WPR17LA099

NTSB accident investigation · Diamond Aircraft Ind DA 40 NG · Goodyear, AZ · April 20, 2017

Accident · No injuriesClass 3 · LimitedFinal report
Date
April 20, 2017, 07:19 local (14:19 UTC)
Place
Goodyear, AZ
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N154BYDiamond Aircraft Ind DA 40 NG
Defining event
Emergency descent: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20170420007119A
Case key
95120

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

Loss of engine power due to the installation of an improper air induction hose, which failed and prevented sufficient air intake to the turbocharger.

Findings · 3

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.

Misc hardware: hoses and tubesAircraft › Fluids/misc hardware · Not serviced/maintainedDiamond Aircraft Ind DA 40 NG: 1 caseAll aircraft: 40 casesProbable cause
Turbocharging (recip only): turbochargerAircraft › Aircraft power plant · Incorrect service/maintenanceDiamond Aircraft Ind DA 40 NG: 2 casesAll aircraft: 29 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelDiamond Aircraft Ind DA 40 NG: 3 casesAll aircraft: 1,386 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 student pilot had been signed off for a solo instructional flight. He performed the preflight check, including a check of the engine control unit (ECU), and noted no discrepancies. The run-up and initial takeoff were normal. However, during the takeoff climb out, the student pilot noted an engine power change followed by an ECU A and ECU B failure annunciation. The student pilot was able to land in an open field and impacted several drainage ditches, resulting in substantial damage to the right wing. Inspection of the engine revealed that the hose that connects the air inlet to the turbocharger inlet was found to have de-laminated or collapsed. The loss of engine power was likely due to a partial vacuum in the turbo inlet and prevented the turbo from supplying the correct air inlet pressure to the engine, thus reducing power output. The investigation found that a generic air induction hose had been installed on the accident airplane that was not part number specific. The Diamond illustrated parts breakdown calls for a specific part number for two flexible induction hoses. The operator reported that they inspected their fleet of airplanes and replaced the generic hoses with Diamond Aircraft Industries Inc. (DAI) hose.

Factual narrative

On April 20, 2017, at 0719 hours mountain standard time, a Diamond Aircraft Industries DA-40NG, N154BY, was substantially damaged when it was involved in an accident near Goodyear, Arizona. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the student pilot, he was on his first solo flight after completing his pre-solo checkout exam. During the preflight check, the student pilot performed a check of the engine control unit (ECU). There were no discrepancies noted with the ECU, and the preflight check, run-up, taxi, and initial takeoff were normal. During the takeoff climb out, about 400 ft above ground level (agl), he heard a power change from the engine. As the student pilot checked the engine load indicator, which read 35%, he moved the power lever up and down to see if he had engine control; however, the engine load indicator remained at 35%. About 5 seconds later, he observed two annunciators illuminated, ECU A FAIL and ECU B FAIL. The airplane’s flight and systems data from the accident flight, captured by its Garmin G1000 integrated flight deck system download, revealed that the engine lost power near the departure end of runway 21 at an altitude of 1,560 ft. mean sea level and an airspeed of 88.6 knots. The data also revealed a sudden drop in engine load from 97% to 39% in less than 4 seconds. The student pilot reported that, because the flight school’s standard operating procedures advised students not to turn back to the airport below an altitude of 1,000 ft agl, he did not have sufficient altitude to turn back to the runway. The student pilot maneuvered to a field to the right of the airplane and attempted to attain an airspeed of 88 knots (glide speed). However, he stated that his altitude was low, and he did not think he was going to be able to clear the power lines around the field, so he decided to fly under the power lines. According to the pilot, as the airplane flew under the power lines, the airplane struck the bottom power line and a white flash appeared in the cockpit. The pilot also reported that, when the airplane first touched down in the field, it bounced. The operator reported that the airplane then impacted two drainage ditches before it came to rest near a third drainage ditch, resulting in substantial damage to the right wing. The pilot reported that he then switched off the fuel pumps, opened the canopy, and exited the airplane. A review of flight and systems data from the G1000 revealed both a nominal rpm change and a decrease in fuel flow during the takeoff; there was no engine roughness and no significant changes in oil temperature, oil pressure, and engine temperature. Postaccident examination of the turbocharger system revealed no visible abnormalities. When it was disassembled, evidence of oil loss was found at the turbocharger seals and outlet; the turbocharger was found to spin freely. Further inspection of thesystem revealed that the interior lining of the air induction hose between the alternate air valve and turbocharger showed signs of deterioration. The air induction hose was installed and tested on another aircraft. During the test, the engine lost power. A subsequent inspection of the air induction hose revealed that its inner liner had separated and collapsed in such a way that it prevented sufficient air intake to the turbocharger. The investigation found that a generic air induction hose had been installed on the accident airplane that was not part number specific. The Diamond illustrated parts breakdown calls for a specific part number for two flexible induction hoses. The operator reported that they inspected their fleet of airplanes and replaced the generic hoses with Diamond Aircraft Industries Inc. (DAI) hose.

Aircraft

Registration
N154BY
Reported as
Diamond Aircraft Ind DA 40 NG (NO SERIES)
Category
Airplane
Serial number
40.N302
Airframe hours
864.4
Engine
Austro E4-A, 168 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Ctc Aviation Leasing (US) Inc
Registered owner
Ctc Aviation Leasing (US) Inc
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · April 11, 2017 · 19.3 hours before
Departed
GYR · Goodyear, AZ
Destination
GYR · Goodyear, AZ
Airport
GYR · Phoenix Goodyear
Equipment
Electronic primary flight display, Electronic multifunction display, Data recorder, Auto-pilot

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
25
Injuries
None
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
14 total · 14 in this make and model · 0 as pilot in command · 14 in the last 90 days · 8 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 30 °F
Altimeter
29.97 inHg
Observed at
KGYR, 1 nm away

Docket · 7

The files NTSB released with the investigation on March 23, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.8 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.