WPR16LA107

NTSB accident investigation · Cessna 208B · Acampo, CA · May 12, 2016

Accident · Minor injuriesLimited investigationFinal report
Date
May 12, 2016, 14:13 local (21:13 UTC)
Place
Acampo, CA
Injuries
1 minor, 17 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1114ACessna 208B
Defining event
Enroute-climb to cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report March 19, 2018
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Adminsitration, P&W Canada, Cessna Aircraft, Blackhawk Modifications Inc
FAA report
20160512007799A
Case key
93159

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

A total loss of engine power due to a fatigue fracture of the fuel pressure line that connected the fuel control unit and the fuel flow transducer due to vibration as the result of a fatigue fracture of an associated support clamp. Contributing to the accident was the mechanic’s inadequate inspection of the fuel line support clamp during the previous replacement of the fuel line.

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.

Engine fuel and control: fuel distributionAircraft › Aircraft power plant · FailureCessna 208B: 1 caseAll aircraft: 55 casesProbable cause
InspectionPersonnel issues › Task performance · Maintenance personnelCessna 208B: 2 casesAll aircraft: 29 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 reported that, after takeoff on the local skydiving flight, the engine experienced a total loss of power. He initiated a turn toward the airport, but realized the airplane would not reach the runway and chose to perform a forced landing to an open field. During the landing roll, the airplane exited the field, crossed a road, impacted a truck, and continued into a vineyard, where it nosed over. Postaccident examination of the engine revealed that the fuel pressure line that connects the fuel control unit to the airframe fuel pressure transducer was fractured below the fuel control unit fitting's swaged seat. In addition, a supporting clamp for the fuel pressure fuel line was fractured and separated. The operator reported that the fractured fuel line had been replaced the night before the accident and had accumulated about 4 hours of operational time. The previously-installed line had also fractured. Metallurgical examination of the two fractured fuel lines revealed that both fuel lines fractured due to reverse bending fatigue through the tube wall where a ferrule was brazed to the outside of the tube. There were no apparent anomalies or defects at the crack initiation sites. Examination of the supporting clamp determined that it fractured due to unidirectional bending fatigue where one of the clamp's tabs met the clamp loop, with the crack initiating along the inward-facing side of the clamp. The orientation of the reverse bending fatigue cracks and the spacing of the fatigue striations on the tube fracture surfaces were consistent with high-cycle bending fatigue due to a vibration of the tube. The cushioned support clamp is designed to prevent such vibrations from occurring. However, if the clamp tab is fractured, it cannot properly clamp the tube and will be unable to prevent the vibration. The presence of the fractured clamp combined with the fact that the two pressure tubes failed in similar modes in short succession indicated that the clamp most likely failed first, resulting in the subsequent failure of the tubes. Since the clamp was likely fractured when the first fractured fuel pressure line was replaced, the clamp was either not inspected or inadequately inspected at the time of the maintenance.

Factual narrative

On May 12, 2016, about 1413 Pacific daylight time, a Cessna 208B, N1114A, was substantially damaged during a forced landing near Acampo, California. The airplane was registered to Flanagan Enterprises (Nevada) INC., and operated by the Parachute Center under the provisions of 14 Code of Federal Regulations Part 91. The commercial pilot sustained minor injuries and his 17 passengers were not injured. Visual meteorological conditions prevailed and no flight plan was filed for the skydiving flight. The local flight originated about 1 minute prior to the accident. The pilot reported that following takeoff from runway 26, he made a right turn and continued his climb for the skydive drop, however, as the airplane passed 1,000 ft above ground level (agl), the engine lost power. The pilot initiated a turn toward the airport, however, realized he was unable to make it, and landed in an open field. During the landing roll, the airplane exited the field, crossed a road, impacted a truck, continued into a vineyard, and nosed over. Examination of the airplane by a Federal Aviation Administration inspector revealed that the fuselage and left wing were substantially damaged. The wreckage was recovered to a secure location for further examination. Examination of the recovered wreckage was conducted on May 17 and 18, 2016. The engine remained partially attached to the fuselage. The fuel pressure line that connects the fuel control unit to the airframe fuel pressure transducer, Pratt & Whitney Canada (PWC) part number 3033981, was fractured below the fuel control unit fitting swaged seat. The supporting clamp, PWC part number 3006614, was fractured and was separated from its mating fuel pressure fuel line, PWC part number 3032010. In addition, the airframe P3 air line that provides air to the vacuum system exhibited a hole within the tube. The operator reported that they had replaced the fuel line, PWC part number 3033981, the night before the accident due to the original fuel line being fractured. They stated that the new fuel line had about 4 hours of operational time since the installation. Review of the maintenance logbooks revealed that an entry regarding the replacement of the fuel line was dated April 11, 2016, with no airframe, engine, or HOBBS meter times listed. The operator was further questioned about what manual they used regarding engine maintenance and they replied they used the manufacturers manual for all engine related maintenance. When questioned about the supporting clamp, PWC part number 3006614, the operator stated that the clamp was attached at the time of the fuel line replacement. Both the new and old fuel lines and separated clamp were sent to the National Transportation Safety Board Materials Laboratory for further examination. A Senior Materials Engineer examined the fuel lines and clamp and reported that the fuel line fracture surfaces were examined with the aid of a digital optical microscope and a scanning electron microscope andboth fractured tubes were found to exhibit features consistent with crack initiation due to reverse bending fatigue. The metal band of the clamp was fractured near the intersection of the tab and the loop portion of the clamp. The fracture surfaces were examined and exhibited features consistent with crack initiation at the inward-facing side of the tab due to bending fatigue. The fracture surface exhibited a comparatively flat appearance with curved crack progression marks on the fracture surface consistent with the crack initiating on the inward-facing side of the tab. For further information, see the Materials Laboratory Factual Report within the public docket for this accident.

Aircraft

Registration
N1114A
Reported as
Cessna 208B (B)
Category
Airplane
Serial number
208B0309
Built
1992
Airframe hours
12,848.9
Engine
P&W PT6A SER, turbo prop
Damage
Substantial damage
Flight
Skydiving · Part 91
Operator
Parachute Center
Registered owner
Flanagan Enterprises (Nevada) Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 10, 2016 · 69 hours before
Departed
1O3 · Acampo, CA
Destination
1O3 · Acampo, CA
Airport
1O3 · Lodi

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
64
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
March 2, 2015
Seat
Left
Restraint
3-point
Flight hours
7,050 total · 253 in this make and model · 6,680 as pilot in command · 80 in the last 90 days · 25 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 54 °F
Altimeter
29.95 inHg
Observed at
KSAC, 21 nm away

Docket · 7

The files NTSB released with the investigation on November 21, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 11.0 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.