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Whose fault, actually? — Common Aviation Information

It was a fairly little factor, the Cherokee. Liquidly gloss white, with two-toned pink stripes on the wings, fuselage, and tail—its gear wrapped in wheel pants.

It had been owned by one man for the earlier 20 years with out incident, and but, 9 months after its sale to a brand new proprietor, the Cherokee was a crumpled pile of junk mendacity in a ditch off the tip of Runway 24 at Oswego County Airport (KFZY) in Fulton, New York.

The NTSB put the blame for the wreck solely on the shoulders of the A&P/IA who accomplished the aircraft’s first annual underneath the brand new proprietor a mere three days earlier than the crash.

Nevertheless, a more in-depth take a look at the small print surrounding the destruction of the airplane exhibits that there might nicely be greater than sufficient fault to unfold round.

the flight

We do not have a file of how lengthy the aircraft was in annual, however as any proprietor can inform you, all annuals are too lengthy — and on this case there was fairly a little bit of further work performed, so it in all probability wasn’t a quick turnaround.

However after the annual, the proprietor picks up his aircraft at Cortland County Chase Area (N03) in Courtland, NY, and begins a ferry flight to his residence base of KFZY some 46 nautical miles away.

On takeoff, he notes a movie of oil beginning to kind on the windshield. It begins on the backside of the glass close to the cowl, primarily on the copilot facet, and quickly migrates 5 or 6 inches up the glass. However then it appears to cease, so somewhat than flip again and return to the upkeep store — which remains to be the closest airport — he decides to proceed the flight residence as a substitute.

You thought this was when the crash was going to occur, did not you?

No. Not but. The gods of flight smile upon our hero and he makes it residence safely.

The following day, he calls his IA, who tells the pilot to not fly the airplane and that he’ll come over and test it out.

However the pilot decides to test it out himself. He opens the cowl and sees no oil. He cleans the windshield and does a run-up. Then, in keeping with his cursive handwritten assertion from him to the NTSB, “I noticed a number of specks of oil, so I made a decision to do a takeoff and touchdown.”

You thought this was when the crash was going to occur, did not you?

The Pilot and the Accident

No, nothing dangerous occurs because the gods of flight as soon as once more smile upon our hero—a 68-year-old male with a non-public pilot certificates and about 170 complete hours, solely 13.3 of which had been within the make and mannequin.

On the third day he decides to do the identical factor once more. However this time, his luck from him runs out.

After takeoff, “oil began masking the windshield,” he advised investigators.

He is lifted off from Runway 15 at KFZY, and makes a tough left financial institution to return round and land on the perpendicular Runway 24. He is available in excessive and scorching, touching down past the midway level of the practically 4,000-foot runway and is unable to cease earlier than the tip.

His runway tour extends for greater than 360 toes past the edge, the place he plows by means of the chainlink airport perimeter fence—taking out three vertical posts within the course of—and involves relaxation in a ditch 30 toes past the fence line.

The pilot sustains solely minor cuts and bruises. The airplane, nevertheless, is fatally injured.

The aircraft after the accident. (Photograph by FAA)

The Oil Leak

On the accident website, an FAA inspector reported that there was no vital quantity of engine oil on the cylinders or equipment contained in the cowl, however that oil coated the floor of the fixed-pitch prop, spinner, and nostril cowling.

The crankshaft with the crankshaft plug lacking. (Photograph by FAA)

The plane is moved to a hangar the place the inspector removes the oil-covered elements “to aim to find out the supply of the engine oil leak,” and when he does, “the plug that’s put in within the entrance opening of the engine crankshaft fell to the bottom.”

The NTSB investigators decided this free plug was the reason for the oil leak and, due to this fact, finally, the reason for the crash.

The plug is formally known as a crankshaft growth plug, and when you image it as a cork in a wine bottle, you will not be far off. Solely the bottle, on this case, is the hole crankshaft of the Lycoming O-320.

The crankshaft plug. (Photograph by FAA)

Why did it turn into dislodged?

