The commercial pilot was traveling in a Navion G to attend an air show the following day. Upon arrival at the destination in Hamilton Township, N.J., he attempted a night instrument landing system approach but, due to low visibility, flew a missed approach.
He subsequently requested and received vectors for a second attempt of the same approach. However, as the airplane neared the final approach course, the controller advised the pilot of worsening weather conditions, and the pilot then requested vectors to an alternate airport.
After receiving a clearance, the pilot added power to the engine and initiated a climb, but the engine lost power, which the pilot attributed to either a fuel or an electrical problem.
The airplane subsequently descended into trees and stuck the ground nose-low, on its left side, in a “violent deceleration.”
The pilot stated that he had checked the fuel quantity in both of the airplane’s wing tip tanks and the connected main tanks before the flight using a calibrated stick and found about 10 gallons of fuel in each tip tank and 15 gallons of fuel in the main tanks.
He also stated that he always took off and landed using the main fuel tanks and used the tip tanks in transit.
He added that, during the flight, he used the left tip tank for 22 minutes 40 seconds and was certain of the time because he used a stopwatch. He then used the main fuel tanks for the first approach and, after the missed approach, switched to the right tip tank.
About one minute before the engine quit, he switched from the right tip tank to the main tanks again. Once the engine quit, he moved the fuel selector through various positions and then checked the ignition, throttle, and mixture.
The airplane was equipped with an engine monitor, which, among other parameters, tracked fuel flow.
Data revealed that, at one point, fuel flow dropped to 0, with a concurrent reduction in all engine temperatures.
Before the end of the recording, fuel flow spiked briefly up to 4 gallons per hour on four occasions before returning to 0, consistent with the pilot’s statement that he moved the fuel selector to different positions.
Two of the spikes occurred for 2 seconds, and the other two occurred for 3 seconds. The pilot reported that, after intentionally running a tank out of fuel during en route operations, the engine would restart about 5 to 10 seconds after switching fuel tanks.
At the accident site, fuel was found in all tanks except the left tip tank. Although compromised upon impact, there was no evidence of fuel leakage underneath or in the vicinity of that tank.
Fuel supply system continuity, with no blockages noted, was later confirmed from all tanks to the engine, and after replacing some impact-damaged items, the engine was run from idle to full throttle multiple times with no anomalies noted.
Although fuel was not found in the left tip tank, a small amount was likely still present when the pilot initiated the climb after the missed approach, which then sloshed toward the aft end of the tank, unporting the fuel pickup. This introduced air into the engine fuel supply, which led to the loss of engine power.
The lack of fuel found in the left tip tank, the absence of anomalies noted in either the fuel supply system or when the engine was test run, the cessation of fuel flow noted in the engine monitor data, and the fluctuation of fuel flow as the pilot subsequently moved the fuel selector through the tank-with-fuel and tank-without-fuel positions indicated the likelihood that the pilot inadvertently moved the fuel selector to the left tip tank when he began the climb to the alternate airport and was operating the engine from an almost depleted left wing tip tank when the engine lost power.
The airplane was manufactured at a time when only seat belts were required; front-seat shoulder harnesses or other restraints with an equal level of protection were not mandatory. The airplane did not have shoulder harnesses at the time of the accident, and the FAA does not mandate retrofit, instead relying on voluntary installation.
The pilot-rated passenger in the right front seat was fatally injured when her head hit the engine controls and instrument panel, an outcome that likely would have been mitigated with the presence and use of adequate shoulder restraints or other equal-level protection.
The NTSB determined the probable cause as the pilot’s mismanagement of the onboard fuel supply, which resulted in fuel starvation to the engine and a subsequent loss of engine power. Contributing to the death of the right front passenger was the inadequate occupant restraint.
NTSB Identification: ERA14FA232
This May 2014 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.
Those old technology aircraft are fun and safe to fly. But, they also need up dated safety equipment too. They never had shoulder harnesses back in their day and should have all been retrofitted for safety sake. The fuel system can be a challenge for most pilots of the Navion. It appears the operator may have been the owner but panicked when the engine stumbled on the go-a-round. Mose aircraft that I have ever flown (CAR 3 and FAR 23) have the operator T.O. and Land on the Main tanks only. Follow the limitations and the placarding.
Single engine night IFR to minimums is a high risk, very low error tolerance operation. While I agree with C J that we should “follow the limitations…” and have “up dated safety equipment” engaging in night IFR ops to minimums is really pushing the envelope. Under those circumstances “Time to spare? GO BY AIR!” is a very good pre-loaded personal limit. One he was fortunately able to find unnecessary during his previous flight experience. The Reward vs Risk outcome of his flight just wasn’t there. Panic or no, the pilot arguably didn’t have his previously experienced “5 to 10 seconds” for the power plant to rise from the dead. One bad decision followed by another series of bad decisions is a fairly normal response to highly stressful, time critical, emergency situations. It’s a regular feature of fatal aviation accidents (GA, airline, etc.).
The NTSB Factual report for this accident is more of a political statement than a “Finding of Facts” pertaining to the event. Based on the text of the Factual report it appears the NTSB has thrown a tantrum because the FAA won’t issue an Airworthiness Direction to require owners of legacy and antique aircraft to fall into line by either (a) employing a DER to redesign the structure of their aircraft to support shoulder harness stresses; or (b) installing airbag lap belt restraints at a cost that approaches the value of the airframe. See the closing dozen or so paragraphs in the NTSB Factual at of which the final three paragraphs are quoted verbatim:
“On September 6, 2013, the FAA again advised the NTSB that many GA airplanes manufactured before December 12, 1986, did not have the necessary structure to install a shoulder harness, and that a two point inflatable restraint would be the only possible solution. The FAA also noted that mandating the retrofit of aircraft manufactured before December 12, 1986, with a two-point inflatable restraint or a shoulder harness would require the determination that an unsafe condition existed and the issuance of an airworthiness directive. The cost of retrofitting the fleet would be substantial, and the economic burden levied on the GA fleet with such a mandate would outweigh any potential benefit. [NTSB quoting from the FAA response] “Therefore the FAA does not intend to mandate the installation of a two-point inflatable restraint system or a shoulder harness on the existing fleet.” [Close quote from FAA response]
“In addition, the FAA noted that [NTSB quoting from FAA response] “the intent has been, and continues to be, to develop a framework that permits an airplane owner to voluntarily replace a two-point conventional restraint with a two-point inflatable restraint. We will continue to promote the safety benefits of voluntary replacement of two point conventional restraints with two-point inflatable restraints. I believe the FAA has effectively addressed this safety recommendation to the extent practicable and consider our actions complete.” [Close quote from FAA response]
On December 26, 2013, the NTSB acknowledged the FAA’s response, including allowing owners to voluntarily replace a two-point conventional restraint with a two-point inflatable restraint as a noteworthy improvement, but [NTSB quoting from its response to the FAA] “we do not consider it an acceptable substitute for the recommended requirement. Because the FAA believes that it has fully responded to this recommendation and no further action, Safety Recommendation A-11 004 is classified as CLOSED – UNACCEPTABLE ACTION.” Updated on Apr 14 2016 7:43AM [Close quote from NTSB response to the FAA]