WPR10FA163

The failure of maintenance personnel to properly secure a fitting cap on the throttle and metering assembly inlet after conducting a fuel system pressure check, which resulted in a loss of engine power due to fuel starvation. Contributing to the accident was the decision by the Director of Maintenance to return the airplane to service without verifying with the assigned inspector that all annual inspection items had been completed.

The airplane was in cruise flight when the engine lost power. The pilot attempted to reach the nearest airport, but the airplane collided with trees about 2.5 miles short of the runway. Non-volatile memory from the cockpit instruments revealed that the engine power decreased to 1,200 and 1,750 rpms, while the fuel flow reached 30 gallons per hour (the maximum range of the fuel flow sensor). Examination of the airframe and engine revealed no evidence of preimpact mechanical anomalies except for the fitting cap on the throttle and metering assembly inlet, which was not installed. The cap was found resting on the cylinder baffle, and there was light blue staining on the crankcase indicating fuel leakage. During a postaccident engine run, the engine operated normally with a substitute cap installed finger tight. An annual inspection was completed about 11 flight hours prior to the accident, during which three engine cylinders were replaced. Following the cylinder replacement, the fuel system pressures were checked with instrumentation that was plumbed into the system at the throttle and metering assembly. Following the pressure tests, the line where the instrumentation was connected should have been secured with the fitting cap that was found not installed. The manufacturer’s maintenance procedure requires that after the pressure tests are completed the cap be torqued and that a leak check be performed. Metallurgical examination of the cap showed that if it had been properly torqued it would have remained secure. Therefore, it is likely that the cap was installed finger tight and was not properly torqued when it was reinstalled. During the accident flight, the cap loosened and came off, resulting in a loss of engine power due to fuel starvation. There was no logbook entry for the most recent annual inspection, nor had the final items on the annual inspection checklist been completed. The Director of Maintenance for the facility had signed off the work order and returned the airplane to service. The assigned mechanic with inspection authorization indicated that he had not completed the annual inspection on the airplane and that the last maintenance he performed was that noted on the work order and annual inspection checklist. If the final checks had been completed, it is likely that the improperly secured cap would have been found because the fuel leakage would have been evident.

