WPR14FA226

The loss of engine power during takeoff initial climb for reasons that could not be determined during a postaccident examination of the airplane.

The two airline transport pilots, one of whom had recently purchased the airplane from the other, departed for the local personal flight to familiarize the new owner, who was seated in the front seat, with the airplane. The airplane was equipped with dual flight controls; however, it could not be determined which pilot was manipulating the controls at the time of the accident. Review of a video provided by a witness showed the airplane take off, and the engine sounded normal. A witness reported that, shortly after the airplane passed the departure end of the runway, the engine began to "sputter." The airplane then initiated a right turn. Throughout the turn, the engine seemed to power up but then lose power shortly thereafter several times. As the airplane completed the turn to a heading toward the departure airport, the engine lost total power. The airplane then descended into trees. Postaccident examination of the airplane revealed that the right wing fuel line was connected to the fuel selector valve outlet port and that the engine fuel supply line was connected to the right fuel tank position of the fuel selector valve. The fuel selector valve was removed, disassembled, and found in the left tank position, slightly away from the detent; however, it could not be determined if the fuel selector valve was moved during the impact sequence. With the right wing fuel tank line and the engine supply fuel line installed as found and with the fuel selector valve positioned to either the left main or left reserve fuel tank positions, fuel could not flow from the left fuel tank to the engine, which would have resulted in a loss of engine power; however, fuel could flow from the left to the right fuel tank. If the selector valve was positioned to the right fuel tank position, fuel could flow to the engine. Examination of the fuel tanks at the accident site revealed that the left fuel tank contained fuel to a level that corresponded to the location of where the fuel tank was breached, and no fuel was observed within the right fuel tank. Based on the available evidence, it could not be determined if the incorrect installation of the selector valve fuel lines prevented fuel flow to the engine and the loss of engine power. The fuel selector valve position at the time of the accident could not be determined because it is possible that the valve moved during the impact sequence. Examination of the carburetor revealed that one of the carburetor floats was partially filled with liquid and that the other float was impact-damaged and separated from the carburetor; it could not be determined if the floats were filled with liquid before the accident. Although a float filled with liquid would allow the fuel flow into the carburetor float bowl to increase and one partially filled float would result in a slightly rich condition, if a rich fuel to air mixture had existed, additional signatures would have been present within the engine exhaust and spark plugs, all of which exhibited normal operating signatures. No additional anomalies were found that would have precluded normal operation of the engine. Autopsy and toxicology findings for the front seat pilot revealed that his heart was heavier than average, likely due to the effects of high blood pressure. However, it is unlikely that this condition or the medications that he was taking to treat it contributed to the accident. Autopsy and toxicology findings for the aft seat pilot revealed that he had significant coronary artery disease with up to 80 percent occlusion of the left anterior descending coronary artery, which would have increased his risk of impairment due to sudden onset symptoms, such as chest pain or irregular heart rhythms. However, the investigation was unable to determine if the aft seat pilot was having any such symptoms at or around the time of the accident. In addition, the aft seat pilot had been using sertraline to treat depression for 2 months before the accident, but the investigation was unable to determine the full extent of the pilot's depression or side effects from the medication. Although the aft seat pilot had coronary artery disease and depression, it is unlikely that these conditions contributed to the accident.

