Form Number: CA 12-12a and Incidents Reports/9452.pdf · CA 12-12a 20 NOVEMBER 2015 Page 1 of 23...

CA 12-12a 20 NOVEMBER 2015 of 23

Section/division Accident & Incident Investigations Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT AND EXECUTIVE SUMMARY

Ref No. CA18/2/3/9452

Aircraft Registration

ZS-FPJ Date of Accident 19 June 2015 Time of Accident 1602Z

Type of Aircraft Cessna C210J Centurion (Aeroplane)

Type of Operation Part 91

Pilot-in-command Licence Type Commercial Age 38 Licence Valid Yes

Pilot-in-command Flying Experience

Total Flying Hours 6 400 Hours on Type 149.1

Last point of departure Piesangshoek airstrip (FAQB): Limpopo province

Next point of intended landing

Nelspruit aerodrome (FANS): Mpumalanga province

Location of the accident site with reference to easily defined geographical points (GPS readings if possible)

On an open field outside FAQB at GPS co-ordinates determined to be S22º 59′ 33. 84 E030º 03′ 54. 17 at an

elevation of about 4 155 above mean sea level (AMSL).

Meteorological Information Wind direction, 090º: Visibility, 10 km: Temperature, 18°C: Wind speed, 15 km/h:

Cloud base, None.

Number of people on board 1 + 0 No. of people injured 1 No. of people killed 0

Synopsis

On Friday 19 June 2015, ZS-FPJ aircraft took off from Piesangshoek (FAQB) airstrip located in Louis

Trichardt on a private flight destined for Nelspruit (FANS) aerodrome. Visual meteorological conditions

(VMC) prevailed in the area and no flight plan was filed. Before departure a thorough pre-flight

inspection was performed and nothing abnormal was detected. Start-up and engine check revealed

nothing out of the ordinary. The aircraft taxied towards the departure point where pre-departure checks

were completed. According to the pilot, take-off run was normal however, during the climb phase at

about 100 ft above ground level (AGL), the engine lost power, upon which the pilot initiated a forced

landing on an open field ahead. During the landing the aircraft collided with tree stumps and burst into

flames. The pilot unbuckled himself and vacated the burning wreckage through the right-hand side

door. The pilot sustained minor bruises to his left hand. Visual inspection on the engine-driven fuel

pump exposed a sheared drive pin caused by the pump seizure with consequent fuel starvation and

loss of engine power.

Probable Cause

Unsuccessful forced landing following an engine failure.

Contributory factor/s:

The pilot’s failure to use the redundancy system “auxiliary fuel pump”.

SRP Date Release Date


Section/division Accident & Incident Investigations Form Number: CA 12-12a

AIRCRAFT ACCIDENT REPORT

Name of Owner/Operator : FFA Assets (PTY) LTD

Manufacturer : Cessna Aircraft Company

Model : Cessna C210J Centurion

Nationality : South African

Registration Marks : ZS-FPJ

Place : Louis Trichardt

Date : 19 June 2015

Time : 1602Z

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z). South

African Standard Time is UTC plus 2 hours.

Purpose of the Investigation:

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (2011) this report was compiled in the

interests of the promotion of aviation safety and the reduction of the risk of aviation accidents or incidents

and not to establish legal liability.

Disclaimer:

This report is produce without prejudice to the rights of the CAA, which are reserved.

1. FACTUAL INFORMATION:

1.1 History of Flight:

1.1.1 On Friday 19 June 2015, ZS-FPJ aircraft took off from Nelspruit (FANS) aerodrome

on a private flight bound for Piesangshoek (FAQB) airstrip located in Louis

Trichardt, Limpopo Province. Visual meteorological conditions (VMC) prevailed in

the area and no flight plan was filed. On-board was a commercial pilot only, and the

intention of the flight was for the pilot to report for fire-fighting operations stand-by

duties at the area command post located in Makhado municipality. Before departure

from FANS the aircraft was refuelled to full capacity, followed by a thorough pre-

flight inspection. All was normal and the aircraft took off and landed without incident

at FAQB, on the airstrip which was about 1000m in length. The day went on without

any fire mishap reported, and later in the afternoon the pilot prepared the aircraft for

a return flight to FANS.


