# NTSB ERA12LA555: Pitcairn PA-4, N3261, Rawlings, MD, September 9, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 9, 2012, 09:45 local (13:45 UTC) - Place: Rawlings, MD - Coordinates: 39.467224, -78.957778 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4672&lon=-78.9578&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report September 12, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 84986 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA555 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84986/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84986 - Page: https://openairdocs.org/ntsb/ERA12LA555 ## Probable cause A total loss of engine power due to fuel starvation, which resulted from a fuel outlet in the fuel tank that was blocked by peeled debris from a previously approved fuel tank sealer. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Damaged/degraded (probable cause); cases with it: [Pitcairn PA-4, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=7180102), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel; cases with it: [Pitcairn PA-4, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=7180102), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Pitcairn PA-4, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=7180102), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Pitcairn PA-4, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=7180102), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Pitcairn PA-4, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=7180102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airplane was climbing through about 150 to 200 feet above ground level after takeoff when the engine lost total power, and the pilot performed a forced landing to a nearby pasture. The airplane descended, impacted the ground, and came to rest on the right side of the fuselage. A postaccident examination of the engine revealed no preimpact mechanical anomalies that would have precluded normal operations. The carburetor bowl and fuel lines contained a trace amount of fuel. Upon further examination, debris was discovered in the fuel tank, and large sections of a material were peeling from the fuel tank walls. In addition, there were rusty areas in the fuel tank. The fuel tank outlet did not contain a fuel screen for fuel to travel through when exiting the tank. Maintenance records indicated that in April 1990, the accident airplane had undergone major repairs and alterations, which included sealing of the fuel tank with a sloshing sealer, use of which was approved at the time. However, in 2009, the Federal Aviation Administration released a Special Airworthiness Information Bulletin stating that over time, that sloshing sealer could deteriorate and peel from the internal wall of the fuel tank. Pieces of the sealer could then block the fuel tank outlet, potentially starving the engine of fuel. It was not possible to determine to what extent maintenance personnel examined the fuel tank during the most recent annual inspection, which was completed in September 2012. It is likely that the sloshing sealer compound that was applied to the fuel tank in 1990 had peeled off the inner wall of the fuel tank and blocked the fuel outlet, resulting in fuel starvation of the engine and the subsequent total loss of engine power. ## Factual narrative On September 9, 2012, at 0945 eastern daylight time, N3261, a Pitcairn PA-4, sustained substantial damaged when it impacted terrain after departing from a private airstrip in Rawlings, Maryland. The airline transport pilot was seriously injured. The airplane was registered to and operated by an individual under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight. The flight was originating at the time of the accident. According to a witness, who helped start the engine of the accident airplane, the pilot fueled the airplane and sampled the fuel from each of the fuel sumps under the engine with no contamination noted. The engine was primed with fuel, started, idled for approximately 10 minutes, and ran "smoothly" prior to takeoff. According to the pilot, after takeoff, the airplane was about 150 to 200 feet above ground level when the engine began to gradually lose power. The pilot noted that the engine did not experience any roughness or surging prior to the total loss of engine power. He elected to land in a nearby pasture and initiated a slight left turn to align the airplane with the field. As the airplane continued to descend, the pilot initiated another shallow left turn to avoid striking trees as well as further align the airplane with the field. However, before he was able to level the wings, the airplane struck the ground with the left wing. After ground impact, the airplane turned about 180 degrees and came to rest on the right side of the fuselage, which resulted in substantial damage to the wings and fuselage. According to Federal Aviation Administration (FAA) records, the airplane was manufactured in 1927, and was registered to the pilot in 1998. The airplane was a three-place, metal and fabric design, single-engine, biplane with conventional landing gear. It was equipped with a Wright Curtiss OX5, 90-horsepower engine. In addition, the airplane was equipped with a 32 gallon aluminum fuel tank. The most recent annual inspection was performed on September 3, 2012, and at that time it had accumulated 2877.7 hours of total time in service. According to FAA Form 337 for major repairs and alterations of the airplane, it underwent restoration and major repairs in April 1990. The mechanic stated on the form that it was disassembled, inspected, and cleaned. In the description of maintenance, it noted “fuel tank cleaned, checked for leaks and sealed with Randolph Sloshing Sealer.” According to a Maryland Department of State Police report, a local fire department responded to the accident site for a small fuel spill. The fuel tank was about one-half full. A postaccident examination of the engine revealed that engine continuity was confirmed. The exhaust valves functioned with no anomalies. The spark plugs were examined with no abnormalities noted. The fuel cap was inspected