Casualties unknown

2014-07-04: Tecnam P2008 — Aérodrome de Lognes Emerainville, FR

Aérodrome de Lognes Emerainville, FR

On July 4, 2014, a Tecnam P2008 was involved in an aviation accident near Aérodrome de Lognes Emerainville, FR. Investigators recorded the probable cause as: Non-conforming attachments on the carburetor hot air collector failed, resulting in debris ingestion into engine cylinders and subsequent loss of engine power during initial climb. This summary draws on records from the French Bureau d'Enquêtes et d'Analyses (BEA).

Sourcesthe French Bureau d'Enquêtes et d'Analyses (BEA)Primary reportUpdated 1785058346Data APIEditorial standards

During a training flight, a Tecnam P2008 experienced engine power loss at 50 ft. The instructor conducted a forced landing, damaging the aircraft. Investigation revealed failed non-conforming carburetor attachments led to debris ingestion.

Accident Sequence

On 4 July 2014 at 18:22 local time, a Tecnam P2008, registration F-HDMV, was conducting a local training flight from Lognes Emerainville airfield with an instructor and a student on board. During the initial climb, at approximately 50 ft above the ground, the instructor noted a decrease in engine power. He took over control and verified that the throttle was fully open. The propeller tachometer indicated around 900 rpm. The runway ahead was occupied by numerous vehicles, so he decided not to land straight ahead. He turned left to land in an obstacle-free area. During the maneuver, the left wing contacted the ground, and the instructor stopped the aircraft on the unpaved runway. Shortly after landing, the engine stopped. The aircraft sustained substantial damage.

Engine Examination

Examination of the Rotax 912 S2 engine revealed metallic debris in the No. 1 cylinder chamber. The debris prevented complete closure of the exhaust valve and damaged both spark plugs in that cylinder. Debris was also found in the No. 3 cylinder. Impact marks were observed in the air vein of the carburetor supplying cylinders No. 1 and 3. The investigation also found that the lower attachment tab of the carburetor hot air collector was missing; a piece of this tab was found near the collector.

Carburetor Hot Air Collector Attachments

The chemical composition of the debris found in the No. 1 cylinder matched that of the missing attachment piece and the upper attachment of the same collector. These attachments were 0.8 mm thick. The hot air collector had no device to prevent foreign object ingestion. On the P2008, the collector is normally equipped with two attachments 1.5 mm thick, riveted by the manufacturer. The accident aircraft had been purchased new by the club and had accumulated about 405 flight hours. Maintenance was performed by the club's approved maintenance unit. The club president stated no intervention on the collector had been reported. The club operated six P2008s; three (including F-HDMV) had collectors with attachments thinner than 1.5 mm. A prior attachment failure had occurred on one other aircraft, serial number 1007, at 260 hours, where both attachments broke and were discovered during a scheduled maintenance visit.

Following this accident, Tecnam issued Service Bulletin No. 163-CS-P2008, requiring inspection and replacement of non-compliant collectors. The bulletin was applied to all P2008s in service. Six aircraft had non-conforming attachments, with serial numbers between 1002 and 1009. Tecnam's internal investigation found that the non-conforming parts were produced for experimental purposes and not intended for series production. Corrective actions were implemented.

Forced Landing Decision

The instructor stated that he teaches students that in case of a major failure after takeoff, the priority is to land more or less straight ahead, a point reiterated during the pre-takeoff briefing. When the power loss occurred, he reduced the pitch attitude, then realized he could not land straight ahead due to vehicles on the runway. He decided to change strategy and turned left toward an obstacle-free area, also turning into the wind to reduce landing distance. The instructor noted that the club had stopped practicing engine failure simulations during initial climb at Lognes after a previous accident involving a DR400 in 2010, which highlighted the lack of suitable forced landing areas near the airfield.

Conclusion

The power loss during initial climb was caused by the ingestion of debris from a failed lower attachment tab of the carburetor hot air collector. The non-conforming attachments, thinner than specification, had been installed by the manufacturer. The instructor, confronted with an unforeseen situation and limited suitable landing areas within the runway axis, attempted a forced landing in an obstacle-free area to the left, resulting in damage to the aircraft.

Probable cause

Non-conforming attachments on the carburetor hot air collector failed, resulting in debris ingestion into engine cylinders and subsequent loss of engine power during initial climb.