WPR16LA101

NTSB accident investigation · Antonov AN2 · San Bernardino, CA · May 6, 2016

Accident · No injuriesLimited investigationFinal report
Date
May 6, 2016, 12:00 local (19:00 UTC)
Place
San Bernardino, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2ANAntonov AN2
Defining event
Enroute: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed · report May 1, 2017
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
FAA Riverside FSDO, Confederate Air Force
FAA report
20160506008979A
Case key
93115

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 mechanic’s failure to inspect the fine fuel filter gascolator as required during the most recent inspection, which resulted in a total loss of engine power due to fuel contamination.

Findings · 2

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.

Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelAntonov AN-2: 1 caseAll aircraft: 320 casesProbable cause
Fuel system: fuel filter-strainerAircraft › Aircraft systems · Not serviced/maintainedAntonov AN-2: 1 caseAll aircraft: 52 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 commercial pilot was entering the airport traffic pattern for landing during a familiarization flight. He reported that he turned on the carburetor heat, switched the fuel tank selector to the right fuel tank, and shortly thereafter, the engine experienced a total loss of power. The pilot attempted numerous times to restart the engine but was unsuccessful. After realizing that he would not be able to reach the runway, he decided to make a forced landing to a small field. During the landing approach, the airplane contacted a power line, nosed over, and came to rest inverted, resulting in substantial damage to the wings and fuselage. During the postaccident examination of the airplane, about 16 ounces of water were removed from the fuel system. Water was present in the lower gascolator, the fine fuel filter (upper gascolator), and subsequent fuel line to the carburetor inlet. A brass screen at the carburetor inlet and 2 carburetor fuel bowl thumb screens also contained corrosion, water, and rust. The approved aircraft inspection checklist called for washing the carburetor and main fuel filter every 50 hours and cleaning and/or replacing the fine fuel filter every 100 hours. The fine fuel filter is not easily accessible and not able to be drained during a preflight inspection. The mechanic who completed the most recent inspection stated that he did not drain or check the fine fuel filter. The last logbook entry that specifically stated the fuel filters were cleaned was about 4 years before the accident.

Factual narrative

On May 06, 2016, about 1200 Pacific daylight time, an ANTONOV AN2 airplane, N2AN, sustained substantial damage during a forced landing, following a reported loss of engine power during approach to the San Bernardino International Airport, San Bernardino, California. The airplane was owned by the American Airpower Heritage Flying Museum, and was being operated by the pilot as a familiarization flight under the provisions of 14 Code of Federal Regulations Part 91. The commercial pilot and sole passenger were not injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight. The airplane departed the Cable Airport, Upland, California, about 1145. In a telephone conversation with the National Transportation Safety Board investigator-in-charge, the pilot stated that the flight was a familiarization flight for a new member of their chapter of the Commemorative Air Force. The flight departed the Cable airport and flew east along the mountains, headed to San Bernardino. They contacted the San Bernardino tower and were instructed to enter the crosswind for runway 24. As part of the before landing checklist, the pilot turned on the carburetor heat and switched the fuel tank selector to the right fuel tank. Shortly thereafter, the engine lost all power. The pilot attempted numerous times to restart the engine, but was unsuccessful. The pilot realized that he would not be able to reach the airport, and decided to make a forced landing to a small field in a residential area. During the landing approach, the airplane contacted a power line. After touching down in the field the airplane nosed over and came to rest inverted, which resulted in substantial damage to the wings and fuselage. During the NTSB examination of the airplane, about 16 ounces of water was removed from the fuel system. Water was present in the lower gascolator, the fine fuel filter (upper gascolator), and subsequent fuel line to the carburetor inlet. A brass screen at the carburetor inlet and 2 carburetor fuel bowl thumb screens also contained corrosion, water and rust. (See Photo 1.) Photo 1 - Fuel and contamination removed from fuel lines and gascolator The approved aircraft inspection checklist called for washing the carburetor and main fuel filter every 50 hours and cleaning and/or replacing the fine fuel filter every 100 hours. The fine fuel filter located halfway up the firewall on the left side of the aircraft is not easily accessible and not in a position to be drained prior to flight. The mechanic that completed the most recent inspection stated that he did not drain or check the fine fuel filter. The last logbook entry that specifically stated the fuel filters were cleaned was in September 2012.

Aircraft

Registration
N2AN
Reported as
Antonov AN2
Category
Airplane
Serial number
43798
Built
1984
Airframe hours
2,924
Engine
PZL ASH 62 IR, 1,000 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
American Airpower Heritage Flying Museum, doing business as Confederate Air Force
Registered owner
American Airpower Heritage Flying Museum
Airworthiness certificate
Special, Experimental (Special)
Last inspection
AAIP · December 1, 2015 · 14 hours before
Departed
CCB · Upland, CA
Destination
SBD · San Bernardino, CA
Equipment
None

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
77
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
August 16, 2014
Seat
Left
Restraint
Lap only
Flight hours
3,350 total · 58 in this make and model
Role
Pilot-rated passenger
Age
44
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
May 4, 2016
Seat
Right
Restraint
Lap only
Flight hours
4,000 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
320° at 4 knots
Visibility
7 statute miles
Lowest ceiling
3,500 ft overcast
Temperature
63 °F, dew point 48 °F
Altimeter
29.88 inHg
Observed at
KSBD, 1 nm away

Docket · 6

The files NTSB released with the investigation on March 13, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.3 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.