N717RRCessna Aircraft LC41-550FG · 2008

On March 21, 2014, about 1050, Eastern Daylight Time, a Cessna LC41-550FG, N717RR, was substantially damage after a loss of engine power while executing a go-around at Palatka Municipal Airport (28J), Palatka, Florida. The certificated private pilot received serious injuries. The pilot-rated passenger was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91, that originated from Northeast Florida Regional Airport (SGJ), St. Augustine, Florida.

According to the pilot, originally he and the pilot-rated passenger were going to fly to Ocala International Airport (OCF), Ocala Florida for lunch but after takeoff from SGJ, decided instead to go to 28J. They initially climbed up to 2,500 feet above mean sea level (msl), but due to clouds they descended to 1,400 feet msl on their way to 28J. Upon arriving in the area of the airport they descended to 1,200 feet msl, and were able to "see the ground really well."

The flight entered a left downwind for runway 9 on a 45-degree angle. An airplane then "passed" them so the pilot made a 360 degree turn for spacing as they approached the "western tip of the runway." Another airplane then passed them, so the pilot extended the downwind leg of the traffic pattern.

When the pilot joined the left base leg of the traffic pattern, he determined that they were "high" and decided to do a "low approach" instead of doing a touch and go landing. He then set 12 inches (") of manifold pressure (mp). When he had descended to about 400 feet msl, he decided to go around and "screwed the throttle in," but the engine did not respond. He then pitched for 100 knots indicated airspeed which was his best glide airspeed. He attempted to land straight ahead but "saw pine trees" ahead of him. The engine was still indicating 12" mp, and the propeller appeared to be "windmilling." He "did not want to stall." He then tried to land on a "pond."

A witness observed the airplane flying over the last 1/3rd of runway 09. The airplane was below a tree line which ran parallel to the runway the entire time he observed it, and he could see "gray" smoke coming out of the exhaust. It appeared to him that the airplane was "struggling to maintain altitude." As the airplane approached the end of the runway it appeared to pitch up and pass over trees at the end of a field, off the end of the runway. He advised that there were "a bunch of airplanes" in the traffic pattern at the time and he could not discern if the airplane's engine was running due to noise from the other airplanes.

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. His most recent FAA third-class medical certificate was issued on April 17, 2013. He reported that he had accrued 466 total hours of flight experience, 235 of which were in the airplane make and model.

According to FAA records, the pilot-rated passenger held a private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on August 9, 2011. He reported on that date, that he had accrued 400 total hours of flight experience.

The accident aircraft was a pre-molded composite built, semi-monocoque, four seat, single engine, low wing, tricycle design airplane. It was powered by a 310 horsepower Continental TSIO-550-C11B, driving a 3-bladed Hartzell constant speed propeller. The airplane was certificated in the utility category and was used primarily for transportation and related general aviation uses.

According to FAA and maintenance records, the airplane was manufactured in 2008.

On June 23, 2009, the airplane was registered in Canada. At the time the airplane and engine had accrued 88.7 total hours of operation.

On November 18, 2009, at 139.9 hours, an oil cooler winterization kit and Tanis preheater were installed on the engine.

On July 15, 2010, at 179.9 hours, the No. 6 cylinder was removed, repaired and reinstalled.

In December 2010, the airplane returned to the United States and was registered as N717RR on March 12, 2011, at 204.7 hours.

On June 1, 2013, the airplane's most recent annual inspection was completed at 384.9 hours. During the annual inspection, the engine's continuous flow injection system was checked in accordance with Continental Motors Service Information Directive (SID) 97-3E.

On February 19, 2014, at 425.1 hours, the engine oil and oil filter were replaced with no contaminants noted.

At the time of the accident, the airplane had accrued 432.8 total hours of operation.

The recorded weather at Palatka Municipal Airport (28J), Palatka, Florida, at 1050, included: winds 070 degrees at 10 knots, 10 miles visibility, sky clear, temperature 20 degrees C, dew point 10 degrees C, and an altimeter setting of 30.14 inches of mercury.

The accident aircraft was a pre-molded composite built, semi-monocoque, four seat, single engine, low wing, tricycle design airplane. It was powered by a 310 horsepower Continental TSIO-550-C11B, driving a 3-bladed Hartzell constant speed propeller. The airplane was certificated in the utility category and was used primarily for transportation and related general aviation uses.

According to FAA and maintenance records, the airplane was manufactured in 2008.

On June 23, 2009, the airplane was registered in Canada. At the time the airplane and engine had accrued 88.7 total hours of operation.

On November 18, 2009, at 139.9 hours, an oil cooler winterization kit and Tanis preheater were installed on the engine.

On July 15, 2010, at 179.9 hours, the No. 6 cylinder was removed, repaired and reinstalled.

