WPR17LA197

A partial loss of engine power during initial climb for reasons that could not be determined based on the available information.

The commercial pilot departed on a sightseeing flight with a passenger onboard; the airplane was near its published gross weight. The pilot had experienced some difficulty starting the engine before takeoff, which he resolved after removing and reinstalling the primer several times. The takeoff roll and departure were uneventful; however, when the airplane transitioned to initial climb, its climb performance reduced, and when it reached about 500 ft mean sea level, the airplane stopped climbing, which the pilot reported that he believed was due to a partial loss of engine power. Subsequently, the pilot turned the airplane back toward the departure airport, but after realizing that it would not reach the airport, he chose to conduct an off-airport forced landing. The airplane touched down in a dry riverbed, and it impacted brush and then nosed over and came to rest inverted, which resulted in substantial damage to the upper and lower wings. The airplane had sufficient fuel for the accident flight. Postaccident examination of the engine revealed numerous preimpact anomalies, including a leak in the engine primer line, which had developed over time due to its repetitive contact with the engine exhaust adjacent to it. The leak likely resulted in the pilot needing to add an excessive number of primer shots to start the engine before departure and led to some of his failed engine start attempts. Further, examination of the engine revealed that the cold compression on the No. 3 cylinder was low, that a spark plug was defective, that two ignition cables had significantly low insulation resistance, and that several of the forward ignition harness elbows were bent. Low compression is not an isolated incident, and it is possible that the pilot had been operating the airplane with low cold compression on the No. 3 cylinder for some time; therefore, it could not be determined if this contributed to the power loss. Although a defective spark plug could have resulted in a negligible power loss, it likely would not have prevented the airplane from climbing during the accident flight. Further, it could not be determined if the ignition harnesses were bent during the impact sequence; therefore, it could not be determined whether the condition of the ignition system contributed to the loss of engine power. Although the atmospheric conditions at the time of the accident were conducive to the accumulation of serious icing at glide power, it could not be determined if carburetor ice had formed while the airplane was idling on the ground. The reason for the loss of engine power could not be determined.

