ERA15LA341

Maintenance personnel’s inadequate fuel injection servo maintenance due to an out-of-date AD list, which resulted in the fuel injection servo plug backing out of the threaded plug hole on the regulator cover of the fuel injection servo and subsequent total loss of engine power.

While the airline transport pilot was flying a practice instrument approach in visual meteorological conditions, the airplane incurred a total loss of engine power. During the forced landing, the fuselage and wings were substantially damaged. Postaccident examination of the engine revealed that the brass fuel injection servo plug had backed out of the threaded plug hole on the regulator cover of the fuel injection servo and was hanging below the fuel servo by a piece of safety wire. The missing plug likely resulted in the engine running excessively lean and losing power. In the 7 years between the manufacturer’s discovery that the fuel injection servo plug could back out of the regulator cover hole, and the accident, the manufacturer had published a safety alert, a mandatory service bulletin, and two service information letters (SILs) advising of the issue and recommending corrective actions to prevent a loss of engine power, all of which were applicable to the accident airplane. The Federal Aviation Administration had also published three airworthiness directives (ADs) mandating the specified changes developed by the manufacturer. Review of the maintenance records for the airplane and engine revealed no entries that indicated when the fuel injection servo had been last overhauled; if any of the actions published in the safety alert, mandatory service bulletin, SILs had been accomplished; or if any maintenance had occurred that would have required removal and reinstallation of the plug. Further review of the maintenance records also indicated that the mechanic who had been maintaining the airplane for about 10 years used a service provider to provide him with ADs; however, the AD list was not current, and none of the three ADs were included in the published AD list. Thus, the ADs had not been accomplished for the airplane.

