ERA09LA532

NTSB accident investigation · Ryan Navion · Fire Island, NY · September 20, 2009

Accident · No injuriesLimited investigationFinal report
Date
September 20, 2009, 10:10 local (14:10 UTC)
Place
Fire Island, NY
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4467KRyan Navion
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report March 16, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20090920025559A
Case key
74780

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 during cruise flight due to fuel starvation as a result of a deteriorated fuel gasket.

Findings · 2

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.

Fuel system: fuel filter-strainerAircraft › Aircraft systems · Damaged/degradedRyan NAVION: 1 caseAll aircraft: 52 casesProbable cause
Fuel system: fuel filter-strainerAircraft › Aircraft systems · Not serviced/maintainedRyan NAVION: 1 caseAll aircraft: 52 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

According to the pilot, the airplane was equipped with three fuel tanks: one main tank in each wing and an auxiliary tank in the fuselage. Each tank had a capacity of approximately 20 gallons. Prior to his departure, the pilot filled the auxiliary fuel tank and determined that there was a total of approximately 25 gallons in the main tanks. During cruise, about 55 minutes into the cross-country flight, the pilot decided to switch from the main wing tanks to the auxiliary tank. In accordance with the normal operating procedure, the pilot first turned on the fuel boost pump and then switched the fuel selector valve to the auxiliary tank. Very shortly thereafter the engine lost all power. The pilot immediately switched the fuel selector valve back to the main tanks. Although all controls were set properly, the engine did not resume developing power and the pilot’s restart attempts were unsuccessful. The pilot then executed a forced landing on a nearby beach. Postaccident examination and testing revealed that the cork gasket in the fuel strainer was deteriorated, did not provide a proper seal, and allowed air to be introduced into the fuel system when the selector valve was switched to the auxiliary tank. The investigation could not determine the age of the gasket or whether it was the correct part. The airplane had accumulated about 5 hours in service since the fuel selector valve was replaced, and the airplane had not been flown using fuel from the auxiliary tank since the valve replacement.

