Fuel Exhaustion & Starvation · NTSB WPR10FA163
CIRRUS DESIGN CORP SR22 — Morton, WA
| Date | March 20, 2010 |
| Location | Morton, WA |
| Aircraft | CIRRUS DESIGN CORP SR22 |
| Purpose of flight | Business |
| Conditions | Day · Visual Meteorological Cond |
| Phase / occurrence | Prior to flight Aircraft maintenance event |
| Pilot age | 39 |
| Pilot total time | 489 hrs · Building experience |
| Time in type | 230 hrs |
| Fatalities | 1, 1 serious |
Probable cause
NTSB findings
- Aircraft-Aircraft power plant-Engine fuel and control-(general)-Inadequate inspection - C
- Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel - C
- Personnel issues-Task performance-Inspection-Post maintenance inspection-Maintenance personnel - F
- Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid level - C
- Environmental issues-Physical environment-Object/animal/substance-Tree(s)-Not specified
- Aircraft-Fluids/misc hardware-Misc hardware-Hoses and tubes-Inadequate inspection - C
What happened
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.