ERA16FA289

A total loss of power in both engines due to fuel starvation as a result of the pilot's fuel mismanagement, and his subsequent failure to follow the emergency checklist. Contributing to the pilot's failure to follow the emergency checklist was his lack of emergency procedures training in the accident airplane.

The private pilot and five passengers departed on a day instrument flight rules cross-country flight in the multiengine airplane. Before departure, the airplane was serviced to capacity with fuel, which corresponded to an endurance of about 5 hours. About 1 hour 45 minutes after reaching the flight's cruise altitude of 12,000 ft mean sea level, the pilot reported a failure of the right engine fuel pump and requested to divert to the nearest airport. About 7 minutes later, the pilot reported that he "lost both fuel pumps" and stated that the airplane had no engine power. The pilot continued toward the diversion airport and the airplane descended until it impacted trees about 1,650 ft short of the approach end of the runway; a postimpact fire ensued. Postaccident examination of the airframe and engines revealed no preimpact failures or malfunctions that would have precluded normal operation. The propellers of both engines were found in the unfeathered position. All six of the fuel pumps on the airplane were functionally tested or disassembled, and none exhibited any anomalies that would have precluded normal operation before the accident. Corrosion was noted in the right fuel boost pump, which was likely the result of water contamination during firefighting efforts by first responders. The airplane was equipped with 4 fuel tanks, comprising an outboard and an inboard fuel tank in each wing. The left and right engine fuel selector valves and corresponding fuel selector handles were found in the outboard tank positions. Given the airplane's fuel state upon departure and review of fuel consumption notes in the flight log from the day of the accident, the airplane's outboard tanks contained sufficient fuel for about 1 hour 45 minutes of flight, which corresponds to when the pilot first reported a fuel pump anomaly to air traffic control. The data downloaded from the engine data monitor was consistent with both engines losing fuel pressure due to fuel starvation. According to the pilot's operating handbook, after reaching cruise flight, fuel should be consumed from the outboard tanks before switching to the inboard tanks. Two fuel quantity gauges were located in the cockpit overhead switch panel to help identify when the pilot should return the fuel selectors from the outboard fuel tanks to the inboard fuel tanks. A flight instructor who previously flew with the pilot stated that this was their normal practice. He also stated that the pilot had not received any training in the accident airplane to include single-engine operations and emergency procedures. It is likely that the pilot failed to return the fuel selectors from the outboard to the inboard tank positions once the outboard tanks were exhausted of fuel; however, the pilot misdiagnosed the situation as a fuel pump anomaly.

