Pilot Debrief

Dragon Fly Aviation GT-500 near Paris, TN — 2008-04-21

Final reportNYC08LA165
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Date
2008-04-21
Location
Paris, TN, USA
Aircraft
Dragon Fly Aviation GT-500
Registration
N101GP
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

A fuel system configuration that was not in accordance with the engine manufacturer's published guidance, which resulted in a complete loss of engine power due to fuel starvation.

NTSB narrative

The certificated commercial pilot was the first registered owner of the amateur-built light sport airplane, but he did not build the airplane. On the day of the accident, after two aerial application flights, he returned to his airport to replenish the application chemical for a third trip to the same agricultural field. About 30 minutes later, a witness heard the engine "sputter" during a spray run, and observed the airplane begin a climbing right turn back towards the airport. The engine stopped and restarted, and the airplane began another climb in the direction of the airport. The engine stopped a second time, and two witnesses saw the airplane descend without engine power into a wooded area. The airplane was substantially damaged, and the pilot was fatally injured. Autopsy results indicated that the pilot had diabetes, coronary artery disease, an enlarged heart, and gallstones. In addition, he was taking a medication commonly prescribed for neurological pain, and another for smoking cessation, both of which had the potential to cause distraction or impairment. It was not clear what role, if any, the medical conditions or medications played in the accident. He did not note any medications or medical conditions on his most recent application for medical certificate, but it is possible that the medications were initially prescribed since that application. At the time of the accident, the airplane and engine had accumulated approximately 89 hours since new. The pilot had previously experienced engine stoppage problems, and had conducted at least one forced landing due to an engine stoppage. Subsequent to that forced landing, and in the weeks just prior the accident, the pilot installed an electric fuel pump, which was in addition to the existing engine-driven fuel pump. Post-accident examination of the airplane indicated that the engine fuel system was not configured or equipped in accordance with the engine manufacturer's published guidance. Differences included fuel lines that were not thermally shrouded, lack of a fuel pump bypass circuit, lack of a fuel return line, and pump output pressure which exceeded the engine manufacturer's limits. The engine manufacturer's guidance contained multiple statements that such differences could result in engine problems and/or stoppage.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have addressed engine oil pressure concerns before the second flight.

NTSB coding

Evidence available

  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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