Pilot Debrief

COSTRUZIONI AERONAUTICHE TECNA P2008 near Burgaw, NC — 2016-04-16

Final reportERA16LA162
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Date
2016-04-16
Location
Burgaw, NC, USA
Aircraft
COSTRUZIONI AERONAUTICHE TECNA P2008
Registration
N588TA
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

Probable cause

The pilot’s failure to activate the airplane’s alternator, which resulted in an eventual loss of electrical power to the engine’s fuel pumps, fuel starvation, and a total loss of engine power. Contributing was the pilot’s use of an incomplete checklist.

NTSB narrative

The airplane was in cruise flight when, according to the pilot, the electronic flight display system "went out." About 10 minutes later, the engine sputtered and lost power. The pilot switched fuel tanks and attempted to restart the engine unsuccessfully then made a forced landing to a field. During the landing rollout, the airplane's nose landing gear struck a ditch and it nosed over, resulting in substantial damage to the wings, vertical stabilizer, and rudder. Review of recorded data from the airplane’s instrument panel-mounted display system indicated that electrical bus voltage started at 12.6 volts when the system was powered on, decreased for the entirety of the recording, decreasing more rapidly near the end of the flight. The alternator electrical current was zero for the entire recording. Postaccident examination and testing of the airplane’s electrical system revealed that the system was functioning normally; all cautions and warnings, including the “ALT OUT” message, were displayed by the system as required. Additionally, testing of the airplane’s engine and fuel pumps showed they also operated normally. Given this information, it is likely that for the entirety of the accident flight, electrical power was being supplied by the airplane’s battery alone and was not being replenished by the alternator. While the airplane was equipped with two fuel pumps, both required electrical power for operation. One fuel pump was likely not operating at all for the flight, as it required electrical power solely from the alternator for operation. The remaining fuel pump, which was powered by the battery, likely ceased operation as the battery voltage decreased to a level below that required to sustain it. With both fuel pumps offline, the engine was subsequently starved of fuel, and lost total power. An abbreviated, 6-page checklist was found in the accident airplane. Comparison of the checklist to the published flight manual revealed differences from the Normal Procedures section in the flight manual, including no mention of checking the position of the alternator side of the split master switch on the checklist. It is likely that as the pilot began the flight, he did not activate the airplane’s alternator, nor did he notice the warning messages and voltage highlights that were called out by the airplane’s electronic flight display system during the flight that would have warned him of this omission.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked alternator switch position before engine start.

NTSB coding

Evidence available

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

Docket documents9

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