CEN23FA314

The pilot’s decision to operate an airplane with known fuel leaks, his failure to conduct an engine run-up before takeoff, his subsequent failure to abort the takeoff, and the mechanic’s inadequate maintenance, which resulted in a partial loss of right engine power during takeoff due to fuel starvation as a result of blocked fuel injector ports.

The pilot was flying the airplane on an FAA Special Flight Permit to another location to complete maintenance and an overdue annual inspection. The airplane had been abandoned, with its most recent flight being 8 years before, and chained to a tree in an agricultural field adjacent to the airport from August 2021 until December 2022 when it was purchased by the current owner. Before the accident flight, an attempt was made to top off the airplane’s fuel tanks. However, fuel started to leak from multiple locations and only three fuel tanks were able to be fueled. The pilot asked the mechanic about the leaks; the mechanic stated that the filler necks were leaking, and the lineman had attempted to top off the fuel tanks instead of the previously agreed upon lower level. The pilot then completed a brief preflight inspection before starting the airplane. During engine start, the pilot requested the mechanic’s assistance three times to ask about various issues that the mechanic talked him through. The pilot then taxied to the runway and departed without performing an engine run-up. Multiple cellphone video recordings of the takeoff sequence showed the airplane veer to the right and attempt to rotate before settling back to the runway. The recordings then showed the airplane become airborne near the end of the runway end and initially yaw to the right before it entered a shallow climb. The witnesses observed the airplane barely clear a line of trees past the departure end of the runway and make a left turn before it disappeared behind trees. Analysis of the video recordings showed that rotation was at a ground speed of about 70.8 knots, corresponding to an estimated air speed of about 74.8 knots, which was significantly below the recommended rotation speed of 85 knots. A witness north of the airport heard a loud airplane that appeared from behind trees and headed toward his residence. He observed the airplane strike two static wires on a power transmission line before it impacted the canopy of a large tree in his front yard. The airplane continued in a left bank toward a nearby soybean field and impacted the terrain in a nose-low, left bank attitude. Distribution of the wreckage and damage signatures observed during postaccident examination were indicative of an off field forced landing. Postaccident examinations revealed no evidence of mechanical malfunctions or failures with the airframe, left engine, or propellers that would have precluded normal operation. Extensive preimpact vegetation and animal debris were found on and in the airplane, indictive of long-term abandonment. The right propeller displayed indications consistent with low power. Examination of the right engine showed corrosion of the induction housing assembly with corrosion debris in the floor of the housing, all fuel injector ports and fully blocking two fuel injectors. The right turbocharger showed no rotational witness marks, which was consistent with low to no right engine power. Additionally, video and sound spectrum analysis showed the right propeller RPM being 100 RPM lower than the left propeller during the takeoff roll. Postaccident examination and interviews with the mechanic revealed that very little maintenance or inspections were performed on the airplane before it was issued a Special Flight Permit by the local FAA Flight Standards District Office (FSDO). Based on the evidence, the right engine likely had a partial loss of engine power due to deterioration of the internal components related to the long-term abandonment of the airplane. Contributing to the accident was the mechanic’s failure to disclose to both the pilot and the FAA the actual extent of the unairworthy condition of the airplane. There was no evidence that the pilot’s medical condition contributed to the accident.