The South Prairie Airport is a private non-towered airport that operates in class G airspace. The airport features a single turf runway, 2,600-feet long and 50-feet wide, oriented on 160 and 340 degrees respectfully. The reported airport elevation is 690 feet. Front Seat Pilot The Pierce County Coroner conducted an autopsy on the front seat pilot on June 5, 2014. The medical examiner determined that the cause of death was "multiple blunt force injuries." The cardiovascular exam identified a 450-gram heart; the average weight for heart of a man his weight is 362 grams (range 275-478 grams). The report identifies multifocal calcified atherosclerosis ranging between 30-50 percent in each of the three main coronary vessels. The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the front seat pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had positive results for 13 ug/ml acetaminophen detected in urine, and unspecified amounts of rosuvastatin detected in urine and liver. According to FAA records, the airline transport pilot reported using lisinopril, rosuvastatin, and ezetimibe. Lisinopril is a blood pressure medication marked under a number of names including Zestril. Rosuvastatin and ezetimibe are cholesterol lowering medications marketed as Crestor and Zetia respectively. The pilot reported high blood pressure and elevated lipids treated with the aforementioned medications. Acetaminophen is a pain reliever marked under many names including Tylenol. Rear Seat Pilot The Pierce County Coroner conducted an autopsy on the rear seat pilot on June 5, 2014. The medical examiner determined that the cause of death was "multiple blunt force injuries." CAMI, performed toxicology tests on the rear seat pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had positive results for unspecified amounts of desmethylsertraline detected in urine and blood (heart), unspecified amounts of salicylate detected in urine, 0.203 ug/ml sertraline detected in blood (heart), and unspecified amounts of sertraline detected in urine. Review of FAA records, the airline transport pilot rated passenger reported using simvastatin, a cholesterol lowering medications marketed as Zocor. He reported a history of a retained kidney stone that was reported to be non-operative and stable. According to an interview with the pilot's wife by the NTSB IIC, the passenger had started taking an antidepressant about 2 months prior to the accident, and on the day of the accident he appeared "pretty happy." According to the Pierce County Medical Examiner autopsy report, the cardiovascular exam identified a 310-gram heart; the average weight for the heart of a man his weight is 317 grams (range 240-419 grams). The report identifies multifocal calcified atherosclerosis greater than 50 percent in each of the three main coronary vessels, with 80 percent occlusion middle aspect of the left anterior descending artery. The report noted that the heart muscle was without evidence of a new or old infarct. Salicylate is the primary metabolite of aspirin, a pain reliever also used to prevent heart attacks in people who have had a heart attack in the past. Sertraline is an antidepressant also marketed as Zoloft. Examination of the accident site by the NTSB IIC revealed that the airplane impacted trees and terrain about 1.25 miles northeast of 02WA within a heavily wooded area. An initial point of contact with trees, about 70-feet in height, was observed. The wreckage debris path was oriented on a heading of about 147 degrees magnetic and was about 238 feet in length. All major structure components of the airplane were located within the wreckage debris path. The fuselage came to rest on its right side, partially inverted. The tailwheel was observed in an extended position. The engine remained partially attached to the fuselage and displaced downward into terrain. The wing center section, which included the inboard portion of the left wing, was located just beyond the fuselage, and was found in an upright, leading edge high attitude, with both the left and right main landing gear extended. The right wing was separated at the center section attach point. The left fuel tank was visually inspected, and fuel was observed up to the area of the fuel quantity indicator, which was separated. The right fuel cap was removed, and no fuel was observed within the right fuel tank. The wreckage was recovered to a secure location for further examination. Examination of the recovered wreckage revealed that the fuselage was bent and buckled throughout. The canopy structure was separated, and the roll bar was partially displaced. The left and right wings and center section were separated from the airframe. The inboard 5 feet of the right wing was separated from the center section. The outboard portion of the right wing was separated. The right flap and aileron remained attached. The left wing outboard 5 feet was separated from the wing. A circular impression was observed on the outboard left wing tip. The left aileron separated, and the left flap remained attached. Both the left and right main landing gear were found in the extended position. The right elevator and horizontal stabilizer were separated at the root. The left elevator and horizontal stabilizer, vertical stabilizer, and rudder remained attached and intact. Flight control continuity was established from the cockpit flight controls to all primary flight control surfaces. Multiple separations were noted on the elevator and aileron control cables. All areas of separation were consistent with tension overload. The left wing fuel tank was breached where the fuel quantity gauge was separated. The right wing fuel tank was intact. The right main, left main, and left reserve fuel screens were removed, and found to be free of debris. The fuel selector handles in the forward and aft seats were intact, and remained attached to the fuel control junction, which was separated from the fuel selector valve. Both the forward and aft fuel selector handle position indicator plates moved freely around the fuel selector valve handle shaft. Both screws that secure either plate to the handle assembly were in place. The fuel selector valve assembly located in the wing center section was intact, and appeared to be undamaged. All fuel lines were intact and secure to the fuel selector valve. The right wing fuel line was found connected to the fuel selector valve outlet port. The engine fuel supply line was found connected to the right fuel tank position of the fuel selector valve. The fuel selector valve was removed and disassembled. The valve was observed in the left tank position, slightly away from the detent. The internal cork was intact and undamaged. The fuel selector valve gasket was intact. It was noted that if the right wing fuel tank line and the engine supply fuel line were installed as noted above, when the fuel selector valve was positioned to either the left main or left reserve positions, no fuel would be able to flow from the left fuel tank to the engine; however, fuel would flow from the left fuel tank to the right fuel tank. If the selector valve was positioned in the right fuel tank position, fuel would flow to the engine supply line. The left and right fuel vent lines were free of debris. Residual fuel was removed from the left and right fuel tanks. The fuel was free of debris, and blue in color. Throttle, mixture, propeller, and wobble pump control continuity was established from the cockpit controls to the firewall. The forward seat primer was in the full in position, however, it was unlocked. It was not determined when or how the primer became unlocked. Examination of the Pratt & Whitney R-1340-AN engine, serial number ZP-101599, revealed that it was partially attached to