and was secure on the fuel tank. The fuelstrainer was removed, with no debris noted. The carburetor bowl was removed from the engine and it contained a few drops of fuel. The fuel lines contained a trace amount of fuel. The fuel tank was void of fuel as a result of how the wreckage came to rest on the right side of the fuselage and partially inverted. Further examination of the fuel tank with a light and borescope revealed debris in the tank and large sections of a material peeling from the tank walls. In addition, there were rust areas throughout the interior of the fuel tank. The outlet of the fuel tank did not contain a fuel screen for fuel to travel through when exiting the tank. In February 2009, Piper Aircraft Inc. released a mandatory service bulletin, Service Bulletin No. 251D, concerning Randolph Products Company Sloshing Sealer. The service bulletin stated “the use of Randolph Products Company 802 Sloshing Sealer was authorized at one time to repair aluminum wing tanks that develop leaks in service. It has been discovered that over time, the cured sealer can separate and detach from the inner walls of the tank and become an obstruction in fuel lines and fuel filters, resulting in a loss of engine power.” In April 2009, the FAA released a Special Airworthiness Information Bulletin (SAIB) for several Piper Aircraft models regarding Randolph 802 sealer. The bulletin stated that the “purpose of this SAIB is to highlight the potential of engine fuel starvation from the environmental deterioration of a sloshing compound.” In addition, the “sloshing compound can peel from the wall of the fuel tank and block the fuel tank outlet, which can starve the engine of fuel.” The SAIB recommended that if the sloshing compound was found to be separating from the inner walls of the fuel tank, the fuel tank should be replaced. Then, in October 2010, an Advisory Circular 43-16A “Aviation Maintenance Alerts Number 387”was distributed concerning sloshing compound that resulted in fuel starvation of a Bird CK airplane. The airframe and powerplant mechanic stated that the airplane was fully restored and Randolph sloshing compound was used to seal the fuel tank. About ten months after the restoration was complete, the airplane experienced a total loss of engine power just after takeoff. An FAA inspector who examined that airplane discovered material in the fuel and large portions of sloshing compound was missing from the sides of the fuel tank. ## Aircraft - Registration: [N3261](https://openairdocs.org/aircraft/N3261), registered now, S/N 5, built 1927 (OpenAirDocs) - Reported make and model: PITCAIRN PA-4 - Registry model: [Pitcairn PA-4](https://openairdocs.org/model/pitcairn-pa-4) (registry code 7180102) (OpenAirDocs) - Registry engine: [Wright CURTISS OX5](https://openairdocs.org/engine/wright-curtiss-ox5) (registry code 67002, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 5 - Airframe hours: 2877 - Engines: WRIGHT CURTISS OX5 90 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 3, 2012 - Departed: Rawlings, MD - Destination: Rawlings, MD - Airport: Private Airstrip, runway 20, 1,700 × 180 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: serious; airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 16, 2012; seat: rear; flight hours: 15,076 total, 78 in this make and model, 14,231 as pilot in command, 46 in the last 90 days, 11 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 6,000 ft broken - Temperature: 70 °F - Altimeter: 29.97 inHg - Observed at: 5 nm away ## Docket (13 files) The files NTSB released with the investigation on June 4, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84986. 7.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 746 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384542&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384543&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Witness Statement (item 3, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384544&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - FAA Inspector Statement (item 4, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384545&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - Memorandum of Record: FAA Inspector (item 5, .PDF, 328 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389949&FileExtension=.PDF&FileName=Memorandum%20of%20Record%3A%20FAA%20Inspector-Master.PDF - Excerpt from Maryland State Police Report (item 6, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389101&FileExtension=.PDF&FileName=Excerpt%20from%20Maryland%20State%20Police%20Report-Redacted.PDF - FAA Form 337: Major Repairs and Alterations (item 7, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389239&FileExtension=.PDF&FileName=FAA%20Form%20337%3A%20Major%20Repairs%20and%20Alterations-Redacted.PDF - Maintenance Log Excerpts (item 8, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384546&FileExtension=.PDF&FileName=Maintenance%20Log%20Excerpts-Redacted.PDF - Piper Service Bulletin Feb. 2009: Randolph Sloshing Compound (item 9, .PDF, 561 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389238&FileExtension=.PDF&FileName=Piper%20Service%20Bulletin%20Feb.%202009%3A%20Randolph%20Sloshing%20Compound-Master.PDF - Excerpt from Aviation Maintenance Alert Oct 2010 with Special Airworthiness Information Bulletin (item 10, .PDF, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384547&FileExtension=.PDF&FileName=Excerpt%20from%20Aviation%20Maintenance%20Alert%20Oct%202010%20with%20Special%20Airworthiness%20Information%20Bulletin-Master.PDF - Weather Observations (item 11, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384548&FileExtension=.PDF&FileName=Weather%20Observations-Master.PDF - Diagram of Private Airport (Google Earth) (item 12, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389952&FileExtension=.PDF&FileName=Diagram%20of%20Private%20Airport%20(Google%20Earth)-Master.PDF - Photo 1: View of Airplane Damage (Courtesy of FAA) (item 13, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384552&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20Airplane%20Damage%20(Courtesy%20of%20FAA)-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.