Shortly after takeoff in Wild Rose, Wis., the Titan Tornado’s engine lost power. The airplane hit trees and then terrain, resulting in substantial damage and serious injury.
A post-accident examination revealed that one spark plug and its lead assembly had separated from its cylinder. Examination of the threads and the orifice on the cylinder revealed no anomalies.
Further examination revealed that the remaining spark plugs were loose but had not separated from their cylinders. It is likely that the spark plug that had become separated was also loose and not properly secured during maintenance.
The NTSB determined the probable cause as the improperly secured spark plug, which resulted in a total loss of engine power.
NTSB Identification: CEN13LA460
This August 2013 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
I am intimately familiar with this accident. I want the readers to know that no A&P or mechanic was involved in the pre-accident maintenance whatsoever and, in fact, the owner / pilot was SUPPOSED to have an IA check the machine over prior to flight but did not.
The last paragraph of the NTSB full report is telling … there are inconsistencies between what witnesses saw and reported and the what the pilot told the FAA investigator during a subsequent telecom after medical treatment.
What this accident REALLY tells everyone is that four sets of eyes are ALWAYS better than two. Nuff said.
20% of GA aircraft accidents continue to have a maintenance root cause. No big surprise. I don’t have time to dig into the docket for this accident, but can’t help wondering if the pilot did a thorough ground run BEFORE pushing the throttle forward on the takeoff run. FWIW, while BJS’s comment about the flight immediately following the annual is on point, the risks of a mechanic induced failure are still high for the first 10 to 20 hours after any invasive maintenance. I like Mike Busch’s description of inspections and ‘heavy’ maintenance: “When a mechanic ‘attacks’ an airplane…” be wary, very wary for several flight hours after!
Couldn’t resist reading the Docket…
According to the Docket the very low time sport pilot (89 hours) told the NTSB and FAA Inspector that he’d not done any maintenance since he bought the aircraft. This was his first flight in the plane since purchasing it. Several witnesses told the Inspector that they observed him run it up and taxi “back and forth”, then taxi back to his hangar where he pulled the spark plugs. After pulling, cleaning, and reinstalling the plugs witnesses said he taxied out and took off. in his report to the NTSB the pilot again asserted that he didn’t do any maintenance or touch the plugs.
I’ve seen it written that the most dangerous flight is the one immediately following the annual.
The estimate is that something like 80% of accidents – due to mechanical failure – occur on the first flight after maintenance was done on the airplane.
There is something to be said about the Air Force policy of doing an FCF (functional check flight) with a highly qualified pilot as the first flight after major maintenance – before returning the airplane to operational status.