In December 2010, the airplane returned to the United States and was registered as N717RR on March 12, 2011, at 204.7 hours.

On June 1, 2013, the airplane's most recent annual inspection was completed at 384.9 hours. During the annual inspection, the engine's continuous flow injection system was checked in accordance with Continental Motors Service Information Directive (SID) 97-3E.

On February 19, 2014, at 425.1 hours, the engine oil and oil filter were replaced with no contaminants noted.

At the time of the accident, the airplane had accrued 432.8 total hours of operation.

Examination of the Accident Site

The airplane initially touched down on the waters of a retention pond that was located on the east side of the airport, skipped twice off the surface of the water, then slid up on an embankment, struck a chain link fence, and then stacks of wooden shipping pallets before coming to rest approximately 30 feet from a home improvement store.

Examination of the Airplane

The lower engine cowling was deformed up and aft, and the top cowling was separated from the lower cowl at its piano hinge. The three-bladed propeller remained attached to the engine crankshaft. The two blades that were in 4 o'clock and 8 o'clock positions below the propeller hub were bent aft around the cowling. The third blade was in the 12 o'clock position and sustained two small leading edge dents. None of the propeller blades displayed leading edge gouging or evidence of s-bending. The cambered sides of the bent blades were scraped. The spinner remained attached to the propeller hub and it sustained inward deformation damage in an area that coincided between the bent blades.

The right main landing gear had separated from its mounting position. The right wingtip was separated from the right wing. The right side of the fuselage was separated from the aft root area of the right wing and the wheel assembly was separated from the right main landing gear leg. The right flap separated from its attachments at both ends of the wing flap.

The pitot tube separated from its mounting location. The aft root area of the left wing was separated from the fuselage. The left main landing gear remained attached to the left wing and was impact damaged. The left main landing gear strut was also bent and the fairing was split open. The bottom of the left wing was impact damaged, the left wing leading edge was impact damaged near the wing root and the spar received impact damage. The aileron trim servo tab was in the faired position, and the elevator trim was 10 to 15 degrees nose up.

The nose landing gear was bent back into the fuselage and the fuselage area behind the nose landing gear area was damaged. The main landing gear assemblies penetrated the cabin area by coming up through the floor of the cabin during the impact sequence.

All of the switches in the cabin and the ignition switch were moved to the "OFF" position by first responders. The wing flap switch was found in the up position and the wing flaps were also determined to be up. The Vernier type throttle was found in the idle position, the Vernier type propeller control was found in the high pitch position, and the Vernier type mixture control was found in the full rich position. The fuel selector was in the left tank position before first responders selected it to the "OFF" position.

Examination and functional testing of the electric boost pump revealed that it functioned in both the vapor suppression (low pressure) and boost pump (high pressure) modes.

Examination of the Engine

The front left engine mount was fractured, the airframe mounts were damaged. The crankshaft was cracked on the side that coincided with the straight blade, and was deformed aft on the side that coincided with the bent blades. There was no external evidence of the engine having suffered some type of operational distress.

The induction system remained intact and undamaged with the exception of the inlet filter and turbocharger inlet ducting. The air filter was in place and sustained deformation damage. The intake tubes remained attached to their respective intercoolers and manifolds. The right side turbocharger impeller contained dirt and debris from the accident site. There were no obstructions in any of the intake tubes or manifolds.

The left magneto remained intact and secured to its mounting pad. The magneto would not rotate on its mounting pad when manually manipulated. The torque putty that was installed during initial installation was in place and intact on the crankcase and magneto flange. During manual rotation of the crankshaft, an audible snap could be heard from the magneto's impulse coupling and a spark was observed on each of the left magneto's top spark plugs in firing order.

The right magneto also remained intact and secured to its mounting pad. The magneto would not rotate on its mounting pad when manually manipulated. The torque putty that was installed during initial installation was in place but slightly displaced between the crankcase and magneto flange (perhaps a degree of rotation). During manual rotation of the crankshaft, an audible snap could be heard from the magneto's impulse coupling and a spark was observed on each of the right magneto's top sparkplugs in firing order.

The ignition harness was secured to both magnetos and all of the sparkplugs. None of the leads appeared to be damaged or chafed. The harness was in place during the testing of the magnetos and sparkplugs. All of the ignition leads remained secured to their respective sparkplugs. Removal of the sparkplugs from their cylinders revealed that they were in a normal worn condition but covered in dark, black soot; consistent with a carbon-fouled condition.

