ERA12LA285

NTSB accident investigation · Willoughby Pete A Streak Shadow · Salem, WV · April 15, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
April 15, 2012, 17:30 local (21:30 UTC)
Place
Salem, WV
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2828WWilloughby Pete A Streak Shadow
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report May 23, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20120415006379A
Case key
83392

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

A total loss of engine power due to a piston seizure that resulted from a fuel system restriction and poorly secured fuel lines. Contributing to the accident were the pilot/builder’s failure to follow the engine manufacturer procedures and his use of nonaviation parts to secure fuel lines.

Findings · 3

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.

Engine fuel and control: fuel flow sensorAircraft › Aircraft power plant · Incorrect service/maintenanceWilloughby Pete A STREAK SHADOW: 1 caseAll aircraft: 3 casesProbable cause
Engine fuel and control: fuel distributionAircraft › Aircraft power plant · Incorrect service/maintenanceWilloughby Pete A STREAK SHADOW: 1 caseAll aircraft: 55 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Owner/builderWilloughby Pete A STREAK SHADOW: 1 caseAll aircraft: 371 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 pilot was attempting the first flight since the airplane was damaged in an accident about 2 years earlier and then “rebuilt.” Shortly after takeoff, the engine sputtered and lost all power. While the pilot was attempting to maneuver for a forced landing, the airplane collided with trees and terrain, resulting in substantial damage to the airframe and serious injuries to the pilot. Examination of the engine and fuel system revealed that the pistons were severely scored, indicative of a seizure. Examinations revealed that nonaviation tie wraps were used to secure the fuel lines to various fittings, and, in one location, no clamp was used. The airplane was equipped with an in-line fuel flow transducer. Disassembly of the engine revealed that the transducer incorporated a 2-millimeter (mm) jet. According to the engine manufacturer, no device with a diameter smaller than 5 mm should be installed anywhere in the fuel system. The transducer was installed on a test engine, and the engine ran normally up to 7,100 rpm with the 2-mm jet. When a small amount of air was introduced into the lines to replicate a poorly secured or unsecured fuel line, low fuel pressure and fluctuating rpm resulted, and subsequent examinations of the pistons showed signs of scoring damage.

Factual narrative

On April 15, 2012, about 1730 eastern daylight time, an experimental, amateur-built Willoughby Streak Shadow, N2828W, was substantially damaged following a loss of engine power and collision with terrain near Salem, West Virginia. The airline transport pilot was seriously injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The local flight was originating at the time of the accident. A Federal Aviation Administration inspector responded to the accident site and examined the wreckage. Structural damage to the wings was evident. The fuel tank was ruptured. No fuel was observed in the in-line fuel filter. The wreckage was recovered to a storage facility where a more detailed examination was conducted. The pilot stated that he was flying the aircraft for the first time since it was “rebuilt” after an accident two years prior. After ground operations, he took off to the west from the grass airstrip at his residence. Shortly after takeoff, above tree top level, approximately 150 feet above the ground, the engine sputtered and stopped running. He attempted a left turn to maneuver for an open area to perform a forced landing. The aircraft collided with trees on a hill adjacent to the airstrip. He did not recall any events after the collision. The engine and fuel system were examined at the pilot’s hangar on August 14, 2012. Partial disassembly of the engine revealed that the pistons exhibited severe scuffing and scoring, consistent with a seizure event. Inspection of the fuel lines revealed that there was a fuel flow transducer, manufactured by MGL, installed in-line, with a 2 millimeter (mm) jet. The fuel lines were secured with plastic tie wraps and in one area no fuel line clamp was used on a fitting. The fuel flow transducer was tested on another engine after the examination. A vacuum and pressure gauge were installed in the fuel system to observe any changes under various running conditions. The engine was started and ran normally up to 7,100 rpm with the fuel flow transducer installed (with the 2mm jet). Another run was attempted with a valve installed between the fuel flow transducer and the fuel pump to allow the introduction of air into the system to replicate unsecured or poorly secured fuel lines. With a small amount of air introduced while the engine was running, fuel flow dropped significantly, resulting in low fuel pressure and fluctuating rpm. After the engine run, the pistons were examined and they exhibited signs of scoring and cylinder polishing. According to the engine manufacturer, although there was no reduction in fuel flow or rpm with a 2mm jet installed in the transducer, there should be no device installed anywhere in the fuel system that is smaller than the minimum fuel line diameter of 5mm.

Aircraft

Registration
N2828W
Reported as
Willoughby Pete A Streak Shadow
Category
Airplane, amateur-built
Serial number
OSS912260003
Airframe hours
101
Engine
Rotax 582 Series, 64 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Martin Joseph K
Registered owner
Martin Joseph K
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · April 12, 2012 · 1 hours before
Departed
Salem, WV
Destination
Salem, WV
Airport
Private Airstrip

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
61
Injuries
Serious
Certificate
Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 30, 2011
Seat
Single
Flight hours
18,000 total · 101 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 50 °F
Altimeter
30.01 inHg
Observed at
CKB, 35 nm away

Docket · 5

The files NTSB released with the investigation on March 21, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 681 KB 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.