HISTORY OF FLIGHT On March 19, 2010, about 1910 Pacific daylight time, a Cirrus SR22, N224GS, collided with trees and terrain during a forced landing following a loss of engine power near Morton, Washington. The private pilot was operating the airplane under the provisions of 14 Code of Federal Regulations Part 91. The airplane was substantially damaged. The pilot was killed and the passenger sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed. The flight departed from Buchanan Field Airport, Concord, California, about 1540, and was destined for Renton Municipal Airport, Renton, Washington. The Safety Board investigator-in-charge interviewed the passenger on Wednesday, March 24, 2010. The passenger indicated that she and the pilot were returning from a business trip. After fueling the airplane, they departed and began the flight home. The passenger stated that while the airplane was in cruise flight, the pilot suddenly placed his hands on the controls, told her that the engine had lost power, and they were going to land at a nearby airport. He entered a steep right turn toward the airport. The passenger could not recall hearing anything unusual at the time of the event. The pilot remained calm throughout the approach to the airport and reassured the passenger during the descent that they would land safely. The pilot also declared a MAYDAY message and spoke on the radio. The passenger sent a text message to a friend at 1909 indicating that they were not going to make it to the airport. She did not recall anything after this point. The passenger indicated that the pilot had discussed the Cirrus Airframe Parachute System (CAPS) with her prior to the trip and showed her how to activate it in the event of an emergency. The passenger reported that the pilot did not attempt to activate the CAPS during the flight. Audio obtained from Prescott AFSS indicated at 1906:51, N224GS transmitted "MAYDAY, MAYDAY, Cirrus N4GS" on frequency 121.5. Part of the audio was unintelligible. Another aircraft, N999VK responded immediately to the MAYDAY call with “Cirrus on guard this is N999VK”, then a Seattle Radio controller responded with “Aircraft calling MAYDAY on 121.5, Seattle Radio." N999VK said “Standby center, 9VK is copying a MAYDAY”, and then asked N224GS to go ahead. N224GS said “I’m west of Strom airport, trying to make the field." N999VK asked N224GS how far he was from the field. No additional transmissions were received from N224GS. Prescott AFSS contacted the local sheriff's office. The wreckage was located immediately following the accident approximately 2.5 miles west-northwest of Strom Field Airport, Morton, Washington. PERSONNEL INFORMATION Pilot Information The pilot, age 39, held a private pilot certificate with an airplane single-engine land rating, and a third-class airman medical certificate issued May 29, 2007, with the limitation that he must wear corrective lenses. Copies of the pilot's logbook were obtained from his family. The last entry was dated February 21, 2010, and showed a total time logged of 219.8 hours. In a second earlier logbook provided by the pilot's family, the total time logged was 258.6 hours. Based on information obtained from the avionics onboard the airplane, the pilot had flown approximately 11 additional hours in the airplane, for a total flight time of 489.4 hours. He had flown 13 hours over the past 30 days and 14.9 hours over the past 90 days. His last flight review was on July 29, 2009. Maintenance Personnel Information Director of Maintenance The Director of Maintenance (DOM) for Auburn Flight Service, the facility that performed the most recent annual inspection on the airplane, was interviewed. He held an aviation maintenance technician certificate with airframe and powerplant (A & P) ratings and also held an inspection authorization (IA). He had worked as an A & P since 1989, and obtained his IA in October of 1999. He had served as the DOM at Auburn Flight Service since October of 2002. The DOM's normal work schedule consisted of a 40-hour work week, although he indicated that he was "juggling a lot" between work and personal life. He usually worked between 50 to 60 hours per week with 10 to 11-hour days. The number of employees he oversaw varied. During high employment periods, he oversaw five to six mechanics. In February of 2010, he employed three mechanics. Airframe and Powerplant Technician with Inspection Authorization The A & P/IA began his maintenance career in the military in 1991. Following the military, he worked in airline heavy line maintenance for seven years. He held employment as a flight engineer and first officer at a cargo company, and then returned to the Seattle area for family reasons. He began work with Auburn Flight Service where he worked for two years until leaving in February of 2010 for career advancement at a different company. The A & P/IA typically worked a 40-hour week with occasional overtime. He never felt like he was asked to do more than he was capable of doing. Airframe and Powerplant Technician The A & P held an aviation maintenance technician certificate with airframe and powerplant ratings. He began his maintenance career in the military in 1974 and obtained his A & P in 1986. He began working for Auburn Flight Service in April of 2007. The mechanic generally worked a 40-hour work week although his workload had recently increased due to more work and fewer employees. The mechanic felt that he had adequate time to perform his job duties. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear airplane, serial number (SN) 1326 was manufactured in 2005. It was powered by a Teledyne Continental IO-550-N engine and equipped with a Hartzell PHC-J3YF-1RF propeller. Maintenance The maintenance records were reviewed and the last annual inspection noted in the logbooks was October 17, 2008. The Safety Board investigator-in-charge contacted the maintenance facility that performed the annual inspection, Auburn Flight Service, and inquired whether or not a more recent annual inspection had been completed. According to the DOM for Auburn Flight Service, the last annual inspection was completed in February of 2010. He was uncertain why the annual inspection logbook entries were not in the logbooks. A work order dated January 8, 2010, contained a stamp dated February 5, 2010, and was signed by the DOM indicating that the airplane and engine had undergone an annual inspection. The DOM indicated that he did not perform the work on the airplane but had signed it off as airworthy. The work order for the airplane showed that cylinders 3, 5, and 6 needed to be replaced due to cracks. The cylinders were replaced on February 2, 2010. On February 3, the work order noted "perform gnd run and leak check…check engine specs per TCM MM Table 19-1/TCM SB M89-71R." Both items were initialed by the A & P. The last item noted on the work order was dated February 3, and stated that "during ground runs L/R mag drops rough." Spark plugs were cleaned, tested, and reinstalled. The A & P also initialed this item. The Cirrus maintenance checklist for the accident airplane was reviewed. The checklist noted the type of inspection as "annual." On page 17, the "Return to Service" checklist, five of the following six items were not initialed as being completed: 1. Close Access 2. Verify all Airworthiness Directives complied with (Initialed) 3. Fuel Injection System (The checklist noted "Functional inspection of fuel injection system in accordance with the manufacturer's approved instructions for continued airworthiness after engine installation, every 100 hours, at annual, or fuel system component replacement.") 4. Perform an airplane run-up (The checklist noted "In accordance with operational/functional check in 5-30. After completing the operational check, perform a walk arou