Narrative medical and pathological information place holder Narrative meteorological information place holder According to Federal Aviation Administration (FAA) and pilot records, the pilot held an airline transport pilot certificate with ratings for airplane multi-engine land, commercial privileges for airplane single-engine land. He also held a flight instructor certificate with ratings for airplane single, multiengine, and instrument airplane, and a basic ground instructor certificate. His most recent FAA second-class medical certificate was issued on January 26, 2015. He reported that he had accrued 17,661 total hours of flight experience, of which, 5,000 hours were in the accident airplane make and model. Examination of the wreckage revealed no evidence of any preimpact failure or malfunction of the airframe. Examination of the engine revealed that the brass regulator hex plug (fuel injection servo plug) had backed out of the threaded plug hole on the regulator cover of the fuel injection servo and was hanging below the fuel injection servo by a piece of safety wire. Further examination revealed that the brass hex plug, had no lettering or numbers scribed or stamped on it, the threads in the regulator cover were damaged, and the gasket was missing. According to FAA and airplane maintenance records, the airplane was manufactured in 1980. The airplane's most recent annual inspection was completed on March 24, 2015. At the time of inspection, the airplane had accrued approximately 5,575 total hours of operation. On September 4, 2015, about 1317 central daylight time, a Piper PA-28RT-201; N8162S, was substantially damaged during a forced landing after a loss of engine power near Russell Springs, Kentucky. The airline transport pilot was not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91. The flight departed from Blue Grass Airport (LEX), Lexington, Kentucky, and was destined for Russell County Airport (K24), Jamestown, Kentucky. According to the pilot, He departed LEX with approximately 36 gallons of fuel for his planned 30 minute flight to K24. Starting and engine runup were normal. After takeoff, he climbed the airplane to 3,500 feet above mean sea level (msl) on a direct route for K24. Upon arrival in the area of K24, he decided to conduct a practice RNAV (GPS) RWY 17 approach in visual meteorological conditions. He crossed the initial approach fix at 3,500 feet; the airplane was performing normally. Manifold pressure was 24 inches of mercury, the tachometer indicated 2,300 rpm, and fuel flow was 10.5 gallons per hour. All temperatures and pressures were normal. At the initial approach fix he also completed the prelanding check, with the exception of extending the landing gear. The fuel selector was on the left tank, the electric boost pump was on, and the mixture control lever was full rich. At the final approach fix, he reduced engine power for the descent to 2,700 feet msl. Then after leveling off, he advanced the throttle lever but there was no response from the engine. He then cycled the electric boost pump switch, varied the mixture control setting, and switched to the right fuel tank without result. The pilot realized that the airplane was losing altitude, and now was at 1,200 to 1,500 feet above ground level. It became obvious to him that he would not be able to make the runway and he was committed to an off airport landing. He then saw a field to his right and turned towards it. There was a tree line between him and the field. He determined that he would be able to clear the trees but had to bank the airplane to line up with the field. He crossed the tree line at 80 knots indicated airspeed and then extended the landing gear and added two "notches" of flaps. He then observed that there was a pond where he thought the airplane would touch down, so he "aggressively" applied full up elevator to assure that the nose of the airplane would clear the pond and not hit the bank on its far edge. After touching down in the field, when the airplane came to a stop, he assessed his condition. He was bleeding heavily from his head but did not have any other injuries. He applied a handkerchief to his head wound, turned off all the electrical equipment, and egressed. Narrative communications place holder Narrative damage to aircraft place holder Narrative fire place holder Narrative flight recorders place holder Narrative injuries to persons place holder Narrative organizational and management information place holder Narrative other damage place holder Narrative survival aspects place holder Narrative useful or effective investigation techniques place holder Narrative airport information place holder About 7 years prior to the accident, the possibility of the brass hex plug backing out of the threaded plug hole on the regulator cover of the fuel injection servo had been identified, and since that time a number of actions had been taken by Precision Airmotive and the FAA to prevent a recurrence. These actions included: - On March 3, 2008, Precision Airmotive published a safety alert advising to immediately inspect all aircraft equipped with RSA-5 or RSA-10 fuel servos which had new, rebuilt, overhauled, or repaired engine and/or servos installed since August 1, 2006. when they learned of two incidents relating to RSA-10ED1 fuel injection servos where the brass hex plug had backed out of the threaded plug hole on the regulator cover of the fuel injection servo. - On March 12, 2008, the FAA issued emergency airworthiness directive (AD) 2008-06-51, regarding certain Precision Airmotive RSA-5 and RSA-10 series fuel injection servos to prevent a lean running engine, which could result in a substantial loss of engine power and subsequent loss of control of the airplane. This AD resulted from eighteen reports of fuel injection servo plugs (P/N 383493), that had loosened or completely backed out of the threaded plug hole on the regulator cover of the fuel injection servo. These servo plugs were installed with servo plug gasket (P/N 365533), under the plug hex-head. The AD required inspecting servo plugs for looseness and damage on fuel injection servos that have a servo plug gasket (P/N 365533), installed, inspecting the servo regulator cover threads for damage, inspecting the gasket for damage, reinstalling acceptable parts, and torqueing the servo plug to a new, higher torque to help maintain the proper clamp-up force against the plug and cover. - On March 21, 2008, Precision Airmotive published service information letter (SIL) RS-87 to advise of a new regulator plug gasket (P/N 2577258) and increased torque on the regulator plug for all RSA-5 and RSA-10 fuel injection servos. - On April 16, 2008, Precision Airmotive published Mandatory Service Bulletin PRS-107, which required immediate action prior to the next flight unless the actions required by AD 2008-06-51 had been accomplished, and required continued periodic inspections to determine if the hex plug was loose until accomplishment of the terminating actions that were listed were accomplished. - On April 18, 2008, the FAA issued AD-2008-08-14 superseding AD 2008-06-51, and approving an alternate means of compliance by accomplishing the terminating actions of Precision Airmotive Mandatory Service Bulletin PRS-107. - On June 16, 2008, Precision Airmotive published SIL RS-88, after receiving information from the FAA relating to Service Bulletin PRS-107, that operators in response to PRS-107, reported to the FAA of finding "loose" regulator hex plugs on fuel injection servos that did not appear to fall within the date range specified on that bulletin. Quantification of "loose" had been anecdotal in nature and it was unknown how those determinations were made. Nonetheless, to ensure safety, Precision Airmotive recommended that