# NTSB WPR12LA070: Ryan Navion, N4398K, Concord, CA, December 27, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: December 27, 2011, 15:30 local (23:30 UTC) - Place: Concord, CA - Coordinates: 37.996112, -122.061111 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.9961&lon=-122.0611&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report March 13, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Continental Motors, Inc, Federal Aviation Administration - NTSB case key (mKey): 82575 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA070 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82575/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82575 - Page: https://openairdocs.org/ntsb/WPR12LA070 ## Probable cause The pilot's inadequate preflight inspection of the airplane and the subsequent total loss of engine power as a result of debris and water contamination in the fuel system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Ryan NAVION, 2 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=6150160), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Ryan NAVION, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=6150160), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Not serviced/maintained (probable cause); cases with it: [Ryan NAVION, 1 case](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=6150160), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Ryan NAVION, 1 case](https://openairdocs.org/ntsb-events/193/sequence.md?model=6150160), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Ryan NAVION, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6150160), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that shortly after takeoff, the engine lost power, and during the subsequent attempt to return to the airport, the airplane collided with the terrain. A postaccident examination of the engine fuel system revealed that the fuel in the accumulator sump and the carburetor inlet screen line were contaminated with debris and water. It is likely that the loss of engine power was due to this contamination as no further evidence of a mechanical malfunction or failure that would have precluded normal operation was found. ## Factual narrative HISTORY OF FLIGHT On December 27, 2011, about 1530 Pacific standard time (PST), a Ryan Navion, N4398K, experienced a loss of engine power shortly after takeoff from Buchanan Field Airport, Concord, California. The airplane subsequently landed hard on airport property and was substantially damaged. The owner/pilot was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger were seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed. Witnesses reported that during takeoff from runway 32R, the airplane was about 250-300 feet above the runway when the engine sounded like it had lost power. The airplane was observed making a banking left turn as it descended toward the parallel runway 14R. The pilot reported that during takeoff as the airplane approached the departure end of runway 32R, the engine quit without warning. He knew that at his current altitude a safe return to the runway was unlikely. He made a left turn away from the busy highway in front of him, and then realized he was headed towards a hangar and made another left turn with added left rudder to avoid the hangar. The pilot lost control of the airplane as it descended to the ground. The airplane hit the ground in a flat, wings level attitude, and slid approximately 100 feet before coming to rest in the dirt area near the approach end of runway 14R. TESTS AND RESEARCH Investigators examined the wreckage at National Aviation Logistics, Madera, California, on January 11, 2012. The airframe and engine were examined with no mechanical anomalies identified that would have precluded normal operation. A detailed examination report with accompanying pictures is contained in the public docket for this accident. The fuel system for the Ryan Navion consists of two aluminum alloy fuel tanks, holding approximately 20 gallons each. An accumulator tank, mounted between the two tanks in the center of the fuselage and interconnected with each, has a capacity of approximately 3/4 gallon. Fuel from both main tanks is gravity fed into the accumulator. From the accumulator, fuel is supplied to the carburetor by an engine driven pump. An emergency electric fuel pump is provided supplying 12 pounds (lbs) fuel pressure for use on takeoff and landing, and in the event of an engine driven fuel pump failure. Examination of the fuel system revealed that the fuel removed from the wing tanks was blue in color, with no sediment or contamination noted. The fuel sample obtained from the fuel line to the carburetor inlet screen was light blue and contained debris. The fuel sample from the accumulator sump was brown in color and had debris; it tested positive for water. ## Aircraft - Registration: [N4398K](https://openairdocs.org/deregistered/N4398K-2012-11-29), registration cancelled 2012-11-29, S/N NAV-4-1398, built 1948 (OpenAirDocs) - Reported make and model: RYAN NAVION - Registry model: [Ryan NAVION](https://openairdocs.org/model/ryan-navion) (registry code 6150160) (OpenAirDocs) - Registry engine: [Continental E185 series](https://openairdocs.org/engine/continental-e185-series) (registry code 17014, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-1398 - Airframe hours: 4717 - Engines: CONT MOTOR E225 SERIES 225 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 20, 2011, 54 hours before - Departed: CCR, Concord, CA - Destination: CCR, Concord, CA - Airport: CCR, Concord/ Buchanan Field, runway 32R, 4,602 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 23, 2010; seat: left; flight hours: 1,718 total, 1,518 in this make and model, 1,698 as pilot in command, 11 in the last 90 days, 8 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 36 °F - Observed at: CCR ## 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 20111227029999A](https://openairdocs.org/incident/20111227029999A), Dec 27, 2011: Ryan NAVION, Concord, CA, Destroyed. Pilot performed a take off on runway 32R, Concord, CA..at an altitude of approximately 200 feet the engine quit, pilot banked aircraft left, lowered the… ## Docket (6 files) The files NTSB released with the investigation on January 25, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82575. 16.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385049&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - N4398K Airframe and Engine Logbook (item 2, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384329&FileExtension=.PDF&FileName=N4398K%20Airframe%20and%20Engine%20Logbook-Redacted.PDF - NTSB Examination Report- 13 Embedded Photos (item 3, .PDF, 13 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384330&FileExtension=.PDF&FileName=NTSB%20Examination%20Report-%2013%20Embedded%20Photos-Master.PDF - Continental Motors Examination Report (item 4, .PDF, 48 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385520&FileExtension=.PDF&FileName=Continental%20Motors%20Examination%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 5.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384332&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40385046&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.