The 1355 recorded weather observation at Camarillo Airport, Camarillo, California, included wind 200° at 11 knots, visibility 10 statute miles, overcast 2,300 ft, temperature 26° C, dew point 19° C, and an altimeter setting of 29.92 inches of mercury. FAA Special Airworthiness Information Bulletin CE-09-35, "Carburetor Icing Prevention," includes a chart indicating conditions were conducive to carburetor icing. For the approximate ambient temperature and dew point at the time of the accident, the flight was conducted in "Serious icing (glide power)" conditions. The pilot reported that he did not use carburetor heat at any point during the accident flight. The pilot, age 57, held a commercial pilot certificate with ratings for single-engine land and instrument airplane. The pilot's most recent second-class medical certificate was issued on September 29, 2016, which included the limitation, "must wear corrective lenses." According to the pilot, his flight time included 814 hours of total flight time in all airplanes, of which 331 hours had been accumulated in the airplane make and model at the time of the accident. Fly Hope Dream The pilot founded an organization in August 2014 known as Fly Dream, Inc. According to the organization's website, the 501(c)3 non-profit organization "provides opportunity to see life from a new perspective and find hope for the future" by participating in a once-in-a-lifetime "Dream Flight." These flights are offered to the families of children battling life-threatening medical conditions and those grieving the loss of a child. Participants are not charged anything for the flight, but are encouraged to donate to the organization. Federal Aviation Administration (FAA) records indicate that the organization had been issued a Letter of Authorization (LOA) to perform commercial air tour operations under 14 Code of Federal Regulations Part 91.147 on August 31, 2017. The LOA authorizes the accident airplane to be used in the organization's commercial air tour operations. In the day that followed, a witness reported fuel staining in the sand below the fuel tank cap. The airplane was recovered and stored by a salvage facility in Santa Paula, California. A postaccident examination of the airplane and engine was completed on November 28 and 29, 2017 by a certificated airframe and powerplant mechanic under the supervision of a representative of the FAA and the National Transportation Safety Board Investigator-in-Charge. The airplane was photographed in its post-recovery condition with the wings and tail removed. Fuel staining was observed on the bottom trailing edge of the upper wing aft of the fuel tank. Additionally, the fuel sight gage indicated a fuel load of 0 gallons. Once the airplane's external condition was documented, the engine cowling was removed. The engine mounts were unremarkable and the engine case was intact. A visual inspection of the accessories revealed that the left magneto top cover was not fully seated as one retaining screw was not secured and the other retaining screw was found on the lower engine cowl. Additionally, the left magneto P lead nut was finger tight. The right magneto P lead was loosened with a wrench. A white wire sheath on the left magneto distributor displayed a tear. Continuity of the mixture and throttle controls were confirmed from the cockpit to their respective arms on the carburetor. The mixture control arm moved freely through its cockpit control lever from the lean position to full rich and the throttle moved freely through its control lever the idle position to full throttle. A visual inspection of the induction tube did not yield any loose matter and the couplings appeared secure. Each of the engine's 7 forward spark plugs were removed and exhibited normal wear when compared to the Champion check a plug chart with the exception of the no. 4 spark plug, which was oil fouled. The no. 4 cylinder sits at the low point of the engine and was later found to have collected oil. Several forward ignition harness elbows were bent. A thumb compression test was performed for each cylinder in the proper firing order: 1, 3, 5, 7, 2, 4, 6. Each cylinder displayed normal compression with the exception of the no. 3 cylinder, which was 34 psi. During each of the 4 tests, air expelled through the exhaust pipe and some through the oil sump. Fuel System A total of 2.5 gallons of fuel that resembled 100 low lead aviation grade gasoline were drained through the fuel strainer. The fuel sight gage erroneously displayed 25 gallons and there was no evidence of damage to the sight tube or buckling to the fuel tank. The fuel valve moved normally from the ON and OFF position. Fuel flowed through the strainer and exited the fuel sump when the valve was in the ON position and stopped when the valve was moved to the OFF position. The fuel strainer was disassembled and no debris or contaminants were observed in the fuel screen. The carburetor butterfly rotated freely between the lean and rich positions. Fuel was discharged when the butterfly was moved to the full rich position. The carburetor gaskets were in good condition and the palnuts and bolts were secure. Flight Control System The cockpit flight controls were traced to their respective control surfaces at the ailerons, elevator, and rudder. Engine Test The airplane tail was secured to a forklift and about 10 gallons of 100 low lead aviation grade gasoline were added to the airplane's fuel tank to facilitate an engine run. The propeller was turned and 6 shots of primer were delivered to the engine. A fuel leak was discovered at the primer line of the no. 1 cylinder. Visual inspection showed fretting of the primer line and polishing of the exhaust tube next to the primer line. The engine failed to start despite the introduction of additional primer, adding several ounces of 100LL into the induction air tube at the air filter, removing the magneto P leads, and cleaning the spark plugs. Both the cylinder no. 2 front and rear spark plugs fired normally when an engine start was attempted. The cylinder no. 3 rear spark plug also fired, but the cylinder's front spark plug did not display any spark. The ignition harness springs for both the cylinder no. 2 and 3 rear spark plugs fired when the engine starter was engaged. Magnetos and Ignition Harness The magnetos and ignition harness were removed from the engine accessory case. The right magneto distributor blocks displayed some grease deposits and the left magneto switch wire had been wired to a ground wire through a rubber shielding. Each magneto was placed on a test bench and tested separately after being connected to a sample set of distributor blocks and ignition harness. All 7 electrodes fired continuously as the right and left magnetos were powered up to about 1,500 rpm. The ignition harness and distributor blocks from the accident airplane were then connected to the right magneto, which normally feeds the electrical current to the front spark plugs through the ignition harness. Spark was observed at each ignition harness coil and as well as each coil elbow. During the harness removal, it was noted that the harness wires had been tie wrapped to the metal shielding between the cylinders and engine case. Carburetor Examination The carburetor was examined by a test and overhaul facility with oversight from a FAA inspector. The unit was unboxed in the presence of the FAA inspector and a visual inspection of the carburetor did not show any damage. The carburetor assembly was split at the mating surfaces and all seals were found to be in good condition. A leak check did not find any leaks and no holes were found in the float. The inlet screen did not display any debris and all linkages were found intact and working correctly. Ignition System Examination Two magnetos, an ignition harness, and fourteen spark plugs were examined by the N