Mooney down in Tampa Bay. No injuries

[LANCECASPER]

@Junkman @Brian E. Thanks for sharing the links

He confirms on the podcast what we were talking about a month ago on here . . . he wanted to go to an airport of his choice where he was familiar with the maintenance facility. Understandable, but not a good choice. Although this turned out well in the sense that both people survived, it didn't have to go this way. It's easy to sit back and play Monday morning armchair quarterback now, but we talk about these things and listen to the podcasts in the hope of learning something, not to overly criticize the pilot. Turning back to Lakeland would have been a good option since early in the flight he realized something was wrong with the engine. There were a lot of other airport options before he lost power. Also he felt that there was fuel spraying on the windshield, that could have turned into an in-flight engine fire, so all the more reason to get it on the ground. But amazing job of staying calm and landing on the water. 

My take-away is (1) that any airport beats flying back over the water in Tampa Bay with a questionable engine and (2) that if you're having engine trouble, the first airport, no matter what the facility is on the field, is the best choice. Get it on the ground and figure it out. 

[larrynimmo]

One other thing…what’s the rush to drop the gear….I wouldn’t drop my gear until short final…even if I ended up doing a belly landing if I didn’t have the juice to get it down in time

[LANCECASPER]

https://www.ntsb.gov/Pages/ResultsV2.aspx?queryId=da535572-bae4-42ec-ae65-353caf48b354
 
If realizing that the fluid on the windshield was fuel and the thought of making it back to the shop on the home field that worked on the fuel system weeks earlier was the reason for passing all of the airports they flew by, that was terribly flawed reasoning.

None of us have ever made a perfect flight but once he diverted and turned toward Tampa, that's a lot of minutes of decision-making going by with a rough running engine, when just hitting the nearest airport function on any device would have eliminated a lot of drama for a lot of people that day.

[chriscalandro]

9 hours ago, 1980Mooney said:

Final is out.  Cause of the crash landing was owner assisted maintenance resulting in improper tightening of the fuel system components. There was a fuel leak causing the engine to run excessively lean and hot.  See NTSB CAROL.

Report_ERA22LA064_104268_9_11_2023 12_25_50 PM.pdf

 

Get outta here with that BS. That is NOT what the NTSB said. They both missed it. 

 

“Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be: Page 1 of 6

The total loss of engine power due to the failure of maintenance personnel to properly tighten the fuel supply line b-nut at the manifold valve during installation.”

7.5 flats is quite a lot I think. I don’t believe I’ve ever measured tightness that way though. 
 

There’s nothing wrong with owner assisted maintenance or owner maintenance in general. In fact, I’d say most owners are more particular about their machines than the shop. 
 

 

[chriscalandro]

No, it isn't.  I quoted the NTSB for you in my previous comment.

 

You said the problem was, quote - 

"Final is out.  Cause of the crash landing was owner assisted maintenance resulting in improper tightening of the fuel system components. There was a fuel leak causing the engine to run excessively lean and hot.  See NTSB CAROL."

 

That is NOT the cause of the crash.

 

When you tighten, torque, replace, adjust any line, it should be tested.  They were both hands on, neither of them tested it.

 

This has nothing to do with owner assisted maintenance and I WOULD be willing to bet the mechanic would have missed it as well.  He's covering his ass here.  

Edited September 12, 2023 by chriscalandro

[LANCECASPER]

One thing we know for sure is that 100% of the airplanes that owner worked on that year ended up in the water at Tampa Bay. I would be willing to bet that 100% of the airplanes that the IA worked on didn't end up there. Maybe just the one.

[Shadrach]

This is an unfortunate situation all around:

Poor maintenance practices (owner and A&P)

Poor supervision (A&P)

Poor final inspection of completed work (A&P)

Poor inflight decision making (pilot)

Poor understanding on this forum of the responsibilities and regulations with regard to supervisory maintenance.

 

14CFR43.3(d) states, “A person working under the supervision of a holder of a mechanic or repairman certificate may perform the maintenance, preventive maintenance, and alterations that his supervisor is authorized to perform, if the supervisor personally observes the work being done to the extent necessary to ensure that it is being done properly and if the supervisor is readily available, in person, for consultation. However, this paragraph does not authorize the performance of any inspection required by Part 91 or Part 125 of this chapter or any inspection performed after a major repair or alteration.”