1.1.2 All was normal and he boarded the aircraft and completed all the relevant cockpit

checks. The pilot reported that before leaving, he requested the weather update

from Makhado military airbase (FALM) control tower on 121.20 MHz. The weather

update was made available, upon which the pilot started the engine. The engine

started without difficulty and the pilot waited until all the engine instruments were

normal before taxiing in an easterly direction for a westerly departure. Pre-departure

checks were carried out. The engine revolution per minute (RPM) stabilised at

1 900 with magnetos at 50 RPM. The pilot selected 10° of flaps and took power,

upon which the aircraft accelerated downhill in a westerly direction. The pilot

reported that during the climb-phase at about 100 ft above ground level (AGL), he

experienced a gradual loss of engine power and the aircraft was unable to gain

altitude. The propeller RPM surged between 2 500 and 2 200.

1.1.3 According to the pilot’s statement, during this time his eyes were outside the cockpit

and he did not consider looking inside, to operate the electric fuel booster pump as

the aircraft was drifting towards the tree tops. The pilot tried to maintain control of

the aircraft before executing a forced landing on an open field. During a subsequent

turn to the right, he lost control of the aircraft. The right wing dropped and the

aircraft entered a near vertical descent, subsequently colliding with tree stumps on

an uphill slope before impacting the ground. A fierce fire broke out, which ultimately

destroyed the aircraft. The pilot unbuckled himself and vacated the burning

wreckage through the right-hand side door. He sustained minor bruises to his left

hand. The farmers in the area drove to the site and assisted with supressing the

fire. The investigator in charge (IIC) was able to locate two witnesses who saw the

aircraft before the accident. The first witness, a farmer who was at the airstrip,

provided a video clip of the aircraft during take-off.

1.1.4 This witness was interviewed. According to his report, the aircraft rotated right at the

end of the runway before climbing and disappearing from his view. The aircraft flight

profile on the video clip showed that towards the end of the runway, after rotation,

the aircraft had a high nose attitude and the wings were level. It was unfortunately

not possible to detect the noise from the engine above the noise generated by the

wind and it was also not possible to establish the engine speed from the audio

recording. The second witness, a farm worker who was located at a farm house;

about 1 km towards the departure flight path, stated that the aircraft was about tree-

top height, less than 100 ft AGL before it crashed. According to this witness, the

engine sounded like it was on a low power setting. The nose of the aircraft was

slightly up, and the wings were level. The aircraft commenced a ten to fifteen

degree bank to the right in the direction of the road, upon which it fell from the sky

and crashed, before bursting into flames.


1.1.5 The accident happened in the afternoon at GPS co-ordinates determined to be

S22º 59′ 33. 84″ E030º 03′ 54. 17″ at an elevation of about 4 155 ft AMSL. Below is

the Google Earth map depicting the aircraft flight path from FAQB to the accident

site.

Figure 1: Google Earth map depicting the aircraft flight path from FAQB to the accident site

1.2 Injuries to Persons:

Injuries Pilot Crew Pass. Other

Fatal - - - -

Serious - - - -

Minor 1 - - -

None - - - -

1.3 Damage to Aircraft:

1.3.1 The aircraft was destroyed by impact and a post impact fuel-fed fire that erupted.


Figure 2: The fire fighting operation conducted by the farm workers

1.4 Other Damage:

1.4.1 The accident site was contaminated, however was subjected to a thorough clean-up

by the operator after the on-site or field investigation was finalised.

1.5 Personnel Information:

1.5.1 Pilot-in-command:

Nationality South African Gender Male Age 38

Licence Number 0270457476 Licence Type Commercial

Licence valid Yes Type Endorsed Yes

Ratings Winching/under sling, instruments and instructor’s

rating grade A

Medical Expiry Date 28 February 2016

Restrictions Suitable corrective lenses

Previous Accidents Nil

Farmers assisting in suppressing the fire at the accident site

The position of the second witness “a farmer at a farm house”, who saw the aircraft before it crashed


Flying Experience:

Total Hours 6 400

Total Past 90 Days 132.6

Total on Type Past 90 Days 120.6

Total on Type 149.1

*NOTE: The pilot’s profile revealed no accident or incident history, enforcement

actions, pilot certificate or rating failure, or retest history. The pilot had accumulated

6 400 hours total flight time. Of the 6 400 total flight hours recorded by the pilot,

1 500 were on helicopters and 2 500 were on gliders. The pilot learned to fly in

1996 on a C-172 aircraft and carried on to fly other aircrafts such as the Piper PA-

28, Cessna C-208 Caravan, the C500 Cessna Citation, EMB-120 Embraer, PA-34

Seneca, C-210, Beech 76 Duches, Robinson helicopters series, Bell 205 and Jet-

Ranger helicopters.

1.6 Aircraft Information:

1.6.1 Aircraft description as per the aircraft manual:

The Cessna C210J aircraft is a single-engine, high-wing monoplane of an all metal,

semi-monocoque construction. Wings are full cantilever, with sealed sections

forming fuel bays. The aircraft includes a fully-retractable tricycle landing gear which

consists of tubular spring-steel main gear struts and a steerable nose wheel with an

air-hydraulic fluid shock strut. It is also equipped with four to six place seating

arrangement. The aircraft construction is of a semi-monocoque type, consisting of

sheet metal bulkheads, stringers and stressed skin. Semi-monocoque construction

is described as a light framework covered by skin that carries much of the stress. It

is a combination of the best features of a strut-type structure, in which the internal

framework carries almost all of the stress, and the pure monocoque where all stress

is carried by the skin.

The fuselage forms the main body of the aircraft to which the wings, tail section and

undercarriage are attached. The main structural features are as follows:

Front and rear spars for wing attachment

A bulkhead and forgings for landing gear attachment


Four stringers for engine mounting attached to the forward door posts

Each all-metal wing panel is a full cantilever type, with a single main spar,

two fuel spars, formed ribs and stringers

The aircraft is powered by a six-cylinder, horizontally opposed piston engine. It

comprises three bladed, variable speed Hartzell propeller, approximately 2m “80

inches” in diameter. It gets off the ground quick and climbs

fast. The aircraft fuel system consists of two vented integral fuel tanks, two fuel

reservoir tanks, a fuel selector valve, an auxiliary fuel pump, a fuel strainer, an

engine-driven fuel pump, a fuel/air control unit, fuel manifold, and fuel injection

nozzles. Electrical energy for the aircraft is supplied by a 14 or 28 volt (V), direct

current, single-wire, negative-ground, electrical system. A 12 or 24 V battery

supplies power for starting and furnishes a reserve source of power in the event of

alternator failure. An external power source receptacle may be installed to

supplement the battery for starting and ground operation.

Figure 3: ZS-FPJ aircraft


Type Cessna C210J Centurion

Serial Number 210-59152

Manufacturer Cessna Aircraft Company

Year of Manufacture 1968

Maximum certificated mass 4 300 lb

Empty Weight 1 950 lb

Service ceiling 18 300 ft

Ground roll 800 ft

Rate of climb 1000 ft/min

Total Airframe Hours (At time of Accident) Could not be confirmed

Last MPI (Hours & Date) 4 435.00 02 June 2015

Hours since Last MPI Inspection Could not be confirmed

C of A (Issue Date) 04 December 2013

C of A (Expiry Date) 03 December 2015

C of R (Issue Date) (Present owner) 25 August 2014

Service Bulletins and Airworthiness

Directives Complied with

Operating Categories Standard Part 91

*NOTE: The aircraft flight folio was not found during the investigation. The aircraft

total flight hours after the mandatory periodic inspection (MPI) could therefore not

be found. The aircraft tachometer could also not be found during the investigation.

The aircraft maintenance organisation (AMO) that performed the last MPI on the

aircraft prior to the occurrence was in possession of a valid AMO approval

certificate no, 1185. All applicable or relevant aircraft documentation such as the

certificate of registration (C of R), the certificate of airworthiness (C of A), the last

MPI work pack, the radio station licence and the mass and balance certificates were

scrutinised during the investigation and all were found to be valid in accordance

with the existing regulations. Further examination of the aircraft maintenance

documentation such as aircraft logbooks and the maintenance work pack were

obtained from the AMO. They were thoroughly reviewed and all entries made were

appropriately certified in terms of general maintenance rules.