TCL was located 3 miles northwest of Tuscaloosa, Alabama, at an elevation of 169.9 ft. It had two runways: 4/22 and 12/30. Runway 4/22 was 6,499 ft long by 150 ft wide, and runway 12/30 was 4,001 ft long by 100 ft wide. At the time of the accident, the airport had an operating control tower between the hours of 0500-2200. Engine-Driven Fuel Pump Examinations The right engine-driven fuel pump was examined at the manufacturer facility. The drive coupling was intact but would not rotate; therefore, it was disassembled for further examination. The relief valve diaphragm was thermally damaged but remained intact. The drive coupling was removed; the drive tang did not exhibit any damage and the teeth were intact. The rear bearing of the pump remained intact and was not cracked. The rear bearing O-ring was pliable. The rear carbon bearing was removed and revealed that the pump liner and rotor exhibited corrosion. The main bearing did not exhibit any cracks or chips. There were no anomalies noted with the right engine-driven fuel pump. The left engine-driven fuel pump examination revealed that the fuel pump drive coupling was intact, and the fuel pump rotated in both directions by hand. The fuel pump was mounted to a test stand and in a cruise power setting, it had a low outlet pressure. When the lock nut was loosened a half turn to adjust the pressure, the engine driven fuel pump passed the cruise power flow test requirements. Emergency Fuel Pump Examinations The right engine emergency fuel pump was examined at the manufacturer facility and revealed all surfaces of the pump were black and thermally discolored. The pump was disassembled, and the flow control was in the partial bypass position and unable to move as a result of corrosion. The rotor and cavity chamber were discolored, and the vanes were seized in the rotor slots. There was no evidence of a coil winding overheat condition present in the electric fuel pump. There were no anomalies noted with the right engine electric fuel pump aside from the postimpact fire damage. The left engine emergency fuel pump examination revealed that the flow control/relief valve was in the partial bypass position in the flow housing. The flow control valve moved without anomaly. The electric fuel pump was mounted to a test bench and operated within all pressure, flow, and current limits. The pump was disassembled, and no anomalies were noted that would have precluded normal operation. Fuel Boost Pump Examinations The right fuel boost pump was examined at the manufacturer facility. The pump exhibited thermal damage to the exterior. When looking into the outlet port, the non-metal portions of the relief/bypass valve assembly were melted away. When the pump was handled, soot fell out of the fluid ports. Further disassembly of the right fuel boost pump revealed that the wear plate spring, the aluminum housing, blades, and rotor were corroded. The field assembly magnets were fractured and thermally damaged. The left fuel boost pump examination revealed that the cable-actuated ball valve was in the open position. The pump was installed onto a test stand and operated with manufacturer test requirements for operating pressure, fuel flow volume, and electrical consumption in amperes. Engine Data Monitor – JPI An engine data monitor was recovered from the cockpit and forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC, for data download. Review of the downloaded data revealed that the accident flight was recorded in its entirety from 0851 to 1120. According to the data, the right engine exhibited an erratic fuel flow beginning around 1105. The recorded fuel flow continued to be erratic and increased to around 110 gallons per hour until the fuel flow decreased at the end of the recording. The right engine turbine inlet temperature, exhaust gas temperature, and cylinder head temperatures all began decreasing within a few minutes after the right engine fuel flow became erratic. The left engine fuel flow became erratic around 1113. The recorded fuel flow continued to be erratic and then increased to over 90 gallons per hour until it decreased at the end of the recording. In addition, the left engine turbine inlet temperature, exhaust gas temperatures, and cylinder head temperatures began to decrease within a minute of the left fuel flow becoming erratic. Normal Procedures Checklist According to the cruise checklist found in the POH, the following items should be completed. Fuel Selectors – OUTBOARD OR INBOARD Power – Set Cowl Flaps – As required Mixture – Leaned Emergency Procedures Checklist – Engine Failure During Flight According to the checklist found in the POH, the following items should be completed. Inop eng – identify Operative eng – adjust as required Airspeed – attain and maintain at least 97 KIAS Before securing inop. Engine: Fuel flow – Check (if deficient – emergency fuel pump ON) Fuel quantity – check Fuel selector (inop. Engine) – Switch to other tank containing fuel Oil pressure and temp – check Magneto switches – check Air Start - attempt Fuel Performance Calculations Using the fuel consumption rate of 23 gallons per hour per engine noted in the pilot's flight log entry for the accident flight, the fuel endurance for the outboard fuel tanks was about 1 hour, 45 minutes. The 1121 recorded weather observation at TCL included wind from 170° at 10 knots gusting to 14 knots, visibility 10 miles, scattered clouds at 2,600 ft above ground level, broken clouds at 3,600 ft above ground level, temperature 30°C, dew point 25°C, and an altimeter setting of 30.09 inches of mercury. The Alabama Department of Forensic Sciences Medical Examiner's Office, Montgomery, Alabama performed the autopsy on the pilot. The autopsy report indicated that the pilot died as a result of multiple blunt force injuries. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. Fluid and tissue specimens from the pilot tested negative for carbon monoxide, ethanol, and other drugs. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane. His most recent FAA third-class medical certificate was issued in August 2014. According to a flight log found in the airplane, the pilot had accumulated 48.7 hours of flight experience in the accident airplane since March 2016. The pilot's logbook noted that he received a total of 2.9 hours of dual flight instruction during two flights on March 17, 2016. The flight instructor who flew with the pilot on March 17 and accompanied him on several other flights stated that he did not provide the pilot with any multi-engine training and he believed that the pilot had not received any training in the accident airplane. The pilot "took the airplane pilot operating handbook home and read it." In addition, the flight instructor did not practice any single-engine operations or emergency procedures with the pilot in the accident airplane. He stated that they couldn't practice those procedures with "people in the airplane and we always flew" with passengers. When asked about the pilot's checklist usage, he stated that the pilot would use the checklists and "go through the cockpit like [he] should." According to FAA records, the airplane was manufactured in 1984, and purchased by the pilot through a limited-liability company on March 14, 2016.. It was equipped with two Lycoming TIO-540-series, 350-horsepower engines, each of which drove a 4-bladed Hartzell controllable pitch propeller. The most recent annual inspection was performed on November 13, 2015; at that time, the airplane had accumulated 3,260.8 total hours in service. According to a flight log squawk list, the right engine fuel boost pump light illuminated s