[Shadrach]

8 hours ago, chriscalandro said:

He's covering his ass here.  

He’s trying to anyway. I don’t think he’ll have much luck. He is responsible for the work he signed off. We use torque seal and do leak checks for a reason. These guys apparently did neither. 

I’m reminded of an instructional flight that crashed due to fuel starvation a few years ago. The aircraft was found to have useable fuel in all of the tanks but the one selected. A 300hr pilot and a 1200hr instructor could not between the two of them, summon the ware with all to move the selector to a different tank. 
The way this thread reads, you’d think the student was the problem. I mean the instructor had never run out of gas on a personal flight…

[FlyingDude]

CFR 43 app A, par c) preventive maintenance, items 21 and 22:

(21) Replacing any hose connection except hydraulic connections.

(22) Replacing prefabricated fuel lines.

https://www.ecfr.gov/current/title-14/chapter-I/subchapter-C/part-43

If that's what they did, in theory, maintenance personnel (mechanic) need not even be involved...  In theory, it should be spotted during annual by the IA.  

[FlyingDude]

38 minutes ago, Shadrach said:

I’m reminded of an instructional flight that crashed due to fuel starvation a few years ago. The aircraft was found to have useable fuel in all of the tanks but the one selected. A 300hr pilot and a 1200hr instructor could not between the two of them, summon the ware with all to move the selector to a different tank. 

Are we thinking of the same crash?  I know an instructor who crashed that way.  The student walked away and the instructor's ribs were crushed.  Turns out, the instructor told the student during short final to NOT touch the fuel selector because they're on the fuller tank but the student swaps tanks just the same.  By the time the engine goes rough, they're a few feet above the trees.

I'm a CFI and sometimes, some students, even those with many many hours, do some stupid shit that scare the hell out of you.  Like guys holding 55kts in downwind on a C182, banking hard to base because of crosswind, and doing short final with the horn running (it sounds before stall).  Why?  Because they have to make the first taxiway.  If you tell them something, the standard answer is "I was already flying while you were shitting your diapers."  OF COURSE such elements are a rarity, but so are accidents (thankfully).  This particular guy was fixed by another instructor who is his age, therefore my words coming out of his mouth were taken more seriously.  However, there are some moves that even a seasoned CFI would not be able to catch and correct immediately.

[Shadrach]

4 hours ago, FlyingDude said:

CFR 43 app A, par c) preventive maintenance, items 21 and 22:

(21) Replacing any hose connection except hydraulic connections.

(22) Replacing prefabricated fuel lines.

https://www.ecfr.gov/current/title-14/chapter-I/subchapter-C/part-43

If that's what they did, in theory, maintenance personnel (mechanic) need not even be involved...  In theory, it should be spotted during annual by the IA.  

Yes an owner can replace fuel hoses. However, in this case, the entire fuel system had been removed several components sent out for overhaul.  The owner was "helping" with the reinstallation and return to service, not performing preventative maintenance.

[Shadrach]

4 hours ago, FlyingDude said:

Are we thinking of the same crash?  I know an instructor who crashed that way.  The student walked away and the instructor's ribs were crushed.  Turns out, the instructor told the student during short final to NOT touch the fuel selector because they're on the fuller tank but the student swaps tanks just the same.  By the time the engine goes rough, they're a few feet above the trees.

I'm a CFI and sometimes, some students, even those with many many hours, do some stupid shit that scare the hell out of you.  Like guys holding 55kts in downwind on a C182, banking hard to base because of crosswind, and doing short final with the horn running (it sounds before stall).  Why?  Because they have to make the first taxiway.  If you tell them something, the standard answer is "I was already flying while you were shitting your diapers."  OF COURSE such elements are a rarity, but so are accidents (thankfully).  This particular guy was fixed by another instructor who is his age, therefore my words coming out of his mouth were taken more seriously.  However, there are some moves that even a seasoned CFI would not be able to catch and correct immediately.

We’re not talking about the same accident. I’m talking about a PA-32 that crashed in CO during a checkout flight. 

Report_CEN21LA261_103248_9_12_2023 2_15_30 PM.pdf

[JimB]

I'd like to know how it flew 2 months and 12 hours with the fuel line not tight and no one noticed. 