Engine:

Type Continental IO-520-J

Serial Number 198058-9-J

Hours since New 4 435.00

Hours since Overhaul 1 092.00

Propeller:

Type Hartzell HC-J3YF-1RF

Serial Number JN494B

Hours since New 189.80

Hours since Overhaul T B O not reached

Weight and balance calculation:

The aircraft empty weight as recorded on 02 December 2013 was 2 231.05 lb. The

aircraft’s weight at the time of the accident can be estimated as follows:

Empty weight: 1 960 lb

Pilot weight : 210 lb

Luggage : 10 lb

Fuel (270L) : 415 lb

Total : 2 866.05 lb

*NOTE: According to the pilot’s operating handbook (POH), the maximum certified

take-off weight for this aircraft type was not allowed to exceed 4 300 lb. The aircraft

empty weight information used in the weight and balance calculation was obtained

from the last weighing report, dated 02 December 2013, and certified by the South

African civil Aviation Authority, Safety Operations Department. The aircraft weight

and balance at the time of the occurrence were calculated to be 2 866.05 lb. A

weight and balance calculation determined that the aircraft was being operated

within its load limits and at close proximity to its forward centre of gravity (CG).


1.7 Meteorological Information:

1.7.1 Weather information as per the pilot questionnaire.

Wind direction 090 Wind speed 15 km/h Visibility 10 km

Temperature 18°C Cloud cover Clear Cloud base None

Dew point N/a

1.8 Aids to Navigation:

1.8.1 The aircraft was equipped with the following navigational aids.

Magnetic compass.

Transponder.

Panel-mounted Garmin GPS.

ILS (Instrument Landing System).

ADF (Automatic Direction Finder).

VOR (Variable Omni Range) finder.

DME (Distance Measuring Equipment).

1.9 Communications:

1.9.1 The communication equipment installed on the aircraft was found to comply with the

approved equipment list. The pilot report showed that he successfully contacted the

controlling air space agency “FALM tower controller” in the area through which he

was intending to enter, informing them of his position and requesting authorisation.

At no time did the pilot report any equipment malfunction.

1.10 Aerodrome Information:

1.10.1 The accident occurred outside FAQB. The airstrip where the aircraft took off was in

a satisfactory condition, with a grass surface. GPS co-ordinates of the airstrip are

S22º 59′ 33. 84″ E030º 03′ 54. 17″. Length – approximately 1 200m; width – 10m:

elevation – 4 155 AMSL. FAQB is an uncontrolled VFR airstrip equipped with only a

windsock. It has no markings at all. It is a private airstrip that is managed and


maintained by the operator.

Figure 4: FAQB easterly side, where the take-off run began

Figure 5: FAQB westerly side-ZS-FPJ direction of departure

1.11 Flight Recorders:


1.11.1 The aircraft was not fitted with a Cockpit Voice Recorder (CVR) or a Flight Data

Recorder (FDR), and neither was required by regulations to be fitted to this type.

1.12 Wreckage and Impact Information:

1.12.1 On-site investigation showed that the aircraft had struck the ground uphill in a nose-

low attitude. The aircraft came to rest in about 80m after first point of impact. The

wreckage site was about a kilometer west of the departure end of the runway. The

landing gear was extended but broken from the mounting points during the accident

sequence. The cockpit/cabin area was consumed by a post-impact fuel-fed fire that

erupted after impact. The instrument panel was severely burned, and none of the

flight instruments contained any legible information. The nature of the damage to

the switches was such that their position prior to the ground impact could not be

determined. The pilot seat frame was completely consumed by the fire. Only parts

of the frames, rails, and locking mechanisms were found. The control columns were

severely damaged. The aircraft remained essentially intact, but was destroyed. The

fire was likely the result of fuel being ignited by hot exhaust components. The fire

consumed the left wing fuel tank first and then the cockpit/cabin area. The right

wing fuel tank did not burn and was found to contain a bit of fuel; the quantity could

not be determined due to spillage from compromised lines. Attached below are the

pictures.

