WPR09FA102

NTSB accident investigation · Siai-Marchetti SF-260C · Santa Monica, CA · January 29, 2009

Accident · FatalField investigationFinal report
Date
January 28, 2009, 17:05 local (Jan 29, 2009, 01:05 UTC)
Place
Santa Monica, CA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N688CSiai-Marchetti SF-260C
Defining event
Takeoff: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed · report May 11, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lycoming
FAA report
20090128001369A
Case key
73286

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

The pilot’s failure to select the proper fuel tank for takeoff, which resulted in a loss of engine power. Contributing to the accident was the pilot's failure to maintain aircraft control while attempting a return to runway maneuver.

Findings · 6

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.

Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationSiai-Marchetti SF-260C: 1 caseAll aircraft: 176 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotSiai-Marchetti SF-260C: 1 caseAll aircraft: 9,295 casesProbable cause
Fluids: fuelAircraft › Fluids/misc hardware · Fluid managementSiai-Marchetti SF-260C: 1 caseAll aircraft: 1,695 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedSiai-Marchetti SF-260C: 1 caseAll aircraft: 1,269 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

Witnesses observed the airplane climb normally after takeoff until reaching an altitude between 200 to 400 feet, then the engine sound stopped. The airplane appeared to slow down as it made a right turn followed by a descending spin until impacting the runway. The main wing tanks had been topped off about 1 week before the accident by another pilot. The pilot reported that he taxied the airplane to the hangar with the fuel selector valve in the right tip fuel tank position per standard operating procedures for the airplane. The pilot stated that a small amount of fuel was in the tip tank; however, the exact quantity was not able to be determined. Postaccident on-site examination of the wreckage revealed that the fuel tank selector valve handle appeared to be in the right tip fuel tank position. Based on detailed examination of the selector, and the nature of the cockpit structure deformation, it was later determined that the fuel tank selector valve was out of its detent and was actually between the Right Tip Tank and the Both Tip Tank selections. The fuel tank selector was probably moved out of the selector detent as a result of the crushing forces and structural deformation around the selector handle during the impact sequence. The fuel tank selector valve assembly was disassembled and found to be operational. The approved airplane flight manual for the airplane indicated that the selector valve should be positioned on the left wing tank for starting. Both the manual and the placards on the instrument panel stated that the use of “Tip Tank” and “both Tips” is limited to level flight only. The airframe and engine were examined with no mechanical anomalies identified.