Review of the maintenance records revealed that nearly 2 months before the accident, fuel system components consisting of the engine-driven fuel pump, servo fuel injector, manifold valve, and fuel injectors were removed for testing and overhaul. The components were installed and according to the pilot, the airplane had been operated about 12 hours over 3 or 4 flights since installation. There was no record of any subsequent engine work after the overhauled components were installed.

[Shadrach]

1 hour ago, JimB said:

I'd like to know how it flew 2 months and 12 hours with the fuel line not tight and no one noticed. 

Review of the maintenance records revealed that nearly 2 months before the accident, fuel system components consisting of the engine-driven fuel pump, servo fuel injector, manifold valve, and fuel injectors were removed for testing and overhaul. The components were installed and according to the pilot, the airplane had been operated about 12 hours over 3 or 4 flights since installation. There was no record of any subsequent engine work after the overhauled components were installed.

12hrs sounds about right to go from hand tight to spraying fuel all over the engine compartment. Maybe an initial leak test was performed and with no leaks noted. Torque seal is underutilized in the industry. I don’t know why. All of my cars have the nuts and bolts marked from the manufacturer.

[flyboy0681]

On 11/16/2021 at 1:45 AM, MooneyMitch said:

Some things look smaller under water .....especially when water is cold . 

"It's shrinkage!"

[skykrawler]

Just recently saw a C182 IO540 fuel injector input line.....the inspector reached to it with his hand and the B nut was loose and turned by hand.  The blue around the fitting was what triggered the check.      The aircraft had nearly 100 hrs since the last annual - oil hadn't been changed (or maybe it would have been noticed sooner.)

 

[EricJ]

It sounded to me like a leak check, or at least a cursory one, was performed and it was okay at that time.   As mentioned, though, if not sufficiently torqued it can work loose from being leak-free to essentially unattached over time.

Torque seal only helps if it gets inspected frequently enough to detect movement.    I'm not sure this would have been seen if it took a while to loosen sufficiently to leak.

 

[Shadrach]

18 minutes ago, EricJ said:

It sounded to me like a leak check, or at least a cursory one, was performed and it was okay at that time.   As mentioned, though, if not sufficiently torqued it can work loose from being leak-free to essentially unattached over time.

Torque seal only helps if it gets inspected frequently enough to detect movement.    I'm not sure this would have been seen if it took a while to loosen sufficiently to leak.

 

To my way of thinking, torque seal is a visual verification that the fastener has been torqued. Marking the fastener immediately follows torquing the fastener.  I have never seen a fastener move after it’s been properly torqued and sealed. 

 

[EricJ]

39 minutes ago, Shadrach said:

To my way of thinking, torque seal is a visual verification that the fastener has been torqued. Marking the fastener immediately follows torquing the fastener.  I have never seen a fastener move after it’s been properly torqued and sealed. 

Agreed.   The torque seal also gives a visual indication of whether it has moved or not since the torque seal was applied.   That's only useful if it gets inspected once in a while, so the comments by the maintainer that they didn't put torque seal on it wouldn't matter if it wasn't ever inspected again after reassembly and leak check.

[Shadrach]

1 hour ago, EricJ said:

Agreed.   The torque seal also gives a visual indication of whether it has moved or not since the torque seal was applied.   That's only useful if it gets inspected once in a while, so the comments by the maintainer that they didn't put torque seal on it wouldn't matter if it wasn't ever inspected again after reassembly and leak check.

The problem is that they likely missed  torquing it and had no visual cue that they hadn’t. It leak checks OK when hand tight but works loose over the next 2 months. Everything could’ve been mitigated with torque seal.

[EricJ]

5 minutes ago, Shadrach said:

The problem is that they likely missed  torquing it and had no visual cue that they hadn’t. It leak checks OK when hand tight but works loose over the next 2 months. Everything could’ve been mitigated with torque seal.

Torque seal does zero to maintain torque, and isn't an indicator that torque was applied.   It's a nice tool to use in a process as you described, but if applying torque got skipped and the torque seal applied anyway, there's no way to know that.    All it can be counted on doing is indicating whether the fastener has moved since it was applied, and that's only useful in subsequent inspections.

[Shadrach]

48 minutes ago, EricJ said:

Torque seal does zero to maintain torque, and isn't an indicator that torque was applied.   It's a nice tool to use in a process as you described, but if applying torque got skipped and the torque seal applied anyway, there's no way to know that.    All it can be counted on doing is indicating whether the fastener has moved since it was applied, and that's only useful in subsequent inspections.