Figure 6: The wreakage engulfed in flames


Figure 7: First point of impact and the final position of the wreckage

Figure 8: Closer view of the wreckage

1.12.2 Both wings/support spars failed due to overload. The engine and the propeller were

exposed to heat and some engine components such as the alternator and the

magnetos detached during the accident sequence. The IIC examined the wreckage

and the following were noted.

Final position of the wreckage, facing the road

First point of impact “mark” left by the aircraft

Portions of the saved structures of the aircraft from the rear and the position of the wing flap at 10°


All flight controls were checked and the remains have proved to be complete.

The engine was intact, but was affected by heat.

The engine crankshaft turned normally and all its drives, such as the drive for

the fuel pump, magnetos and generator functioned properly. Compression in the

cylinders was considered normal. The spark plugs were intact and in normal

condition, and the ignition harnesses were intact but damaged by heat.

The oil tank filler cap was properly secured. The assessment of the oil that

remained was not considered significant. It was also assumed that, if the aircraft

had lost oil in flight, the pilot would have given notification of such.

The right wing flap position was measured and found to be between 0º and 10º

flaps down.

The rudder linkages and the turnbuckles were still secured and were able to

move freely. The beacon, aerials and rear navigation light undamaged and

secure. The emergency locator transmitter (ELT), cabin sidewall furnishings,

seat coverings and aircraft documents including manuals were burnt.

The landing gear selector handle was destroyed.

All three blades of the propeller remained secured inside the hub. Two blades

were bent aft and one was intact.

Figure 9: The condition of the propeller as found

1.13 Medical and Pathological Information:

1.13.1 Not applicable.

1.14 Fire:

1.14.1 The aircraft was destroyed by post-impact forces and a fuel-fed fire that erupted

during the accident sequence.


1.15 Survival Aspects:

1.15.1 The accident was considered survivable. The emergency locator transmitter (ELT)

was destroyed by the post-impact fire. There was no report from the search and

rescue authorities to indicate that the ELT had activated on ground impact.

1.16 Tests and Research:

1.16.1 The last recorded refuel of the aircraft was the addition of 243L of Avgas LL 100

aviation fuel on 17 June 2015. It was reported that the pilot refuelled the aircrafts

tanks to capacity at FANS. The IIC took a sample of Avgas LL 100 fuel from the

right tank for analysis. The analysis showed that the fuel was contaminated or

mixed with water and impurities as a result of the fire-fighting operation. FANS fuel

supplier records indicated that about four aircrafts were refueled from the same

source the same day ZS-FPJ was refueled. There were no reports of any fuel-

related anomalies reported to the supplier. During the engine analysis, a small

amount of fuel was recovered in the fuel line from the engine-driven fuel pump to

the fuel metering unit. The fuel was bright, clear and consistent in colour and odour

to LL 100 aviation fuel. The check valve that directs excess fuel from the engine-

driven fuel pump and the fuel control unit (FCU, serial no M106639A), through the

fuel selector to the collector tanks was tested and found to be functioning properly.

1.16.2 The fuel system components were bench tested and found to be capable of normal

operation within the manufacturer's parameters. The top spark plugs were removed

from the engine for testing. Sparks were observed at the termination of each top

spark plug lead and both magneto impulse couplings audibly triggered

simultaneously. Their electrodes were intact and light grey in colour. The valve

covers were removed from the cylinders and oil was observed throughout the

engine. When the propeller was rotated by hand, crankshaft, camshaft, and valve

train continuity were confirmed to the rear accessory section of the engine.

Compression was attained on all cylinders and the magnetos produced spark to all

top leads. Both magnetos (Slick 6310, serial no’s. right 97102215 and left

99061480) functioned and produced sparks when tested. All spark plugs

{(Champion RHB-32E Model, 6310)} were clean and in good condition. According

to the engine documents, engine compression was most recently evaluated in an

annual inspection and found to be normal.