All flight history and hours were obtained through the pilot’s FAA medical certificate applications due to his pilot logbook not being located. The pilot’s recent and make/model experience was not available. Multiple witnesses reported that the airplane was chained to a tree in an agricultural field adjacent to GPH from August 2021 until December 2022 due to its previous owner being evicted from the airport. Before the eviction, the airplane’s last recorded annual inspection was on August 15, 2015, with a tachometer (tach) time of 1182.2 hours. A propeller inspection record on May 19, 2019, still reported a tach time of 1182 hours. According to the same witnesses, the owner and a mechanic with airframe and powerplant ratings worked on the airplane for about six months; the most recent annual inspection was completed in 2015. Two witnesses reported that during an engine ground run about two weeks before the accident, the right engine was difficult to start and would not produce full power. The witnesses also stated that the inboard fuel tanks leaked “horribly” when the airplane was fueled. About two weeks before the accident, the owner received a Special Airworthiness Certificate: Special Flight Permit to ferry the airplane from Mosby, Missouri, to Kingman, Kansas, to complete an annual inspection. Witnesses and the mechanic reported that two or three pilots declined to perform the ferry flight for the owner before the accident pilot agreed to take the flight. An interview of the mechanic was performed via telephone on July 26, 2023. During the interview, the mechanic stated that the only work performed before the accident flight was replacing the nose and one main landing gear tire, servicing the brakes, a landing gear swing, replacement of burnt wiring in the right engine, and several maintenance engine runs. The Special Flight Permit was requested so the airplane could be ferried back to the mechanic’s hangar in Kingman, Kansas, for maintenance. The mechanic stated that he knew about the fuel leaks coming from the various tanks and further stated that it was an item to be fixed once the ferry flight was complete. Additionally, he and the owner spent several days vacuuming out various bird nests and debris from the airplane. During engine start, the mechanic stated that the pilot contacted him several times to ask about various issues, such as the location of the radio master switch, how to transfer fuel between fuel tanks, and the left vacuum pressure gauge being inoperative. The Special Airworthiness Certificate: Special Flight Permit for a one-time maintenance ferry flight between GPH to Clyde Cessna Field (9K8) was issued by a Kansas City Federal Aviation Administration (FAA) Flight Standards District Office inspector on June 29, 2023, and then reissued on July 11, 2023, with an expiration date of July 23, 2023. The airplane was inspected, and a logbook entry was recorded with a tach time of 1192.2 hours by the mechanic on June 28, 2023, for the one-time ferry flight. Part of the logbook entry stated that the mechanic removed the emergency locator beacon (ELT) for repair during his inspection. However, postaccident examination showed that the ELT was in the airframe cradle with an undisturbed animal nest in the antenna wiring. The animal nest had to be removed by investigators to disconnect the antenna from the ELT (See Figure 3.) Figure 3. ELT as found during the postaccident examination. Additionally, the mechanic stated that he reviewed the applicable airworthiness directives (AD) and part of the ferry flight logbook entry stated that he “checked the Ads.” Paperwork provided as part of the application for the permit showed that the ADs were signed off by an apprentice and not the mechanic as stated in the logbook entry. The FAA Inspector who issued the Special Airworthiness Certificate, when asked what actions he performed while issuing the permit, stated that he assisted the owner’s wife in completing the application electronically in the FAA Airworthiness Certification (AWC) tool web portal and reviewed the application via the same portal. He also stated that he did not physically inspect the airplane or logbooks due to no “indication that there was something wrong with the airplane [or] that it wasn’t safe for the flight.” When asked if he had reviewed the AD Compliance Report provided with the application, he stated that he was not sure he saw a specific AD report. He stated that, “the log entry said that the ADs had been checked. I didn’t see an actual itemized report except from the previous inspection.” Forensic Medical of Kansas performed the pilot’s autopsy for Clay County, Missouri. According to the pilot’s autopsy report, his cause of death was inhalation of the products of combustion and thermal injuries, and his manner of death was accident. His autopsy identified evidence of hypertensive cardiovascular disease, with an enlarged heart and dilated cardiac ventricles. His cardiac pacemaker was identified and recovered. The pilot’s pacemaker interrogation summary report provided no clear evidence of a potentially impairing arrhythmia leading up to the time of the crash. Episodes of elevated atrial rate lasting seconds to minutes, without rapid ventricular rate, were recorded hours before the crash. The FAA Forensic Sciences Laboratory also performed toxicological testing of postmortem specimens from the pilot. Carboxyhemoglobin was measured at 20% in femoral blood. Warfarin, carvedilol, and valsartan were detected in femoral blood and liver tissue. Carboxyhemoglobin is formed when carbon monoxide binds to hemoglobin in blood, diminishing the blood’s ability to deliver oxygen to body tissues. Carbon monoxide is an odorless, tasteless, colorless, nonirritating gas that can be produced during hydrocarbon combustion. Exposure to carbon monoxide usually occurs by inhalation of smoke or exhaust fumes. Nonsmokers normally have carboxyhemoglobin levels of less than 1-3%, while heavy smokers may have levels as high as 10-15%. Warfarin is a prescription blood thinning medication with a variety of uses, including to help prevent stroke in people who have atrial fibrillation/flutter. Warfarin is not typically impairing, although the medication and the conditions it treats may convey some medical risks. According to the FAA medical case review for this accident, warfarin is conditionally acceptable for pilots, requiring case-by-case Authorization for Special Issuance for medical certification. Caffeine is a central nervous system stimulant that is commonly ingested, including in coffee, tea, soft drinks, and chocolate; caffeine also is an ingredient in certain anti-drowsiness medications and headache medications. Carvedilol and valsartan are prescription medications that can be used to treat high blood pressure and heart failure. Caffeine, valsartan, and valsartan are not generally considered impairing. Postaccident examination of the accident site revealed that the airplane impacted terrain in a relatively flat agricultural field about 1.6 nautical miles north of the runway. The first impact point consisted of struck electrical wires that were located about 735 ft before the main wreckage and were about 65 ft above ground level (agl). The second identified point of contact was a tree canopy impact about 60 ft agl and 150 ft after the wire strike. The airplane then impacted the ground, and a debris path extended into the field about 313 ft on a heading of 254°, to where the main wreckage came to rest. The main wreckage consisted of the fuselage, empennage, left wing, and the inboard portion of the right wing. The outboard 4 ft of the right wing was found separated about 210 ft from the first ground impact point. The left propeller and gear reduction drive were found separated and located on the right side of the debris path about 30 ft from the airplane (See figure 4) Figure 4