MIA05LA071

NTSB accident investigation · Piper PA-24-260 · Merritt Island, FL · March 7, 2005

Accident · No injuriesLimited investigationFinal report
Date
March 7, 2005, 13:00 local (18:00 UTC)
Place
Merritt Island, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9446PPiper PA-24-260
Weather
Visual (VMC) · Day
Status
Completed · report April 25, 2006
Report
Approved by Office Director
Parties
Orlando FSDO-15, New Piper Aircraft, Inc.
FAA report
20050307003249A
Case key
61103

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

The owner/pilot/mechanics inadequate installation of a fuel line resulting in a fuel leak, partial loss of engine power, and force landing in swampy terrain.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - nonmechanicalTakeoff - initial climb
Maintenance,installation - inadequateOwner/pilot mechanicCause
Fuel system,line fitting - not secured
Fuel system,line fitting - leak
Forced landingEmergency landing after takeoff
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - swampy

Analysis

The owner/pilot mechanic stated that during a maintenance test flight for a newly overhauled engine, he slowly started losing engine power at approximately 300 feet of altitude during the initial takeoff climb. He elected to turn left to return to the airport and not having enough altitude impacted with the swampy terrain, on the west side of lagoon. During the return to airport maneuver, he switched the fuel selector from the left tank to right tank and then back to left tank with no correction to the partial loss of power. He noted the fuel flow indicator want from 28 to 17. The owner/pilot mechanic performed two ground run up checks to the engine to about 2,200 rpms. He did not note any discrepancies during those checks. After the recovery of the accident airplane an engine examination was conducted by the owner/pilot mechanic and a representative of the New Piper Aircraft, Inc. with FAA oversight. During the fuel flow test, the electrical fuel pump was energized; the fuel out line at the fuel servo supplying fuel to the flow divider was observed spraying fuel and the B-nut was found loose. The fuel flow test was stopped. The line's B-nut was tightened and the test resumed. A test of the fuel mixture flow noted a rich mixture flow of approximately 7 gallons an hour while a mixture lean noted a flow of approximately 4 gallons an hour. A review of the accident airplane's maintenance log book document the engine installation work was completed per Lycoming O/H # 60294-7 (Textron Lycoming, Part number 60294-7, Overhaul Manual for Direct Drive Engine). Textron Lycoming, Service Instruction No. 1427B, outlines for the overhauled engine to have a ground run check up to full-static recommended power for a period of no more then 10 seconds. The full-static power for the accident airplane as per the airplane's flight manual is 2,700 rpm, with turbocharger control off. After operating the engine at full power, allow for cooling, check idle mixture and shutdown. The Piper PA-24-260, Comanche, Service Manual, 7A-33, details the procedures for engine installation; including cautions and warning pertaining to fluid leaks on the airframe components.

Factual narrative

On March 7, 2005, about 1300 eastern standard time, a Piper PA-24-260, N9446P, registered to and operated by a private individual, as a Title 14 CFR Part 91 maintenance test flight, crashed in a swampy area on the shoreline of the New Found Harbor Lagoon, during a return to the airport after takeoff, at the Merritt Island Airport, Merritt Island , Florida. Visual meteorological conditions prevailed and no flight plan was filed. The airline transport-rated pilot received no injuries, and the airplane incurred substantial damage. The flight was originating at the time.

The owner/pilot mechanic stated the purpose of the flight was for a maintenance test flight of a newly overhauled engine, which he performed. It was a normal power takeoff, departing from runway 11, and at approximately 300 feet of altitude, the engine slowly started losing power. He elected to return to the airport by turning towards the left. During the return to airport maneuver, he switched the fuel selector from the left tank to right tank, and then back to left tank. The partial loss of power did not correct. He could not maintain altitude and impacted with the swampy terrain, on the west side of the lagoon.

The owner/pilot mechanic added the airplane had been sitting in the hanger for about 6 weeks awaiting the overhauled engine, which included new ECI cylinders and crankcase shaft. The fuel system was overhauled about one year before. He performed two ground run up checks to the engine to about 2,200 rpms. He did not note any discrepancies during those checks. He had about 60 to 70 gallons of fuel on board. He did not refuel before the accident flight. He noted, during the accident flight, the fuel flow indicator went from 28 to 17.

After the recovery of the accident airplane an engine examination was conducted by the owner/pilot mechanic and a representative of New Piper Aircraft with FAA oversight. During the fuel flow test, the electrical fuel pump was energized; the fuel out line at the fuel servo supplying fuel to the flow divider was observed spraying fuel and the B-nut was found loose. The fuel flow test was stopped. The line's B-nut was tightened and the test resumed. The fuel mixture test noted a mixture rich fuel flow of approximately 7 gallons an hour while mixture lean noted a fuel flow of approximately 4 gallons an hour.

A review of the accident airplane's maintenance log book pages provided by the owner/pilot mechanic documents the overhauled engine was installed on March 6, 2005. "The engine was removed and reinstalled after complete overhaul, new shock mounts installed, engine ground run with no defects and all operations normal. Work completed per Lycoming O/H # 60294-7" (Textron Lycoming, Part number 60294-7, Overhaul Manual for Direct Drive Engine).

Textron Lycoming, Service Instruction No. 1427B, outlines for the overhauled engine to have a ground run check up to full-static recommended power for a period of no more then 10 seconds. The full-static power for the accident airplane as per the airplane's flight manual is 2,700 rpm, with turbocharger control off. After operating the engine at full power, allow for cooling, check idle mixture and shutdown. The Piper PA-24-260, Comanche, Service Manual, 7A-33, details the procedures for engine installation, including cautions and warning pertaining to fluid leaks on the airframe components.

Aircraft

Registration
N9446P
Reported as
Piper PA-24-260
Category
Airplane
Serial number
24-4954
Airframe hours
4,845
Engine
Lycoming IO-540, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Kenneth Rivard
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2004 · 85 hours before
Departed
COI · Titusville, FL
Airport
COI · Merritt Island Airport

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
66
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine sea, Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 1, 2003
Seat
Left
Flight hours
18,800 total · 300 in this make and model · 18,800 as pilot in command · 60 in the last 90 days · 20 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 45 °F
Altimeter
30.03 inHg
Observed at
MLB, 15 nm away

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.