Factual narrative

HISTORY OF FLIGHT On September 20, 2009, about 1010 eastern daylight time, a Ryan Navion, N4467K, was substantially damaged during a forced landing on a beach on Fire Island, New York. The certificated airline transport pilot and two passengers were not injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight. According to the pilot, the airplane was equipped with three fuel tanks; one main tank in each wing, and an auxiliary tank in the fuselage. Each tank had a capacity of approximately 20 gallons. The fuel selector valve had three positions: off, main tanks, and auxiliary tank. The pilot's normal procedure was to fly using fuel from the main tanks for approximately 1 hour, and then switch to the auxiliary tank. Prior to his departure, the pilot determined that there was a total of approximately 25 gallons in the main tanks, and filled the auxiliary fuel tank. The airplane departed Quonset State Airport (OQU) Kingstown, Rhode Island, about 0915, with an intended fuel stop at Cape May County Airport (WWD), Wildwood, New Jersey. The planned route of flight was south/southwest across the Long Island Sound, Long Island, and the Great South Bay, and then west along the south shore of Long Island to Sandy Hook, New Jersey. The pilot reported that he transited Long Island below the outer shelf of the class C airspace to the east of Islip MacArthur Airport (ISP), Islip, New York, where the charted floor of the airspace was 1,500 feet above mean sea level (msl). Approximately 55 minutes into the flight, when the airplane was over the Great South Bay south-southeast of ISP, and on a westerly course, the pilot decided to switch from the main tanks to the auxiliary tank. At that time, the airplane was at an altitude of approximately 1,400 feet msl. The pilot turned on the fuel boost pump, and then switched the fuel selector valve to the auxiliary tank. Very shortly thereafter, the engine quit suddenly, but the propeller continued to windmill. The pilot immediately switched the fuel selector valve back to the main tanks. The boost pump switch was still in the "ON" position, but the engine did not resume developing power. The pilot verified that the magneto switch was set to "BOTH," and the mixture control was set to full rich. He manipulated the throttle control; the engine "coughed" but did not resume developing power. When the engine "coughed," the fuel pressure gauge indication "spiked," but then returned to approximately zero. The pilot realized that he would have to conduct a forced landing, and saw that the land area to his right (north) was populated, while the land area to his left (south) was an unpopulated beach. He turned the airplane to the south to reach the unpopulated beach area, and kept the landing gear retracted to extend the glide range of the airplane. The pilot visually scanned the beach andobserved it to be clear of people. The pilot elected to keep the landing gear retracted to avoid a nose-over in the sand. The airplane grazed some sand dunes before it touched down on the beach, and slid to a stop. All occupants were uninjured, and no persons or ground items were struck by the airplane. The pilot then called 9-1-1 on his mobile telephone for assistance, and the first responders arrived at the accident site about 10 minutes after the telephone call. PERSONNEL INFORMATION Federal Aviation Administration (FAA) records indicated that the pilot held an airline transport pilot certificate with an airplane multiengine land rating, a commercial pilot certificate with single engine land, single engine sea, and glider ratings, and a flight instructor certificate with airplane single engine, multiengine, and instrument ratings. His most recent FAA second-class medical certificate was issued in May 2009. According to the pilot, he had approximately 9,860 total hours of flight experience, and approximately 125 hours in the accident airplane make and model. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 1948, and was equipped with a Continental E225 series piston engine. It was registered to an individual who based the airplane in Rhode Island. The registered owner reported that each yearly period, he tied the airplane down outside from approximately mid spring to mid fall, and hangared it for the remainder of the period. Maintenance records were not provided for the investigation. According to the owner, the airplane had a total of approximately 4,000 hours in service. In 2005, a significant amount of mechanical refurbishment was conducted on the engine, but that maintenance activity did not constitute an overhaul. Also according to the owner, the fuel selector valve was replaced in June 2009, in order to comply with FAA airworthiness directive (AD) 2008-05-14. The compliance method utilized the service instructions provided by the American Navion Society, which was one of two sources explicitly specified in the AD. The most recent annual inspection was completed on September 1, 2009, and the airplane had accumulated approximately 5 hours of flight time between the annual inspection and the accident flight. According to the owner, as part of the valve replacement maintenance activity, the engine was successfully run on the ground with the fuel selector valve set to the auxiliary tank, but until the accident flight, no-one had attempted to fly the airplane with the valve selected to the auxiliary tank since the valve was replaced. FAA AD 2008-05-14 became effective on April 16, 2008. According to the AD text, the AD required "a one-time inspection of the entire fuel system and repetitive functional tests of certain fuel selector valves. This AD results from reports of airplane accidents associated with leaking or improperly operating fuel selector valves. We are issuing this AD to detect and correct fuelsystem leaks or improperly operating fuel selector valves, which could result in the disruption of fuel flow to the engine. This failure could lead to engine power loss." METEOROLOGICAL INFORMATION The 1356 ISP recorded weather observation included winds from 140 degrees at 4 knots, 10 miles visibility, few clouds at 3,500 feet, temperature 18 degrees C, dew point 9 degrees C, and an altimeter setting of 30.34 inches of mercury. WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA inspector who responded to the accident scene, the airplane sustained substantial damage. It was upright, but listing to the left, with the left wing resting on the sand, and the right wing canted in the air due to wing dihedral. The upper skin of the right wing was wrinkled and torn near its midspan point, and the right aileron was detached from the wing at its outboard hinge. The aft fuselage exhibited slight crumpling on its right side, and the engine cowl/mount assembly was crushed on its underside. The upper cowl was separated from the firewall. One propeller blade appeared intact, and the other one was bent aft approximately 45 degrees near its 1/3 span point. All three fuel tanks remained intact. Since the main fuel filler port was on the right wing, and the two main tanks were interconnected, the fuel level in the main tanks could not be readily determined due to the list of the airplane. Fuel was observed in the fuel strainer; the fuel was removed from the strainer, examined, and appeared to be uncontaminated. The airplane was partially disassembled, and transported to a secure facility. Once the airplane was situated in the secure facility, at least 13 gallons of fuel were recovered from the main tank, and at least 8 gallons of fuel were recovered from the auxiliary tank. ADDITIONAL INFORMATION Several days after the accident, FAA inspectors and an aircraft mechanic who was familiar with the accident airplane make and model, as well as the installed fuel selector valve, examined the airplane and the fuel system components. The installed arrangement sequence of the fuel system components was fuel tank(s), fuel selector valve, fuel strainer, electric fuel pump, engine-driven fuel pump, and carburetor. It was determined that the fuel selector valve was installed correctly. The engine-driven (mechanical) fuel pump was determined to be functional. Fuel was placed in the main tanks and the auxiliary tank, and with the fuel line to the engine disconnected prior to the engine-driven pump, the electric fuel pump was tested. The electric fuel pump was observed to be functional, and produced an output pressure within design limits. The selector valve was used to switch tanks (from main to auxiliary) while the pump was running, and no abnormalities were observed. The fuel line to the engine was connected, and the test was repeated. With the fuel selector set to the main tank, when the electric fuel pump was activated, no abnormalities wereobserved. However, when the selector valve was switched to the auxiliary tank, air was observed to be bubbling in the fuel strainer, and the electric fuel pump was heard to be "cavitating." The electric fuel pump was turned off, the fuel line to the fuel strainer was bled of air, the line was re-secured, and the test was repeated. The same results were observed when the selector valve was switched from main to auxiliary tank. The electric pump was turned off, and the fuel strainer was opened by separating the glass bowl from the top of the unit. The cork gasket that was situated between those two components was observed to be deteriorated and non-resilient, was "very thin," and did not provide a proper seal. The investigation could not determine the age of the gasket, or whether it was the correct part. The gasket was coated with a light layer of petroleum jelly on both sides, the fuel strainer was re-assembled, and the test was repeated. No abnormalities were observed.

Aircraft

Registration
N4467K
Reported as
Ryan Navion
Category
Airplane
Serial number
NAV-4-1467
Airframe hours
4,000
Engine
Continental E225, 225 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 1, 2009 · 5 hours before
Departed
OQU · Kingstown, RI
Destination
WWD · Wildwood, NJ

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Last flight review
October 27, 2008
Seat
Left
Flight hours
9,857 total · 120 in this make and model · 9,565 as pilot in command · 266 in the last 90 days · 103 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 48 °F
Altimeter
30.34 inHg
Observed at
ISP, 12 nm away

Docket · 10

The files NTSB released with the investigation on December 23, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 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 N4467K · 1

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