Covering form of preliminary or final report
| Date of event : | 2020-09-05 |
| Incident number : | CZ-20-0577 |
| Report : | Final report |
| Place of event : | Field 1,12 km E LKRY |
| Registration mark : | Accident |
| Weight category MTOM: : | <2250 kg |
| Type of operation : | Recreational and sport aviation |
| Plane / SFM : | Sports flying machines |
| Type of plane / SFM : | P 92 Echo Super |
| Health effects of event : | The fatal injuries |
| PDF document : | 
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Description:
SUMMARY
Synopsis
The pilot with another person on board (hereinafter the passenger) carried out a recreational navigation flight. After a stopover at SLZ LKBURA, where they spent some 1.5 hours, they continued in the flight along the planned route. Having passed Zbiroh at ALT 2,500 ft, the pilot noticed an increasing disproportion in the indication of fuel quantity in the left and right tanks. The pilot performed a right turn by 360 degrees to level out the fuel levels. As the situation did not improve, the pilot switched on the electric fuel pump, closed the right fuel tank fuel cock, and continued in flight directly to LKRY. The engine then started losing power and failed to respond to the movement of the throttle pull rod. The pilot decided for emergency field landing and extended the flaps for take-off. When approaching the ground, the engine stopped. The UL aircraft flew over the high-voltage line and turned over after rough landing on the freshly shallow-ploughed field.
The tractor driver helped the pilot to get out the UL aircraft and they together got the unconscious passenger out of the cockpit too. Following resuscitation, the passenger had been airlifted to hospital where he died on the fourth day after the accident. The pilot sustained a minor injury.
The UL aircraft was damaged to a large extent after emergency landing.
Factual Information
Having passed Zbiroh at ALT 2,500 ft, the pilot noticed an increasing disproportion in the indication of fuel quantity in the left and right tanks. The pilot performed a right turn by 360 degrees to level out the fuel levels. As the situation did not improve, the pilot switched on the electric fuel pump, closed the right fuel tank fuel cock, and continued in flight directly to LKRY. The engine then started losing power and failed to respond to the movement of the throttle pull rod. The pilot decided for emergency field landing and extended the flaps for take-off. When approaching the ground, the engine stopped. The UL aircraft flew over the high-voltage line and turned over after rough landing on the freshly shallow-ploughed field.
Analyses
The pilot had a lifetime of flying and decision-making experience not only in piloting general aviation sport aircraft but also commercial air transport aircraft. After retiring from his career as a professional transport pilot, he devoted himself fully to flying UL aircraft. For the last five years, he has flown two types of UL aircraft. He flew regularly without major breaks in flying and the numbers of his annual hours flown were sufficient to maintain the required skills and abilities. The pilot was fit to fly and was a holder of adequate qualification for performing a flight with the UL aircraft of the specified type.
After a completely erroneous assessment of the fuel level in the individual tanks and after closing the fuel cock on the tank with a significant amount of fuel, the fuel in the tank with the critical amount of fuel was consumed within approx. 6 minutes after closing the fuel cock. No evidence was found that the fuel gauges were not operational during the critical flight. Also, the engine examination and the damage to the propeller showed that the propulsion unit was not operating at the time of impact with the ground. The damage to the UL aircraft was caused by a rough landing with subsequent transfer of forces to the nose gear and fuselage structure. Upon investigation of UL aircraft wreckage at the place of air accident and subsequent technical investigation of the UL aircraft wreckage at the place of its deposition, technical investigation did not detect any facts that would indicate that the air accident was caused by a technical defect.
The critical situation occurred approx. in the 18th minute after take-off from LKBURA, when the UL aircraft was positioned between the villages of Zbiroh and Mýto. Here, the pilot first noticed a “supposedly” striking difference in the fuel amount indication between the right and left tanks. From this point on, he focused on levelling up the fuel levels between the left and right tanks, the right tank appearing to him as almost empty, which he justified by the fact that he was performing negative rolls during the flight. He first performed a 360° right turn and, when he found that the condition did not improve, he switched on the auxiliary electric fuel pump and closed the fuel cock of the right fuel tank in the 20th minute after take-off from LKBURA. As the fuel distribution situation was not developing according to the pilot’s expectations, he correctly decided to abort the flight and land at the nearest suitable aerodrome. He again concentrated fully on the approach to the aerodrome and did not open the right fuel cock even when the engine started to become erratic and the revolutions began to fluctuate significantly. When the engine drained all the fuel from the left tank, the pilot was forced to make an emergency field landing. The not-so-successful rough landing, according to the traces in the shallow-ploughed field surface and the GPS monitoring device recording, was performed on small flaps, at low speed and on three points. A short bounce followed with an impact on the nose landing gear. The nose landing gear leg broke off, one propeller blade broke off, and the UL aircraft rolled over the nose and came to rest in the aft attitude.
Conclusions/Causes
The cause of the accident was an engine shutdown due to a fuel supply interruption caused by improper handling of the fuel cock on one of the fuel tanks during flight and subsequent failure to correctly perform an emergency field landing.
Safety Recommendations
In view of the circumstances of the accident and similar events related to the incorrect handling of the fuel cocks, the operator of the UL aircraft, F AIR s.r.o., issued on 6 November 2020. Safety Information Bulletin No. 2020-05.
Given the circumstances of the air accident, the AAII issues no safety recommendations.
Attached final report in PDF file is in original Czech language.