No one is saying the torque seal maintains torque. Torque seal does two things. It serves as a visual verification that the fastener has been torqued and ad a visual verification that the fastener has not moved during subsequent inspections. 
 

In this case, the B nut did not lose torque…It was not ever torqued in the first place.  If the maintenance personnel involved had made it policy to use torque seal on every fastener after tightening/torquing, they would’ve known they missed it during the final inspection and leak test.

Don’t ask me how I know this method works. I’m all too familiar with human shortcomings both my own or others.

The auto workers in Munich that assembled my cars didn’t torque seal all of the suspension subassemblies so that they could check on it in a month to see if the fasteners moved; they did it so the inspector at the end of the assembly line could verify that they did their jobs.

 

[EricJ]

29 minutes ago, Shadrach said:

No one is saying the torque seal maintains torque. Torque seal does two things. It serves as a visual verification that the fastener has been torqued and ad a visual verification that the fastener has not moved during subsequent inspections. 
 

In this case, the B nut did not lose torque…It was not ever torqued in the first place.  If the maintenance personnel involved had made it policy to use torque seal on every fastener after tightening/torquing, they would’ve known they missed it during the final inspection and leak test.

Don’t ask me how I know this method works. I’m all too familiar with human shortcomings both my own or others.

The auto workers in Munich that assembled my cars didn’t torque seal all of the suspension subassemblies so that they could check on it in a month to see if the fasteners moved; they did it so the inspector at the end of the assembly line could verify that they did their jobs.

 

Sure, if a process says that you are supposed to put on torque seal after applying torque, and the torque seal isn't there, it's an indicator that the process wasn't completed.    The presence or absence of the torque seal does not and cannot guarantee whether torque was applied or not, it only is a partial indicator of completion of a process if that process is intended to be in place.    The only thing the torque seal can actually do is indicate whether the fastener moved after application.

In this case it's moot because it wasn't applied.    Application of torque seal can't guarantee that torque was applied. 

[Shadrach]

30 minutes ago, EricJ said:

Sure, if a process says that you are supposed to put on torque seal after applying torque, and the torque seal isn't there, it's an indicator that the process wasn't completed.    The presence or absence of the torque seal does not and cannot guarantee whether torque was applied or not, it only is a partial indicator of completion of a process if that process is intended to be in place.    The only thing the torque seal can actually do is indicate whether the fastener moved after application.

In this case it's moot because it wasn't applied.    Application of torque seal can't guarantee that torque was applied. 

[Shadrach]

1 hour ago, 1980Mooney said:

Since this repair was "owner assisted" and many here have made an impassioned case for greater "hands on" owner involvement in Annuals and repairs, I am curious to know the position of the insurance companies providing A&P Mechanic's Liability Insurance. 

For those shops and A&P's carrying Mechanics Insurance:

• Are there any limitations or exclusions?
• Is it limited to employees of the shop or those employed by the A&P if they have a mobile service?
• Is it limited to certified aircraft mechanics working at the shop or for the A&P?
• Does it exclude any maintenance or "hands on" action taken by an owner? (i..e. the liability of the Owner's actions, even under supervision, remain with the Owner's Liability insurance policy?)

Let's face it - when you take your car to the dealership for repair, there is no "owner assisted" activity allowed.  They won't let you in the repair area.  I suspect their liability insurance policy restricts it to only employees.

I don't know if this falls in @Parker_Woodruff 's wheelhouse.  If Clarence were still here he could clarify ASAP.

This will likely come as a surprise to you, but many mechanics do not carry liability insurance. The airport may require anyone hanging a shingle out on the premises to carry insurance, but it is not required to act as an A&P/IA.

Most repair stations have numerous individuals working on airplanes that are not credentialed. I worked for such an organization in college (we were insured). I did lots of disassembly, cleaning and bucked lots of rivets that summer. The primary engine builder at the repair station on my field had zero aviation credentials. When the owner of that repair station passed away his engine builder had no problems getting a job at another engine shop 40 miles south of my airport.  I don’t think insurance companies distinguish maintenance from owner assist maintenance. The credentialed individual that puts their signature in the book and gets compensated for verifying airworthiness.