The fuel pump remained secured to the backside of the engine and all of the fuel lines remained attached. Manipulation of the mixture control inside the cockpit resulted in a coinciding movement of the mixture control lever and shaft. The fuel pump was removed from the engine and the drive coupling was intact and in place. Manual rotation of the drive coupling while installed in the drive shaft resulted in a free and unrestricted rotation of the pump shaft. Fuel, consistent with 100LL aviation gasoline, poured out of the fuel pump fittings and the fuel lines. The fuel manifold remained intact and attached to the topside of the engine, and all of the fuel lines remained attached to the manifold valve. The fuel injector lines still had their torque putty intact and in place. The fuel manifold was removed from the topside of the engine and fuel, consistent with 100LL aviation gasoline, poured out of the manifold fittings and the fuel lines. All of the fuel nozzles were also secured to their respective fuel line and upper deck reference line, and there was no sign of fuel leakage around the base of the nozzles. Removal of the nozzles revealed that some contained fuel consistent with 100 LL aviation gasoline and none of the nozzles were obstructed.

The throttle body was secured to the left and right intake manifolds and the intake plenum. Manual manipulation of the throttle lever in the cockpit resulted in a coinciding movement of the throttle lever and throttle shaft. The throttle body was removed from the engine and fuel poured from the fuel lines that led to the metering unit.

There was no indication of an oil starvation event. The oil pump was intact and secured to the backside of the engine. Though the oil pump was not disassembled or visually examined, it demonstrated its ability to pump oil from the oil filter adapter during manual rotation of the crankshaft. The oil sump remained intact and attached to the bottom side of the crankcase. The oil quantity dipstick was examined and 4 quarts of oil registered on the dipstick. However, it was noted that the engine was resting in a nose low position when the oil quantity was checked. The oil filter was secured to the oil filter adapter and there were no signs of an oil leakage. The oil filter was removed and cut open for examination. There were no visible signs of metal contamination in the filter or the residual oil from the filter. The oil cooler was intact and remained attached to the back left side of the engine. The oil cooler winterization kit was installed and worked properly. There were no signs of operational distress or anomalies with the cooler.

All six cylinders were secured to the crankcase. There were no external anomalies with the cylinders. Borescope examination of the cylinders revealed evidence of dark soot adhering to normal combustion deposits on the pistons and cylinder heads. There were no signs of operational distress to the pistons, barrels, cylinder heads, or valves. Thumb compression and suction was obtained during manual rotation of the propeller flange, verifying crankshaft, connecting rod, and valve train continuity. All of the rocker arms and shafts were intact and secured in place. All of the rocker arms were well lubricated and displayed no signs of operational distress. During the compression check, all of the rocker arms and valves were observed moving through their normal range of motion. The crankcase was also intact and did not display any external evidence of operational distress. There was no evidence of an oil leak from any of the crankcase seams.

The crankshaft had sustained bending damage during the impact sequence that resulted in multiple cracks on one side. Despite the bending damage and cracking, crankshaft continuity was able to be confirmed from the propeller flange back to the accessory gears and out to each piston during the thumb compression test. No internal binding was noted during rotation of the crankshaft.

The No.1 turbocharger remained secured to its mounting bracket and the exhaust manifold. The inlet tubing to the impeller was distorted due to impact damage. The induction tubing remained attached. The oil lines to the turbocharger bearing remained in place. Removal of the turbocharger from the intake and exhaust systems revealed that the impeller/turbine rotated in unison without any evidence of internal binding when the impeller was manually rotated. The No. 2 turbocharger had also remained secured to its mounting bracket and the exhaust manifold. The inlet tubing was separated and distorted due to impact damage. Organic matter was located in the impeller inlet. The oil lines to the turbocharger bearing remained in place. Removal of the turbocharger from the intake and exhaust systems and removal of the dirt located in the impeller inlet revealed that the impeller/turbine rotated in unison without any evidence of internal binding when the impeller was manually rotated. The pressure controller for the turbochargers remained secured to its mounting bracket. The oil and reference lines also had remained secured to the controller, and no external anomalies were noted with the controller. The wastegate actuator remained secured to the exhaust system and the oil lines to the actuator remained intact and secured. The actuator arm remained attached to the wastegate valve. There were no signs of operational distress with the wastegate. The overboost valve remained secured to the left side intake manifold. There were no external anomalies noted.

The propeller governor remained attached to the front left side of the engine crankcase. Manual manipulation of the propeller control in the cockpit had a coinciding movement of the propeller governor control lever. No external anomalies were noted. The propeller hub remained attached to the propeller flange. All three blades had remained attached to the hub. There were no pre-accident anomalies noted with any of the propeller blades or the hub.

Toxicological testing of the pilot and pilot-rated passenger was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

The provided specimens from the pilot were insufficient for analysis.

No hazardous compounds or drugs of abuse were detected in the provided specimens for the pilot-rated passenger.

An Autopsy was performed on the pilot-rated passenger by the State of Florida, Medical Examiner District 14. The listed probable cause of death was injuries sustained in airplane crash.

