NTSB: Maintenance-Induced Fuel Starvation Caused Cirrus Crash at Morton, Washington

Posted on April 23, 2011 by Mike Danko

We knew from the surviving passenger that the Cirrus' engine quit before crashing at Morton, Washington.  But did the engine quit because of a mechanical problem? Or did it quit, perhaps, due to fuel starvation?

I discussed those questions here, days after the accident happened.  Now, a year later, the NTSB says the engine failure was the result of both.  Or, more accurately, fuel starvation caused by faulty maintenance.

Not surprisingly, the surviving passenger has sued Auburn Flight Service, which performed theMorton Washington Cirrus Crash Photo by Sarah Erskine faulty maintenance.  From the NTSB's report, it seems that Auburn Flight Service's liability is clear.  When putting the plane's fuel system back together just 11 hours before the crash, it failed to tighten a cap on the throttle and metering-assembly inlet.  The cap came loose in flight.  That allowed fuel to escape the assembly and flow overboard without getting to the engine. 

The loose cap wasn't caught and the aircraft was released to the pilot because Auburn failed to perform the "post-service inspection" it boasts of on its website.

Auburn Flight Service has not taken responsibility for the crash.  It reports that it feels badly, but not, apparently, for anything it may have done or failed to do.

Everyone at Auburn feels very badly about this tragic accident as we would any tragic accident where people were injured or killed."

One would think that, in this case, the Auburn folks would feel just a little worse than usual.

The injured passenger, who was the pilot's employee, also sued the pilot's estate. Why? Well, certainly there will be questions raised concerning the pilot's decision to attempt to land in a field, rather than deploy the aircraft's parachute.  Many Cirrus pilots would argue that the parachute should be deployed in any case of engine failure, unless there is a long, paved runway beneath the aircraft such that a safe on-airport landing is assured. Interestingly, however, the NTSB did not cite the pilot's failure to deploy the parachute as a contributing factor. 

Regardless, the "pilot error" part of the case is apt to be quite controversial.  That's if the passenger's case against the pilot's estate makes it past the workers' compensation defense.

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Morton, Washington Cirrus Crash: Should the Pilot Have Deployed the Parachute?

Posted on March 27, 2010 by Mike Danko

That's the number one question I've been asked about this accident.  Not "why did the accident happen," but "why didn't the pilot use the parachute?"

As I note here, most Cirrus pilots would say that the parachute should be deployed in the event of engine failure, unless there is a long, paved runway beneath the aircraft such that a safe on-airport landing is assured.  But that doesn't mean that, if there is no airport within range, a pilot who opts to glide to a field rather than pull the chute is negligent.

Pulling the parachute has serious risks.  The aircraft's rate of descent under the parachute is high.  Ground impact forces are severe. Cirrus warns that the decision to deploy the parachute should

not be made lightly because parachute deployment may result in "severe injury or death to the aircraft occupants."CAPS cover

The Cirrus, like every aircraft, comes with a Pilot Operating Handbook.  That's the "bible" that the pilot is supposed to follow.  The emergency checklist for an "engine out" scenario does not mention the parachute system:

Forced Landing (Engine Out):  If all attempts to restart the engine fail and a forced landing is imminent, select a suitable field and prepare for the landing.

A suitable field should be chosen as early as possible so that maximum time will be available to plan and execute the landing. . .

The checklist then sets forth the 12-step "forced landing" checklist.  No mention of the parachute, anywhere.

In the back of the Handbook, there is a separate section on the use of the parachute.  This section lays out various scenarios in which the pilot should consider deploying the parachute, such as after a mid-air collision, aircraft structural failure, or loss of aircraft control  One scenario deals with engine failures:

Landing Required in Terrain not Permitting a Safe Landing

If a forced landing is required because of engine failure, fuel exhaustion. . .or any other condition, [parachute] activation is only warranted if a landing cannot be made that ensures little or no risk to the aircraft occupants.  However, if the condition occurs over terrain thought not to permit such a landing, such as: over extremely rough or mountainous terrain, over water out of gliding distance to land, over widespread ground fog or at night, [parachute] deployment should be considered.