Factual narrative

HISTORY OF FLIGHT On January 28, 2009, about 1705 Pacific standard time, an experimental Siai-Marchetti SF-260C, N688C, crashed during takeoff following a loss of engine power at Santa Monica Municipal Airport (SMO), Santa Monica, California. The pilot was operating the borrowed airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certificated private pilot and passenger were killed; the airplane was substantially damaged by impact forces and the post crash fire. The local personal flight was departing SMO at the time of the accident. Visual meteorological conditions prevailed, and no flight plan was filed. During takeoff witnesses observed the airplane climb normally until reaching an altitude between 200 to 400 feet, then the engine sound suddenly stopped. The airplane appeared to slow down as it made a right turn followed by a descending spin until impacting the ground between Runway 21-3 and taxiway A. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 45-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and helicopter. The pilot held a third-class medical certificate issued on March 2, 2007. It had no limitations or waivers. No personal flight records were located for the pilot. The aeronautical experience listed in this report was obtained from FAA airmen medical records on file in the Airman and Medical Records Center. The pilot reported on his most recent medical application that he had a total time of 1,400 flight hours. In May 2008, the insurance company for the accident airplane added the pilot to the approved pilot list for the airplane. At that time the pilot reported 1,600 hours total flight time, with 5 hours in make and model. The owner of the airplane estimated that the accident pilot had accumulated about 20 hours of flight time in the make and model airplane involved in the accident. AIRCRAFT INFORMATION The airplane was a Siai-Marchetti, SF-260C, serial number 466 (37-004). A review of the airplane’s logbooks revealed that the airplane had a total airframe time of 3,654.6 hours at the last condition inspection, which was completed on July 1, 2008. The airplane was powered by a Textron Lycoming IO-540-D4A5, serial number L-19695-40, rated at 260 horsepower. Total time recorded on the engine at the last 100-hour inspection was 2,845.2 hours; time since major overhaul was 1,512.9 hours. Fueling records at SMO established that the airplane was last fueled on January 20, 2009, with the addition of 11.7 gallons of 100LL-octane aviation fuel, topping off the main wing tanks. The pilot who refueled the airplane stated that after refueling he taxied the airplane back to the hangar with the right tip fuel tank selected, which he reported was standard operating procedure in this airplane. He also stated that the tip tanks had a very small amount of fuel; the exact quantity was undetermined. Examination of themaintenance records revealed no unresolved maintenance discrepancies against the airplane and or engine prior to departure. COMMUNICATIONS The airplane was cleared for departure by Santa Monica tower Air Traffic Controllers. No distress transmissions were recorded from the pilot prior to the accident. AIRPORT INFORMATION The Airport Facility Directory, Southwest U. S., indicated that SMO runway 21 was 4,973 feet long and 150 feet wide. The runway surface was asphalt. WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident site. The accident site was located on the northwest side of runway 21/3 on turnoff A-1 between taxiway A and runway 21/3. The first identified point of contact (FIPC) was a ground scar, which was an impression of the right wing with scrape marks and paint transfer oriented towards the main wreckage. The debris field was contained within a 50-foot radius of the main wreckage. The fuselage was orientated on a 300-degree heading. Extensive thermal and impact related damage was noted to both wings and fuselage. The tail section sustained thermal and impact damage, but to a lesser degree than the wings and fuselage. During documentation of the accident site investigators observed the fuel tank selector valve handle appeared to be selected to the right tip fuel tank. The valve and handle assembly was examined on site and it was determined that the assembly was physically frozen in place due to the aircraft structure crushing around the selector assembly. The extensive impact damage and crushing forces upon the airplane structure around the fuel tank selector assembly made it difficult to positively identify the actual position of the fuel valve selector prior to the examination. The fuel tank selector valve assembly was cut from the main wreckage and secured for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The Los Angeles County Coroner completed an autopsy on the pilot on January 31, 2009. The cause of death was listed as the result of multiple traumatic injuries. The FAA Civil Aerospace Medical Institute (CAMI), Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and tested drugs. TESTS AND RESEARCH Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on March 10, 2009. The airframe and engine were examined with no mechanical anomalies identified. Investigators examined the fuel valve selector assembly at Stealth Aviation, Santa Monica, California, on April 14, 2009. The investigators determined that the fuel tank selector valve, which was originally believed to be positioned to the right tip tank position, was actually positioned out of its detent and was between the Right Tip Tank and the Both Tip Tank selection, as a result of the impact forces displacing the selector valve. The fuel tank selector valve assembly was disassembled andfound to be operational and undamaged. The fuel tank selector valve has five selection positions; Left Tip Tank, Left Main Tank, Right Main Tank, Right Tip Tank, and Both Tip Tanks. ADDITIONAL INFORMATION A review of the approved airplane flight manual for the Siai-Marchetti F260 revealed that the use of “Tip Tank” and “both Tips” is limited to level flight only. The Normal Operating Procedures sections indicated that before starting the engine, the fuel selector valve should be positioned on the left wing tank. Investigators noted during the post accident examination that there was a placard on the instrument panel which stated “USE WING TIP TANKS IN LEVEL FLIGHT ONLY.”

Aircraft

Registration
N688C
Reported as
Siai-Marchetti SF-260C
Category
Airplane
Serial number
466 (37-004)
Airframe hours
3,655
Engine
Lycoming AEIO-540-D4A5, 260 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
100 hour · July 1, 2008 · 90 hours before
Departed
SMO · Santa Monica, CA
Destination
SMO · Santa Monica, CA
Flight plan
Unknown
Airport
SMO · Santa Monica Municipal Airport, runway 21, 4,973 × 150 ft, asphalt

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
46
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Right
Flight hours
1,600 total · 5 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 19 °F
Altimeter
30.13 inHg
Observed at
SMO, 1 nm away

Docket · 21

The files NTSB released with the investigation on March 12, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.8 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.