The NTSB’s remaining report on the crash states that, “The mechanic who carried out the upkeep acknowledged that he put in the crankshaft plug utilizing a ball peen hammer, as a substitute of following the procedures outlined by the engine producer, which known as for using a particular device to correctly deform and seat the plug.”

The Mechanic

The particular device known as a Lycoming Driver Crankshaft Welch Plug, which Plane Spruce lists for an eye-popping $1,677 every.

It is form of like these instruments you employ to put in clothes snaps, , those you whack with a hammer to shut the metallic. And also you whack the $1,677 device with a hammer, too, however apparently the mechanic determined to chop out the intermediary and simply use the hammer.

The device. (Photograph Courtesy Lycoming)

When the FAA inspector arrived on the store to interview him, the inspector described the mechanic as “well mannered and cordial.” However then issues begin to get squirrelly.

When the inspector requested to see the technical publications he used, the mechanic “replied that each one the tech information for the store was on a pc at his residence, and never available.” When requested for his IA and A&P certificates, the mechanic “suggested inspectors that he didn’t have them with him, although he was actively exercising their privileges and was within the strategy of performing an annual inspection on one other plane.”

The mechanic’s dangerous day ended with the FAA inspector giving him a replica of the Pilot’s Invoice of Rights and being advised to count on a Letter of Investigation from the FSDO.

Sarcastically, within the accident plane’s engine logbook, above the usual, “I certify that this engine was inspected in accordance with an annual inspection and has been decided to be in airworthy situation,” the mechanic entered the next disclaimer: “The beneath assertion by no means implies or ensures that this engine will proceed to operate for any time period after this inspection.”

The NTSB dropped the ball peen hammer on the mechanic, itemizing the possible trigger as “the mechanic’s improper upkeep, which resulted within the crankshaft growth plug dislodging in flight and a subsequent compelled touchdown.”

The pilot wasn’t known as out for his actions by the NTSB.

Evaluation and Dialogue

The mechanic used the unsuitable device, apparently did not preserve his tech information in the identical constructing that he labored in, and did not know the laws nicely sufficient to grasp he was required to have his certificates in his pockets. There isn’t any defending any of that.

Positive, the device is dear, nevertheless it’s used for an every-five-year AD on a big household of engines discovered on a wide selection of airplanes, together with Cherokees, Tremendous Cubs, and Cessna 172s.

However balancing that, he did inform the pilot to not fly and that he would come to the pilot’s location to take a look at the airplane.

So now we have to take a look at the pilot.

Keep in mind the Spiderman Rule, 14 CFR 91.3, which says “with nice energy comes nice accountability.” Nicely, really it says the PIC “is instantly answerable for, and is the ultimate authority to, the operation of the plane.”

So did the pilot present a great accountability quotient when he flew residence with oil creeping up his windshield, somewhat than aborting the flight and returning to the sphere? Did the pilot present a great accountability quotient when he disregarded the mechanic’s urging to not fly the airplane? Did the pilot present a great accountability quotient when, regardless of extra thriller oil “specks” on the windshield, he flew once more. Twice?

Now, granted, it is a difficult oil leak. It is arising the hole crankshaft and exiting behind the spinner, leaving the engine compartment clear. It is a fixed-pitch prop, so it is potential the pilot did not even know the engine had a hole crank.

However nonetheless, the airplane was speaking to the pilot, and the pilot—the ultimate authority—wasn’t listening.

View of the oil leak on the nostril cone. (Photograph by FAA)

The Takeaway

We pilots typically discover ourselves between a rock and a tough place with 91.3. Think about the newly minted non-public pilot. Although probably not the plane’s proprietor, barred from doing a lot of the upkeep, and possibly not understanding the deep inside workings of the airplane’s programs, that new pilot remains to be the ultimate authority on its airworthiness.

The NTSB, considerably uncharacteristically, hung the hat solely on the mechanic on this accident.

However the query for dialogue is: Ought to this all be on the mechanic or did the pilot — on this case — share a number of the accountability?

Wish to study extra?

Obtain the NTSB’s remaining report right here or view the objects on docket right here.

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