The pilot was not over "extremely rough or mountainous terrain." He had apparently picked out what he believed to be a suitable field for a forced landing.  The Cirrus Pilot Operating Handbook does not require pilots to deploy the parachute in the situation this pilot faced.  To the contrary, the Handbook leaves that decision to the pilot's discretion:

It is the responsibility of you, the pilot, to determine when and how the [parachute system] will be used.    

Related Post: Cirrus Crash at Morton, Washington
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Cirrus Crash at Morton, Washington

Posted on March 20, 2010 by Mike Danko

A Cirrus SR-22, N224GS, crashed yesterday in Washington state.  The pilot was killed.  The passenger was critically injured.  The aircraft departed Concord, California (CCR) in good weather, bound for home.  It crashed in Morton, 60 miles from its destination, which was presumably Renton (RNT).

The accident appears to have been the result of engine failure:

Facts suggesting that the engine failed because it ran out of gas:

  • Fuel exhaustion is the leading cause of engine failure.
  • The pilot reported to his wife that he was battling a "stiff headwind." Unexpected headwinds are common to many fuel exhaustion accidents.
  • The aircraft was only about 20 minutes from landing, 
  • Most fuel exhaustion accidents happen close to the intended destination.There was no post-crash fire. No fire suggests that there was no fuel on board to burn.

Facts suggesting that the engine failed because of a mechanical problemCirrus Parachute Deployment:

  • Assuming the Cirrus was fully fueled at Concord, the Cirrus should have been able to make Renton even with "stiff" head winds.
  • The pilot's widow reports that the aircraft had engine problems that were recently repaired.

Why didn't the pilot deploy the Cirrus parachute? 

There is no consensus among Cirrus pilots as to exactly when the parachute should be deployed. 

  • Some pilots say it should not be deployed in the event of engine failure.  Rather, it's safer for the pilot to glide the aircraft to a safe off-airport landing area. 
  • Other pilots say the parachute should be deployed in all cases of engine failure unless the aircraft is directly over a long, paved airport runway.

The wreckage photos show that the parachute was, in fact, deployed.  An NTSB investigator has told the press that it cannot be determined at this point whether the parachute was deployed before impact or instead as a result of impact forces.  But the photos strongly suggest that it was deployed by impact forces and not by the pilot. Cirrus at morton - CAPS handle cover in place

 

 

 

 

 

 

 

 

 

 

 

 

 March 26 Update:  The NTSB has released its preliminary report of the accident.  Investigators drained 7 gallons of fuel (about half-hour's worth) from the left tank.  That rules out fuel exhaustion -- there was definitely fuel on board the aircraft.  The right tank was ruptured in the crash.  That means it could not be determined if there was any fuel in it before impact.  As a resCirrus fuel guagesult, while fuel exhaustion can be ruled out, fuel starvation is still a possibility.

In a "fuel exhaustion" accident, the engine stops because there is no fuel left on board the aircraft.  In a "fuel starvation" accident, there is fuel on board, but the engine stops because the pilot has not positioned the fuel valve or valves properly to allow the fuel to flow to the engine.  For example, fuel starvation results when the pilot tries to feed the engine from a tank that is empty.  Fuel starvation most commonly happens after the pilot runs one tank dry, and then fails to switch properly to another with fuel in it.

Fuel starvation is common in aircraft with complex fuel systems.  The Cirrus' fuel system, however, is a model of simplicity.  Point the valve to the left fuel gauge to feed from the left tank, point to the right gauge to feed from the right.  There's not much chance of confusion.

Unfortunately, the NTSB report doesn't say what position the fuel valve was found in: "left," right" or "off."  If the valve was found in the "right" position, fuel starvation remains a possibility.  If it was found in the "left" position (as shown in the photo), that would suggest the engine failed for reasons unrelated to fuel starvation.

Related Post: Should the Pilot Have Deployed the Parachute?
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