1.16.3 A three-bladed constant speed Hartzell (HC-J3YF-IFR, serial no JN494B) propeller

and hub remained attached at the crankshaft flange; two blades sustained minimal

damage and displayed similar pitch angles at the hub. The condition of the propeller

indicated that it had no power when the aircraft crashed. The pitch setting of one

blade was measured and found to be according to the aircraft type certificate. The

engine was subjected to a teardown examination at the engine overhaul facility at

Springs aerodrome (FASI) under supervision of the IIC. History showed that the

engine had accrued a total time of 4 435.00 hours of operation. It had accumulated

1 092.00 total flight hours since overhaul. Examination of the engine and

components revealed normal operation signatures.

1.16.4 The engine-driven fuel pump (serial no 142549), was removed and examined. The

gears that engage the pump into the engine accessory section were intact. The

pump was overhauled on 15 October 2014 at 85.8 flight hours. Inspection on the

pump exposed a sheared drive pin, P/N 631684, caused by the pump seizure, with

a consequent fuel starvation and loss of engine power. When the pump was

actuated by hand, there was no movement or continuity to its mechanical linkage

that connected into the engine. The primary source of fuel pump seizure could not

be determined. Scrutiny of the engine logbook showed no history of the engine-

driven fuel pump installation date. Nonetheless, this engine-driven fuel pump

appeared to have been attached to the engine for an undetermined period time.

Figure 10: The engine-driven fuel pump broken drive pin


Figure 11: Illustration parts catalogue (IPC) showing the engine-driven fuel pump sheared drive pin

1.16.5 Though the engine-driven fuel pump is the primary source of fuel pressure to the

engine/injectors, the aircraft had also a back-up auxiliary fuel pump "boost-pump,

redundancy system" installed on it. In a case the engine-driven pump fails or is

unable to maintain adequate fuel flow to the engine, the auxiliary fuel pump must be

instantly turned on. This pump is driven by a self-contained electric motor that is

controlled by a switch on the instrument panel (Figure 10). According to the pilot

statement, he didn’t monitor the engine fuel flow pressure during take-off and at no

time did he think of turning on the auxiliary fuel pump as detailed in the aircraft flight

manual which might have remedied the anomaly and kept the engine running at

maximum power.


Figure 12: C210 instrument panel displaying the auxiliary fuel pump and the pressure gauge

Figure 13: Fuel injection system

1.16.6 The engine driven fuel pump provides fuel under pressure to the fuel/air control unit

for engine starting and/or emergency use. After starting, the engine-driven fuel

pump provides fuel under pressure from the fuel tank to the fuel/air control unit. This

control unit meters fuel based on the mixture control setting, and sends it to the fuel

manifold valve at a rate controlled by the throttle. After reaching the fuel manifold

valve, the fuel is distributed to the individual fuel discharge nozzles. The discharge

nozzles, which are located in each cylinder head, inject the fuel/air mixture directly

into each cylinder intake port.

The aircraft’s auxiliary fuel pump switch

The aircraft fuel flow pressure gauge in a C210 aircraft


1.17 Organisational and Management Information:

1.17.1 This was a private flight.

1.17.2 The last annual inspection prior to the accident was certified by AMO 1185 based in

the Nelspruit, Mpumalanga Province. Airframe, engine and aircraft technical log

books were reviewed and examined to assess any discrepancy, none was found.

1.18 Additional Information:

1.18.1 None.

1.19 Useful or Effective Investigation Techniques:

1.19.1 None.

2. ANALYSIS:

2.1 Records indicated that the aircraft was certified, equipped, and maintained in

accordance with existing regulations and approved procedures. The aircraft had a

valid maintenance release at the time of the accident with no maintenance overdue.

The pilot performed an engine run-up before departure and reported no

discrepancies. Post-investigation revealed that the take-off run was normal.

However, after rotation, during climb phase at about 100 ft AGL, the engine lost

power. The pilot indicated that he immediately initiated a forced landing on an open

field. During a subsequent turn, he lost control of the aircraft. The right wing

dropped and the aircraft entered a near vertical descent, subsequently colliding with

tree stumps on an uphill slope before impacting the ground.

