDF&FileName=Special%20Airworthiness%20Information%20Bulletin-Redacted.PDF - Navion Service Bulletin No. 101A (item 6, .PDF, 471 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260496&FileExtension=.PDF&FileName=Navion%20Service%20Bulletin%20No.%20101A-Master.PDF - Teledyne Continental Service Letter SIL98-9A (item 7, .PDF, 468 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40260497&FileExtension=.PDF&FileName=Teledyne%20Continental%20Service%20Letter%20SIL98-9A-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419984&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40419988&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.