Crash of a Cessna 208B Grand Caravan in Lodi

Date & Time: May 12, 2016 at 1413 LT
Type of aircraft:
Registration:
N1114A
Flight Phase:
Survivors:
Yes
Schedule:
Lodi - Lodi
MSN:
208B-0309
YOM:
1992
Location:
Crew on board:
1
Crew fatalities:
Pax on board:
17
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
7050
Captain / Total hours on type:
253.00
Aircraft flight hours:
12848
Circumstances:
The commercial pilot reported that, after takeoff on the local skydiving flight, the engine experienced a total loss of power. He initiated a turn toward the airport, but realized the airplane would not reach the runway and chose to perform a forced landing to an open field. During the landing roll, the airplane exited the field, crossed a road, impacted a truck, and continued into a vineyard, where it nosed over. Postaccident examination of the engine revealed that the fuel pressure line that connects the fuel control unit to the airframe fuel pressure transducer was fractured below the fuel control unit fitting's swaged seat. In addition, a supporting clamp for the fuel pressure fuel line was fractured and separated. The operator reported that the fractured fuel line had been replaced the night before the accident and had accumulated about 4 hours of operational time. The previously-installed line had also fractured. Metallurgical examination of the two fractured fuel lines revealed that both fuel lines fractured due to reverse bending fatigue through the tube wall where a ferrule was brazed to the outside of the tube. There were no apparent anomalies or defects at the crack initiation sites. Examination of the supporting clamp determined that it fractured due to unidirectional bending fatigue where one of the clamp's tabs met the clamp loop, with the crack initiating along the inward-facing side of the clamp. The orientation of the reverse bending fatigue cracks and the spacing of the fatigue striations on the tube fracture surfaces were consistent with high-cycle bending fatigue due to a vibration of the tube. The cushioned support clamp is designed to prevent such vibrations from occurring. However, if the clamp tab is fractured, it cannot properly clamp the tube and will be unable to prevent the vibration. The presence of the fractured clamp combined with the fact that the two pressure tubes failed in similar modes in short succession indicated that the clamp most likely failed first, resulting in the subsequent failure of the tubes. Since the clamp was likely fractured when the first fractured fuel pressure line was replaced, the clamp was either not inspected or inadequately inspected at the time of the maintenance.
Probable cause:
A total loss of engine power due to a fatigue fracture of the fuel pressure line that connected the fuel control unit and the fuel flow transducer due to vibration as the result of a fatigue fracture of an associated support clamp. Contributing to the accident was the mechanic's inadequate inspection of the fuel line support clamp during the previous replacement of the fuel line.
Final Report:

Crash of a Beechcraft A90 King Air in Pitt Meadows

Date & Time: Aug 3, 2008 at 1524 LT
Type of aircraft:
Registration:
N17SA
Survivors:
Yes
Schedule:
Pitt Meadows - Pitt Meadows
MSN:
LJ-164
YOM:
1966
Country:
Crew on board:
1
Crew fatalities:
Pax on board:
7
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
4800
Captain / Total hours on type:
1290.00
Aircraft flight hours:
13257
Circumstances:
The Bill Dause Beech 65-A90 King Air (United States registration N17SA, aircraft serial number LJ-164) took off from Pitt Meadows Airport, British Columbia, with the pilot and seven parachutists for a local sky diving flight. At 1521 Pacific daylight time, as the aircraft was climbing through 3900 feet above sea level, the pilot reported an engine failure and turned back towards Pitt Meadows Airport for a landing on Runway 08R. The airport could not be reached and a forced landing was carried out in a cranberry field, 400 metres west of the airport. On touchdown, the aircraft struck an earthen berm, bounced, and struck the terrain again. On its second impact, the left wing dug into the soft peat, spinning the aircraft 180 degrees. Four of the parachutists received serious injuries and the aircraft was substantially damaged. There was no fire and the occupants were evacuated. The emergency locator transmitter functioned at impact and was turned off by first responders.
Probable cause:
Findings as to Causes and Contributing Factors:
1. The general condition of the aircraft, the engine time before overhaul (TBO) over-run and the missed inspection items demonstrated inadequate maintenance that was not detected by regulatory oversight.
2. The TBO over-run and missed inspections resulted in excessive spline wear in the left engine-driven fuel pump going undetected.
3. The left engine lost power due to mechanical failure of the engine fuel pump drive splines.
4. The horizontal engine instrument arrangement and the lack of recent emergency training made quick engine malfunction identification difficult. This resulted in the pilot shutting down the wrong engine, causing a dual-engine power loss and a forced landing.
5. Not using the restraint devices contributed to the seriousness of injuries to some passengers.
Finding as to Risk:
1. There is a risk to passengers if Transport Canada does not verify that holders of Canadian Foreign Air Operator Certificates-Free Trade Agreement meet airworthiness and operational requirements.
Final Report: