WPR21LA072

NTSB accident investigation · Navion Navion A · Livermore, CA · December 21, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
December 21, 2020, 15:25 local (23:25 UTC)
Place
Livermore, CA · Airport environment
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N4106KNavion Navion A
Defining event
Approach-VFR pattern crosswind: Loss of engine power (total)
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
20201221019079A
Case key
102448

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 improper installation of the gascolator fuel inlet line and hose clamp connection, which resulted in the total loss of engine power.

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: installationPersonnel issues › Task performance · Maintenance personnelNavion NAVION A: 1 caseAll aircraft: 371 casesProbable cause
Fuel system: fuel distributionAircraft › Aircraft systems · Incorrect service/maintenanceNavion NAVION A: 1 caseAll aircraft: 141 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 airplane had an annual inspection and new wingtip fuel tanks installed about 6 months before the accident. The accident flight was the first flight since the maintenance. The pilot completed a normal runup inspection and the engine developed full power during takeoff. However, at an altitude of approximately 500 ft above ground level (agl), as the pilot turned onto the crosswind leg of the traffic pattern, the engine began to surge and lose power. As the pilot reduced the power for landing on the downwind leg, the engine lost total power. When the pilot realized the airplane would not make it to the runway, he prepared for a landing on the grass area parallel to the runway. The airplane touched down and the left wing impacted concrete blocks. A postaccident examination of the engine revealed a leaking gascolator fuel inlet line caused by a loose hose clamp connection on the fuel line from the fuel selector to the gascolator. The loose connection allowed a large amount of air to be introduced into the fuel line going to the engine and fuel pumps, which caused the engine to surge and eventually lose power. The examination also revealed several maintenance discrepancies. The leaking fuel inlet line was made of rubber instead of aluminum tubing, and the fuel selector's connection was improper. Additionally, the wingtip fuel tank installation revealed several inconsistencies with the installation, such as loose clamps and improper hardware installed. These discrepancies were an indication of improper recent maintenance.

Factual narrative

On December 21, 2020, at 1525 Pacific standard time, a Navion A, N4106K, was substantially damaged when it was involved in an accident near Livermore, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane had new wingtip fuel tanks installed in July 2020, and an annual inspection was completed at the same time. The accident flight was the first flight since the fuel tank installation. The pilot departed from runway 7R at Livermore Municipal Airport (LVK), after a normal runup inspection. The engine developed full power during takeoff; however, at an altitude of approximately 500 ft above ground level (agl), as the pilot turned onto the crosswind leg of the traffic pattern, the engine began to surge and lose power. As the pilot reduced the power for landing on the downwind leg, the engine lost total power. When the pilot realized the airplane would not make it to the runway, he prepared for a landing on the grass area parallel to the runway. The airplane touched down and the left wing impacted concrete blocks. A postaccident examination of the engine revealed a leaking gascolator fuel inlet line and a loose hose clamp connection on the fuel line from the fuel selector to the gascolator. The line was made of rubber instead of aluminum tubing, and the fuel selector's connection was improper. Additionally, the wingtip fuel tank installation revealed several inconsistencies with the installation, such as loose clamps and improper hardware installed.

Aircraft

Registration
N4106K
Reported as
Navion Navion A
Category
Airplane
Serial number
NAV-4-1106
Airframe hours
5,277
Engine
Continental Motors IO-520-BB3B, 205 horsepower, reciprocating
Damage
Substantial damage
Flight
Flight test · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 28, 2020 · 0.2 hours before
Destination
Same as departure
Airport
LVK · Livermore Muni, runway 25R, 5,253 × 100 ft, asphalt
Equipment
ADS-B, 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
82
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine sea, Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
August 8, 2019
Seat
Left
Restraint
Lap only
Flight hours
17,341 total · 10 in this make and model · 7,611 as pilot in command · 1 in the last 90 days · 1 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
61 °F, dew point 39 °F
Altimeter
30.02 inHg
Observed at
KLVK
METAR
KLVK 212253Z VRB03KT 10SM CLR 16/04 A3002 RMK AO2 SLP165 T01560039

Docket · 6

The files NTSB released with the investigation on August 23, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 45.4 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.