# NTSB ERA10LA370: Piper PA-28R-200, N8900E, New Bern, NC, July 20, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 20, 2010, 16:30 local (20:30 UTC) - Place: New Bern, NC - Coordinates: 35.073055, -77.043052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.0731&lon=-77.0431&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 20, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Precision Airmotive, FAA/FSDO - NTSB case key (mKey): 76706 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA370 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76706/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76706 - Page: https://openairdocs.org/ntsb/ERA10LA370 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Manufacture/production: equipment manufacture](https://openairdocs.org/ntsb-findings/04013010): Organizational issues › Development · Manufacturer (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/04013010/cases.md?model=7102811), [All aircraft, 36 cases](https://openairdocs.org/ntsb-findings/04013010/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=7102811), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28R-200, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102811), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Piper PA-28R-200, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=7102811), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28R-200, 32 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102811), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-200, 45 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102811), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N8900E-2011-11-29), registration cancelled 2011-11-29, S/N 28R-7635219, built 1976 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7635219 - Airframe hours: 6347 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; 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 ## 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 20100720043189A](https://openairdocs.org/incident/20100720043189A), Jul 20, 2010: Piper PA-28R-200, New Bern, NC, Destroyed. Scenario: the aircraft had a reduction of engine power at about 400 feet AGL after take off from runway 22 with full length of 6004 feet available. Pilot… ## Docket (11 files) The files NTSB released with the investigation on May 5, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76706. 10.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343576&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Interview Summaries (item 2, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344180&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Mechanic Statement (item 3, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344181&FileExtension=.PDF&FileName=Mechanic%20Statement-Redacted.PDF - Report From Fuel Servo Manufacturer (item 4, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347289&FileExtension=.PDF&FileName=Report%20From%20Fuel%20Servo%20Manufacturer-Redacted.PDF - Evidence Control Forms (item 5, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343578&FileExtension=.PDF&FileName=Evidence%20Control%20Forms-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343579&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1: Main Wreckage in Field (Photo Courtesy of FAA) (item 7, .PDF, 875 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343580&FileExtension=.PDF&FileName=Photo%201%3A%20%20Main%20Wreckage%20in%20Field%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2: Accident Fuel Servo, Main Metering Orifice With Debris (Photo Courtesy of Precision) (item 8, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343581&FileExtension=.PDF&FileName=Photo%202%3A%20%20Accident%20Fuel%20Servo,%20Main%20Metering%20Orifice%20With%20Debris%20(Photo%20Courtesy%20of%20Precision)-Master.PDF - Photo 3: Accident Fuel Servo, Fuel Diaphragm With Debris (Photo Courtesy of Precision) (item 9, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343582&FileExtension=.PDF&FileName=Photo%203%3A%20Accident%20Fuel%20Servo,%20Fuel%20Diaphragm%20With%20Debris%20(Photo%20Courtesy%20of%20Precision)-Master.PDF - Photo 4: Accident Fuel Servo, Idle Plug With Debris (Photo Courtesy of Precision) (item 10, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343583&FileExtension=.PDF&FileName=Photo%204%3A%20Accident%20Fuel%20Servo,%20Idle%20Plug%20With%20Debris%20(Photo%20Courtesy%20of%20Precision)-Master.PDF - Photo 5: Additional Debris Recovered From Accident Fuel Servo (Photo Courtesy of Precision) (item 11, .PDF, 342 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40343584&FileExtension=.PDF&FileName=Photo%205%3A%20Additional%20Debris%20Recovered%20From%20Accident%20Fuel%20Servo%20(Photo%20Courtesy%20of%20Precision)-Master.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.