Pilot Debrief

JOHNSON JOEL H RANS S-6ES COYOTE II near Rincon, PR — 2015-02-19

Final reportERA15LA133
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Date
2015-02-19
Location
Rincon, PR, USA
Aircraft
JOHNSON JOEL H RANS S-6ES COYOTE II
Registration
N5196W
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The inadequate maintenance and inspection of the fuel system, which resulted in partial blockage of a fuel filter, a partial loss of engine power, and subsequent ditching.

NTSB narrative

The private pilot had just purchased the experimental, amateur-built airplane on the day of the accident following a short flight with the previous owner. The pilot purchased premium automobile gasoline at a local gas station and refueled the airplane for the flight to his home airport. He and his passenger then boarded the airplane and taxied for takeoff. After takeoff, the pilot climbed the airplane along the shoreline to about 1,000 ft above sea level. About 20 minutes into the flight, the pilot noticed that the engine was not producing enough power to sustain level flight, so he began to troubleshoot while he flew a course parallel to the shoreline over shallow water. Due to people and rocks along the shoreline, he decided not to land on the beach, but to ditch the airplane in the water. Upon touchdown, the airplane decelerated and sank. The pilot released his seatbelt, egressed, and swam to the surface. When the pilot reached the surface, he did not see his passenger. He swam back down to the wreckage, released the passenger's seatbelt, and swam him up to the surface. However, the passenger was not breathing and cardiopulmonary resuscitation was unsuccessful. Examination of the airplane's fuel system revealed that the single fuel filter located between the electric fuel pump and the primer plunger was full of sand and debris, which obstructed the mesh filter screen. The condition of the filter indicated that it was not being maintained and inspected regularly, even though the fuel filter had a transparent housing and was in a location that allowed it to be inspected easily. The airplane build manual, engine operator's manual, engine installation manual, and engine maintenance manual all called for frequent inspection of the fuel filter. According to the maintenance manual, the flow through the filter could be restricted due to long-term buildup of dirt, and the fuel filter should be inspected every 25 hours of operation and replaced every 100 hours of operation. Review of the airplane's maintenance records found no entries indicating the inspection or replacement of the fuel filter since 2009, when a new engine was installed. The airplane's most recent condition inspection was performed about 3 months before the accident.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have checked fuel system and engine condition before flight.

NTSB coding

Evidence available

  • Video
  • Photos
  • 15 docket documents
View NTSB final reportView NTSB docket

Docket documents15

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