2.2 A fierce fire broke out and consumed the wreckage. The pilot held a valid

commercial pilot license for single and multi-engine aircraft, and a valid medical

certificate and instrument rating. The pilot had accrued approximately 6 400 total

flight time hours, of which 149.1 hours were on type. The weather was suitable for

the flight and was not considered to have been a factor in the accident. The engine

was transported to FASI, where it was examined. The engine-driven fuel pump was

removed from the crankcase and examined. Visual inspection revealed a sheared

drive pin caused by the pump seizure, with a consequent fuel starvation and loss of

engine power. The exact cause of seizure could not be determined. The

investigator in charge (IIC) however, considered a few scenarios to help determine


the probable causes of seizure. (1) Possible failure of upper-deck reference lines to

a pump aneroid and a possible contamination of the poppet valves and main jet

orifices. According to the aircraft flight manual, in the event the engine-driven fuel

pump fails during take-off, the pilot should immediately hold the left half of the

auxiliary fuel pump switch in the high position until the aircraft is well clear of

obstacles. The pilot was experienced and familiar with the type of aircraft and very

much aware of all the emergency procedures as stipulated/laid out in the aircraft

flight manual. The investigation concluded that the pilot failed to conform to the set

standard engine emergency procedure “redundancy system” as stipulated in the

aircraft flight manual which would have remedied the situation and kept the engine

running.

3. CONCLUSION:

3.1 Findings:

3.1.1 The pilot held a valid commercial licence and had the aircraft type endorsed in his

logbook.

3.1.2 The pilot’s medical certificate was valid with restrictions to wear suitable corrective

lenses.

3.1.3 The flight was operated as a general aviation flight under VFR.

3.1.4 The aircraft was in possession of a valid certificate of airworthiness at the time of

the accident.

3.1.5 The aircraft was destroyed by impact and a post fuel-fed fire that erupted after the

accident.

3.1.6 Good weather conditions prevailed in the area at the time of the accident.

3.1.7 The accident was considered survivable.

3.2 Probable Cause/s:

3.2.1 Unsuccessful forced landing following an engine failure.

3.3 Contributory factor/s:

3.3.1 The pilot’s failure to use the redundancy system “auxiliary fuel pump”.


4. SAFETY RECOMMENDATIONS:

4.1 None.

5. APPENDICES:

5.1 Fuel system description: Cessna Handbook.

Fuel is pumped or gravity fed from the fuel tanks to the engine. At the engine, it is

mixed with air in a carburetor or injected directly into the cylinders where it is ignited

by spark plugs. The resulting explosion drives the piston down and turns the

crankshaft which, either directly or in some cases through a gearbox, turns the

propeller. Fuel cannot burn without oxygen and, in order to achieve optimum

efficiency, fuel and air must be mixed in the right proportion. The volume of oxygen

available for combustion is determined by air density, which is a function of altitude,

temperature, and humidity. Therefore, for any throttle setting, altitude, temperature

combination there will be a given amount of oxygen. Using the mixture control,

pilots adjust the amount of fuel to achieve the proper air to fuel ratio. Reducing the

fuel flow is called leaning the mixture. Increasing the fuel flow is called enriching the

mixture. Even in a properly leaned engine, not all the fuel that reaches the cylinders

is burned. Some of the unburned fuel contributes to engine cooling before it leaves

the aircraft through the exhaust system. Attached below is the fuel system

schematic.


Auxiliary fuel-pump operation: Cessna Handbook.

The pump is not to be used in flight except in an emergency. Unlike some other

high performance aircrafts, and even some other Cessna’s, it is not supposed to be

operated during take-off, on approach, during maneuvers or while switching tanks

(unless you have actually run a tank dry and the engine has begun to lose power or

has lost power completely). If you run the electric auxiliary fuel boost pump while

the regular engine-driven fuel pump is working normally, this will cause the engine

to receive about twice as much fuel as it needs and cause it to lose power or even

stop running. The electric auxiliary fuel boost pump consists of a split rocker switch

located on the lower left side of the instrument panel next to the master switch. The

left side is red and the right side is yellow. The left/red side is HIGH; the right/yellow

side is LOW. The HIGH side is required to keep the engine running at high power

settings such as takeoff and initial climb. The LOW side should be adequate to keep

the engine running at cruise power settings, depending upon conditions.


END

Form Number: CA 12-12a and Incidents Reports/9452.pdf · CA 12-12a 20 NOVEMBER 2015 Page 1 of 23...

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