ERA10LA370

NTSB accident investigation · Piper PA-28R-200 · New Bern, NC · July 20, 2010

Accident · No injuriesLimited investigationFinal report
Date
July 20, 2010, 16:30 local (20:30 UTC)
Place
New Bern, NC
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8900EPiper PA-28R-200
Defining event
Initial climb: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report June 20, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Precision Airmotive, FAA/FSDO
FAA report
20100720043189A
Case key
76706

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Inadequate quality control at the fuel servo overhaul facility, which resulted in contamination of the fuel servo and a subsequent loss of engine power due to fuel starvation.

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.

Manufacture/production: equipment manufactureOrganizational issues › Development · ManufacturerPiper PA-28R-200: 1 caseAll aircraft: 36 casesProbable cause
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Not specifiedPiper PA-28R-200: 1 caseAll aircraft: 195 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 accident flight was the first flight after an overhauled fuel servo was installed on the airplane. During initial climb, about 600 feet above ground level, the engine experienced a partial loss of power. The pilot performed a 180-degree turn and attempted to land in the opposite direction of takeoff; however, the engine lost all power during final approach, and the airplane impacted a fence about 150 feet prior to the runway. Examination of the wreckage did not reveal any anomalies with the airframe or engine, and adequate fuel was onboard. A subsequent teardown examination of the fuel servo revealed that small, clear, spherical particles were found on the threads of the inlet fitting and plug of the fuel inlet screen. The particles were consistent with glass beads and were also found in the manual mixture control valve chamber and on the unmetered side of the fuel diaphragm. One particle was found underneath the diaphragm. According to the Federal Aviation Administration principle maintenance inspector of the company that overhauled the fuel servo, the glass beads found in the accident fuel servo were similar to the glass beads used by the company. Although the company did not bead-blast their fuel servos, bead-blasting was performed in other locations in the factory, including areas approximately 20 feet from where the fuel servos were overhauled.

Factual narrative

On July 20, 2010, about 1630 eastern daylight time, a Piper PA-28R-200, N8900E, operated by Tradewind Aviation International, was substantially damaged during impact with a fence, following a loss of engine power while departing Coastal Carolina Regional Airport (EWN), New Bern, North Carolina. The certificated commercial pilot and passenger were not injured. The maintenance test flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. According to a Federal Aviation Administration (FAA) inspector, the engine was recently overhauled and the airplane flew uneventfully during several subsequent flights, for a total of approximately 6 hours. During that time, pilots reported difficulty starting the engine. Once the engine was started, there were no other problems during the flights. Through trouble-shooting, a certificated airframe and powerplant mechanic diagnosed the starting problem as the result of a faulty fuel servo. The mechanic replaced the fuel servo with an overhauled fuel servo. The accident flight was the first flight after the overhauled fuel servo was installed. During takeoff from runway 22, the engine experienced a partial loss of power, about 600 feet above ground level. The pilot performed a 180-degree turn and attempted to land in the opposite direction of takeoff, on runway 4; however, the engine lost all power during final approach, and the airplane impacted a fence about 150 feet prior to the runway. During the impact, the nosegear, fuselage, and both wings were substantially damaged. Examination of the wreckage by the FAA inspector revealed fuel system continuity and fuel present to the fuel servo. That fuel was recovered from the fuel lines and no contamination was noted. The fuel strainer located at the firewall was also absent of visible contamination. The right fuel tank was compromised during impact and evidence of a fuel spill was observed near the accident site. The left fuel tank remained intact and contained fuel. When the FAA inspector moved the fuel selector from "RIGHT" to "LEFT," fuel flowed freely from the selector. Following recovery, further examination of the airplane by a mechanic did not reveal any evidence of catastrophic engine failure. The fuel servo and fuel flow divider were retained for further examination. A teardown examination of the fuel servo and fuel flow divider was performed at the manufacturer's facility, under the supervision of an FAA inspector. During the examination, small, clear, spherical particles were found on the threads of inlet fitting and plug of the fuel inlet screen. The particles were consistent with glass beads and were also found in the manual mixture control valve chamber and on the unmetered side of the fuel diaphragm. One particle was found underneath the flow divider diaphragm. The fuel servo and flow divider flowed within limits when tested after theaccident. According to the FAA principle maintenance inspector (PMI) of the company that overhauled the fuel servo, the glass beads found in the accident fuel servo were similar to the glass beads used by the company. Although the company did not bead-blast their fuel servos, bead-blasting was performed in other locations in the factory, including areas approximately 20 feet from where the fuel servos were overhauled. The PMI did not know how the glass beads entered the accident servo and did not discover any other servos with contamination; however, he planned additional inspections of the company. The recorded weather at EWN, at 1654, included clear skies and wind from 230 degrees at 8 knots.

Aircraft

Registration
N8900E
Reported as
Piper PA-28R-200
Category
Airplane
Serial number
28R-7635219
Airframe hours
6,347
Engine
Lycoming IO-360, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Tradewind Aviation International LLC
Registered owner
Tradewind Aviation International LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 16, 2010 · 7 hours before
Departed
EWN · New Bern, NC
Destination
EWN · New Bern, NC
Airport
EWN · Coastal Carolina Regional, runway 04, 6,004 × 150 ft

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
28
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 26, 2009
Seat
Left
Flight hours
893 total · 11 in this make and model · 853 as pilot in command · 105 in the last 90 days · 23 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 72 °F
Altimeter
30.06 inHg
Observed at
EWN

Docket · 11

The files NTSB released with the investigation on May 5, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.2 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.