Pilot Debrief

PIPER PA36 near El Campo, TX — 2017-05-28

Final reportCEN17LA202
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Date
2017-05-28
Location
El Campo, TX, USA
Aircraft
PIPER PA36
Registration
N3711E
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Climb

Probable cause

Foam contamination in the fuel injector nozzles from deteriorated foam baffles and water in the fuel flow divider, the combination of which resulted in the loss of engine power.

NTSB narrative

The commercial pilot was conducting an agricultural application flight when the airplane experienced a loss of engine power. The airplane subsequently impacted an adjacent field in a nose-low, left-wing-low attitude. Due to his injuries, the pilot did not recall the details of the accident flight, loss of engine power, or impact sequence. The location of the wreckage, the debris field, and the damage to the airplane are consistent with the airplane being in a turn at the time of the accident. An examination of the engine revealed no evidence of any preimpact mechanical anomalies that would have precluded normal operation. An examination of the fuel system revealed that the internal foam baffles in both fuel tanks were discolored and deteriorated, and they disintegrated into very fine particles when touched. According to the owner/operator, during routine maintenance 5 days before the accident, a mechanic found blue foam, which he identified as coming from the foam baffles, in the fuel filter at the engine. Subsequent periodic inspections of the screen revealed no contaminants. The postaccident examination of three fuel injector nozzles revealed that they were plugged with an unknown substance. In addition, evidence of water was found in the fuel flow divider. It is likely that, given the condition of the foam baffles and the owner's previous identification of foam in the fuel system, that the particles found in the fuel injector nozzles were from the foam baffles. This contamination, in combination with the water found in the fuel flow divider, likely resulted in the loss of engine power.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot could have addressed engine starting issues before flight.

NTSB coding

Evidence available

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

Docket documents5

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