Accident Report re: electronic gyro install error?

[GAHorn]

AvWeb reported this accident recently. I am posting it because of the recent popularity of Electronic “gyro” Instrument conversions.
No blame is being insinuated on the new instruments…but discoveries may point to improper conversion/installation/removal of old equipment.
(I believe the reference to a “vacuum pump cover” may actually intend to be a “blanking-cover” to close-out the vacant mounting-pad.)

September 14, 2022, Conway, S.C.

Piper PA-28R-201 Arrow III

The airplane was destroyed at about 1222 Eastern time as the pilot attempted an off-airport landing after reporting total engine failure. The pilot and passenger were fatally injured. Visual conditions prevailed.

Shortly after departure, the pilot reported to ATC that he was having problems with cockpit instrumentation resulting in difficulty maintaining assigned headings. He wanted to return to the departure airport and was not declaring an emergency. About 30 seconds later, the pilot reported loss of engine power, that he was unable to make it back to the departure airport and that he had identified an off-field landing area. Witnesses reported seeing the airplane but they heard no engine sound. The airplane impacted a tree and a powerline before coming to rest. A post-crash fire consumed much of the wreckage.

Examination revealed catastrophic failures of three of its four connecting rods. The left engine crankcase half was fractured inboard of the #4 cylinder mounting pad. During engine disassembly, a vacuum pump cover was found installed to the vacuum pump drive pad without a gasket. Maintenance records revealed the airplane had just undergone an avionics upgrade, which included removal of the vacuum system and installation of electronic flight instruments. The accident flight was the first one after the upgrades.

[wingnut]

Most avionics techs that I've met are not mechanics and should <not> be removing systems without appropriate supervision. They may have an A&P cert, but most do not have the experience or aptitude, nor enough opportunity to stay actively engaged and current on mechanical systems. Sad deal.

About 25 years ago I was doing some work on a Bonanza at another shop on the field. An avionics crew was also working on it, installing later model wing tips and strobes. The avionics tech zip-tied the strobe wiring to the landing gear retract rods.

In fairness, I've never met a good mechanic that could do anything with avionics. Most struggle with basic electricity troubleshooting.


<corrected by moderator>

[ghostflyer]

OMG wing nut you bring a tear to my eye . that’s a bit harsh hitting at the poor avionics guys. But due to industry pressures and the lack of qualified people there are some avionics guys that do need mechanical training and also there are some mechanical guys need avionics training . it’s due to the changing of technology , the lines of mechanical and avionics are getting very blurred.
In my humble opinion it’s all about training and competency and being able to demonstrate it . This also includes pilots , who are allowed to do some maintenance on their aircraft. The amount of errors by pilots doing maintenance is unbelievable.

[voorheesh]

Avionics technicians involved in aircraft maintenance including repairs, installation, and alterations should work under supervision of a certificated repair station with specific authorizations for work performed. A repair station should have expertise and procedures in place to ensure any task is accomplished properly. Many “radio shops” perform excellent work and follow up, but there are probably some renegades out there.

The AvWeb piece doesn’t conclude the engine failure was caused by the improperly installed plate and does not mention who installed it. It would be interesting to learn the full story.

[voorheesh]

The AvWeb story makes me wonder: Could they have been buttoning that job up and couldn’t come up with the right gasket? Could some well meaning person (avionics or maintenance) have put the vacuum cover plate on the engine so it wouldn’t get lost? We’ll finish the job when gasket comes in. Then they might forget about it. Or another mechanic looks at it and assumes it's a done deal. Unfortunately, mistakes like that can happen and worth reminding ourselves.

[GAHorn]

Avionics technicians involved in aircraft maintenance including repairs, installation, and alterations should work under supervision of a certificated repair station with specific authorizations for work performed. A repair station should have expertise and procedures in place to ensure any task is accomplished properly. Many “radio shops” perform excellent work and follow up, but there are probably some renegades out there.

The AvWeb piece doesn’t conclude the engine failure was caused by the improperly installed plate and does not mention who installed it. It would be interesting to learn the full story.

There is no general requirement for an avionics installer (A&P) to work under the supervision of a CRS.

I once was loaned a Twin Bonanza (Excalibur Conversion 8-cyl Lycoming IO-720s) ) for the 1980 Christmas Holidays to take to Atlanta to visit in-laws. It was just fresh from Annual Inspection.

Without asking, the wife volunteered me to drop her friend off at her friend’s grandparents for their holidays…. in ENID, OKLAHOMA (nowhere near our route from Bryan/College Station to ATL(

The entire U.S. from East Texas, Oklahoma, LA, MS, GA… ALL had a large snowstorm with ceilings of 200-400 and viz 1-2 miles the entire route. I was pizzed I had to make an extra leg in that weather which wasn’t even on our route.

We left CLL and a couple hours later landed just after-dark in a snowstorm and winds gusting to 35 kts. Wind-chill Temp was about Zero-F.

I gave the lineman refueling instructions and helped our “guest” get her luggage into the Enid terminal to meet her grandmother…paid the fuel bill…then dashed back out into the blizzard to jump up the air-stairs (D-Model) to get out of the Blizzard and get on our way to ATL.

My conscience was nagging me as I raced thru the darkend snow-storm toward the airplane and just as I reached the right wingtip I decided to make a dash-around the airframe to check fuel-caps were properly installed…. And racing around to the left side… SLIPPED AND FELL on a ramp COVERED IN OIL!

The annual inspection had included changeout of the left-engine tach-generator…which was held onto the engine with 4 plain nuts…that had been put on only FINGER-TIGHT and never properly torqued! The engine barely had enough oil to leave one drop on the bottom of the dipstick!

If my wife had not promised her friend a trip to Enid ….instead of us going direct to Charlie Brown/Fulton County at Atlanta….. That engine would have failed somewhere over Mississippi …and the rest of the flight and approach to FTY would have been in 200-1 in blowing snow weather.

(We spent two hours with a flashlight and a wrench in the dark using frozen fingers on an open ramp properly tightening that tach-generator, then used the jet-fuel truck to wash-down the engine to check for leaks in that blowing blizzard. Got to FTY about 2 A.M. and completed a two-engined approach in snow.)

Sometimes we survive only due to pure luck or fate…events which have killed good friends.

[Richgj3]

There was a long discussion about this accident on another forum months ago centering on skepticism that enough oil could come out of that spot in the period of time described to cause the failure. No question that the gasket was missing. But?

I had a Comanche 250 years ago where the mechanical fuel pump safety wire was not done properly and the bolts loosened. The result was a small amount of oil on the hangar floor after a four hour flight.

[mmcmillan2]

GAHorn, great story!

[mit]

Yes, but where the gas caps on????

[GAHorn]

The right side of the airplane was facing toward the FBO office and the flood-lights of the ramp…Due to the bitter cold conditions I was sorely tempted to just climb aboard and close the door… but my conscience made me go to to the dark left-side to make a hasty-check of those gas-caps. In the dark, that oil-soaked left engine and ramp would have been unnoticed otherwise. Ernest K. Gann was correct about Fate and Fortune.