Unresolved Service Bulletin Leads to Engine Failure and Forced Landing of Ultralight Aircraft

Casualties unknown • FI

A failure to implement a critical engine service bulletin caused metal debris to clog a carburetor, resulting in an engine shutdown and the subsequent crash of an ultralight aircraft in Finland.

What happened

On August 29, 2010, an ultralight aircraft, a FK9 MK IV with registration OH-U482, performed an emergency landing near Ruukki, Finland. The flight, which began at Ahmosuo, proceeded toward Raahe before the pilot experienced engine instability while flying over the Siikajoki river. As the pilot attempted to increase power, the engine failed completely.

The pilot was forced to land in a field, where the aircraft struck a transverse stabilizer during the landing roll. The impact caused the aircraft to flip upside down, resulting in significant damage to the amphibious floats, wings, propeller, engine mount, and the tip of the vertical stabilizer. The pilot, who was flying alone, sustained minor abrasions but no serious injuries.

The investigation

Investigators from OTKES conducted a technical examination of the engine, a Rotax 912 ULS. Upon dismantling the carburetors, they discovered metal shavings at the bottom of the right carburetor float chamber, which had obstructed the main jet. Laboratory analysis of the float shaft pin revealed that a copper and nickel coating had partially delaminated from the steel surface.

The investigation established that the engine manufacturer, BRP-Powertrain Inc, had previously issued Service Bulletin SB-912-048 to address this specific coating issue. The bulletin required the replacement of the old pins with a new version that lacks the copper layer. While the aircraft had undergone a major engine overhaul in 2007, the required modification had not been performed.

Findings

  • The engine failure was caused by metal shavings from the float shaft pin delaminating and clogging the main jet.
  • The required replacement of the float shaft pin, which was due by December 1, 2005, had been overlooked.
  • During a 2007 engine overhaul, the mechanic failed to implement the service bulletin because the carburetors showed no visible defects at that time.
  • The maintenance records used a generalized statement claiming all relevant service bulletins had been completed, which masked the fact that this specific modification was still outstanding.
  • The aircraft owner holds the ultimate responsibility for monitoring and implementing all necessary service bulletins.

Probable cause

The engine failure was caused by the accumulation of metallic debris in the carburetor main jet, resulting from the delamination of a coating on the float shaft pin. This failure occurred because the mandatory engine service bulletin (SB-912-048) regarding the replacement of these pins had not been implemented by the time of the accident.

Frequently asked questions

What happened in the 2010-08-29 aircraft accident near FI?

A failure to implement a critical engine service bulletin caused metal debris to clog a carburetor, resulting in an engine shutdown and the subsequent crash of an ultralight aircraft in Finland.

What aircraft was involved and where did it happen?

The accident on 2010-08-29 involved a aircraft, registration OH-U482, at FI.

What was the probable cause of the accident?

The engine failure was caused by the accumulation of metallic debris in the carburetor main jet, resulting from the delamination of a coating on the float shaft pin. This failure occurred because the mandatory engine service bulletin (SB-912-048) regarding the replacement of these pins had not been implemented by the…

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