Runway excursion Accident Papa 51 Thunder Mustang N352BT,
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ASN Wikibase Occurrence # 210334
 
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Date:Tuesday 1 May 2018
Time:19:31
Type:Papa 51 Thunder Mustang
Owner/operator:Private
Registration: N352BT
MSN: JHTM017
Year of manufacture:2009
Total airframe hrs:236 hours
Engine model:Falconer V12
Fatalities:Fatalities: 1 / Occupants: 1
Aircraft damage: Substantial
Category:Accident
Location:Reno/Stead Airport (KRTS), Reno, NV -   United States of America
Phase: Landing
Nature:Private
Departure airport:Reno, NV (RTS)
Destination airport:Reno, NV (RTS)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The airline transport pilot of the high-performance air racing airplane was taking part in an in-flight photography mission with two other airplanes. About 1 hour into the second flight of the day, the group was getting fatigued and decided to return to the departure airport. As the airplanes approached the airport, the accident pilot transmitted a "mayday" call and reported that he was going to land on the runway located directly ahead of his position. The airplane began to descend while performing an S-turn, and touched down beyond the midpoint of the 9,000-ft-long runway at a slightly higher speed than normal. A 4-knot tailwind prevailed on the landing runway about the time of the accident.

A 1,200-ft-long series of propeller strikes on the runway were consistent with the pilot applying heavy braking after touchdown. The airplane veered right as it reached the end of the runway, entered a gravel area, nosed over, and came to rest inverted. Given the airplane's nominal landing distance in addition to the factors that increased that distance on the accident landing, namely, remaining runway at the time of the touchdown, the airplane's higher landing speed, and the tailwind, the pilot would have had very little margin for error before the airplane's landing distance required exceeded the available runway.

The vertical stabilizer collapsed when the airplane nosed over, which resulted in the canopy structure contacting the ground and subsequently failing. As a result, the pilot's head was impinged at an angle against the ground, resulting in airway restriction. The pilot's extraction from the airplane by first responders took about 45 minutes, and during that time, the pilot died of asphyxiation. However, unless he had been repositioned and his breathing enabled almost immediately following the accident, survival would have been unlikely, and based on the airplane's weight and inverted position, an immediate rescue was not possible.

It could not be determined if the canopy bow was designed to be structural in nature; additionally, visual inspection revealed defects that would have further weakened its supporting properties.

Examination of the engine revealed that the coolant pump drive pulley had detached due to fatigue failure of its attachment cap screws. Separation of the pulley resulted in the detachment of the engine's two parallel serpentine drive belts, which drove multiple other engine accessories. This design allowed for a single point of failure, which resulted in a total loss of engine oil pressure, propeller governor control, and auxiliary electrical power. The belts also dislodged a coolant line, resulting in the loss of all engine coolant. With these failures, the engine would have been able to operate for a short duration before experiencing catastrophic failure, negating the pilots ability to perform a go-around, and evidence suggests that it continued to operate at a low power setting during the descent and the landing roll.

Hardness testing of the pulley attachment screws revealed that they were of the proper tensile strength. Substantial fretting damage was present on the pulley contact faces and under the screw contact areas, and thread wear was present in the pulley attachment holes. Evidence of the use of thread locking material was observed; therefore, it is likely that the screws detached due to insufficient tightening at the time of installation. Although the thread locking material used was consistent with the engine manufacturer installation instructions, product literature from the manufacturer of the thread locking material indicated that another type was available that was specifically tailored for pulley applications. Whether the use of the alternate thread locking material would have affected the outcome could not be determined.

The pilot performed all the maintenance work on the engine, which had been overhauled about 20 flight hours before the accident; however, he performed multiple significant maintenance events on the engine between the overhaul and the accident flig

Probable Cause: The pilot's failure to properly secure the engine coolant pump pulley during recent maintenance, which resulted in a loss of the engine's lubrication, cooling, and propeller control systems, and a forced landing, during which the airplane nosed over. Contributing was the design of the accessory drive system, which allowed for multiple simultaneous failures of critical engine components. Contributing to the pilot's fatal injuries was the inadequate support provided by the airplane's canopy structure, which did not protect him during the relatively innocuous nose-over event.

Accident investigation:
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Investigating agency: NTSB
Report number: WPR18FA131
Status: Investigation completed
Duration: 2 years
Download report: Final report

Sources:

NTSB
FAA register: http://registry.faa.gov/aircraftinquiry/NNum_Results.aspx?NNumbertxt=352BT

Location

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Revision history:

Date/timeContributorUpdates
02-May-2018 16:02 Geno Added
02-May-2018 20:17 Geno Updated [Phase, Destination airport, Source]
02-May-2018 20:25 Iceman 29 Updated [Source, Embed code]
02-May-2018 20:27 Iceman 29 Updated [Embed code, Photo, ]
22-May-2020 09:26 ASN Update Bot Updated [Time, Operator, Nature, Departure airport, Destination airport, Source, Embed code, Narrative, Accident report, ]

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