Carbon Fouling of Spark Plugs

Examination of the engine spark plugs revealed that they were covered in black sooty deposits (carbon fouled). Carbon deposits are conductive, and as they accumulate along the nose of a spark plug, they reduce the insulation resistance of the spark plug. As electricity always takes the path of least resistance a misfire may occur if a significant amount of carbon deposits accumulate. A spark will not form as electricity can track along the conductive carbon deposits to the metal shell of the spark plug rather than forming a spark across the electrode gap which has a very high resistance.

According to Champion Aerospace Aviation Service Manual AV-6R, carbon fouling can be both fuel- and ignition-related. Typical fuel-related causes are over-rich fuel mixture, excessive idle or excessive operation at closed-throttle idle. Other causes might be improper idle mixture setting or improper (too cold) spark plug application. Ignition-related causes of carbon fouling include improper magneto timing, a failing lead or failed spark plug.

Systems Component Testing

The throttle and metering unit, fuel pump, fuel manifold valve, magnetos, turbochargers, pressure controller, wastegate actuator, and pressure relief valve were tested for functionality.

The fuel system components were intact and demonstrated the ability to function properly on the test bench; however: the fuel pump produced a higher-than-specified pressure through all ranges. The test results were likely a result of fuel pump adjustments being made during fuel system setup on the airplane. The throttle body/metering unit met the specified fuel flow for a given throttle angle with the exception of 2 degree and 74 degree throttle settings. The out of specification observations at the 2 degree setting were likely due to idle RPM/mixture adjustments made on the throttle body while installed on the airplane. The fuel manifold valve, fuel injector lines, and nozzles met the specified test parameters throughout the full test range. Though some of the fuel system components (without adjustments and as received) did not meet new product specifications, the components demonstrated their ability to pump, meter, and distribute fuel at their adjusted settings.

No anomalies were noted during testing of the ignition system components that would have precluded their normal operation, and examination of the sparkplugs revealed that they were an appropriate sparkplug for use in the Continental TSIO-550-C11B engine.

No anomalies were noted during examination and testing of the turbocharger components that would have precluded their normal operation.

Pilot Statements

During a postaccident interview, the pilot advised that usually he would run 18" mp in the pattern which would give him 115 knots. On base leg, his normal practice was to reduce to 12" mp which would enable him to descend at 500 feet per minute. At his minimum descent altitude or decision height, he would "screw the power back in." he would also on the 45-degree entry "dump 1st flap on downwind or base," then on final approach the "second set." He advised that on the day of the accident though, he could not do his normal power settings where he normally would do them in the pattern because of the traffic.

He advised that normally in cruise flight he would have "leaned the machine" to 31" mp, at 2,450 rpm, which would give him 17 pounds an hour fuel flow, and he would look at the cylinder head temperatures and turbine inlet temperatures. He did not however lean the mixture on the flight from SGJ to 28J.

When asked if he noticed what the fuel flow indication was on the Garmin G1000 prior to the loss of engine power, he said that he did not notice.

He would "go to" full rich on landing. When asked if he may have had the vapor suppression switch on, or the backup fuel pump armed, he stated that he did not think so.

He also advised that on three different occasions, he had the engine quit while the airplane was on the ground. The first time was when he had the airplane for 40 hours. He landed at an airport and the engine quit during landing rollout. The second time the engine quit might have been in Venice, Florida about a year before the accident, where after landing during taxi to the ramp, the engine quit again. After that occurrence, he took it to Southwest Aero but, they could not find anything wrong with the airplane.

Checklist Usage

During the examination of the airplane, a checklist was found on the pilot's seat. Examination of the checklist revealed that it was not the checklist issued by Cessna Aircraft for the airplane but was labeled "Normal Procedures-Abbreviated Checklist." Further examination of the checklist also revealed that it was labeled "FOR TRAINING PURPOSES ONLY," and did not contain any detailed guidance regarding spark plug fouling, power settings, use of mixture control, or balked landing (Go Around) procedures.

Examination of the "NORMAL PROCEDURES CHECKLISTS" published by Cessna Aircraft for use with the airplane revealed that they contained detailed guidance for minor spark plug fouling as well as power settings, detailed instructions for use of the mixture control, and balked landing (Go Around) procedures which required that the backup fuel pump be in the "ARM" position.

Pilot's Operating Handbook

Review of the Pilot's Operating Handbook (POH) and FAA Approved Airplane Flight Manual (AFM) revealed that, in cruise flight, and cruise climb, "the mixture must be adjusted" and "The pilot is responsible to lean the mixture in cruise for lower fuel flow."

Further review of the POH/AFM revealed that it contained cruise performance charts which listed mixture setting information, lean of peak engine operation data, and mixture control, backup fuel pump, and vapor suppression system operating information.

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