N787AS

HISTORY OF FLIGHTOn July 23, 2022, at 1331 Pacific daylight time, a North American T-28B, N787AS, was substantially damaged when it was involved in an accident near Fallbrook, California. The pilot was seriously injured and the pilot-rated passenger was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

A law enforcement officer interviewed the pilot immediately after the accident. The pilot stated that he and the passenger have been good friends for over 50 years, and both have extensive aviation experience. Earlier in the day, he and the passenger both departed from Chino, California, in separate airplanes. The pilot was flying the T-28 and the passenger was flying the pilot’s Cessna 150 with the purpose of dropping it off in Fallbrook. The plan was for them to both leave Fallbrook in the T-28, stop for lunch in Temecula, California, and then return to Chino.

The airplanes departed from Chino and the T-28 landed in Fallbrook about four minutes ahead of the Cessna. After dropping off the Cessna, the pilot performed a pre-flight inspection. The pilot then positioned himself in the front seat and the passenger was in the rear seat. The pilot stated that after takeoff, with the airplane about 200 feet above ground level (agl), the engine sustained a total loss of power. He checked the mixture, power, and fuel, and lowered the nose in an effort to avoid a stall. The airplane collided with a plant nursery. The pilot estimated that about 30 seconds had elapsed from the engine failure to the time of impact. After impact, several people helped him exit the airplane by prying the canopy open. The pilot stated that he forgot to open the canopy before impact.

The pilot additionally stated that he is a mechanic and performs the maintenance on the airplane. He recalled the last time he performed any maintenance on the airplane was about six months before the accident.

Investigators reviewed video recordings, audio recordings, and flight track data covering the area of the accident during the time surrounding the accident using automatic dependent surveillance-broadcast (ADS-B) data. A review of the data revealed that the T-28 landed in Fallbrook about 1255. At 1326:01 the airplane taxied to runway 18 and began the takeoff roll at 1331:20. The airplane began the departure roll and was midfield about 12 seconds later at a ground speed of 88 kts. At 1331:44, the airplane was about 300 ft south of the runway identifier markings and the airspeed was 97 knots. The last position recorded was at 1331:49 and located about 160 ft north of the first identified impact point; the airspeed at that point was 94 knots and the airplane was on a heading of about 180° (see Figure 1 below).

Figure 1: ADS-B Plot with Inset of Video Images of the Takeoff

A sound spectrum analysis from a witness’s recorded cell phone video revealed the engine was idling smoothly about 1,530 rpm. Thereafter, it was running rough for about 10 seconds as it increased its speed to about 2,420 rpm and the airplane was moving along the runway. The engine was then running smoothly for the next 12 seconds as it passed by the camera. The engine then suddenly decreased in rpm, similar to when it was at idle, and the airplane impacted several seconds later. AIRCRAFT INFORMATIONThe T-28B trainer was a two-place, single-engine, low-wing monoplane. The airplane was powered by a nine-cylinder R-1820-86 Wright engine developing 1,425 horsepower and driving a Hamilton Standard three-blade constant-speed propeller. Dual flight controls were installed in the tandem cockpit, and a speed brake was installed on the bottom fuselage aft of the main landing gear wheel wells. The tricycle landing gear was fully retractable.

The pilot owned the airplane for over 10 years. During that time, he never had any work done on the carburetor and never had issues with it. He estimated that at the time of the accident, the engine had just under 400 hours since major overhaul.

A review of the maintenance records revealed that they were incomplete, and it is unknown the full extent of maintenance the airplane and engine had undergone. The last conditional inspection was recorded as occurring on September 5, 2021, at an airframe total time of 14,772.3 hours and a Hobbs time of 362.3 hours. The rebuilt electric fuel pump was purchased in September 2015. The carburetor was last overhauled in February 2010, over 12 years before the accident. The engine-driven fuel pump was last overhauled in February 2010 and the paperwork indicated the reason for removal as “engine failure,” and normal wear was noted. There was no other indication of an engine failure. The last engine overhaul was recorded as being completed in April 2010.

Fuel System

The fuel system consisted of four bladder-type fuel cells, an aluminum alloy sump tank containing an electric boost pump, a fuel shutoff valve, a fuel strainer, an engine-driven fuel pump, check valves, and necessary fuel feed and vent lines. The system was controlled by the fuel shutoff valve handle in either cockpit.

The system is designed where fuel flows by gravity from all internal cells into the sump tank (located in the inboard right wing). A fuel shutoff control handle, located on the left console of each cockpit, has two positions: “ON” and “OFF”. Each position operates the fuel shutoff valve and the electric boost pump simultaneously. An electric fuel-boost-pump test switch was located on the electrical switch panel in the bottom forward right cockpit. The test switch was wired in series with the electric fuel pump switch on the fuel shutoff control handle. When held in the “TEST” position, the system was designed for power to the electric pump to be interrupted, allowing the pilot to confirm that the engine-driven fuel pump pressure is adequate.

The electric pump forced fuel under a pressure of 19 to 24 psi through the shutoff valve, strainer, and engine-driven fuel pump. When the engine started, the engine-driven fuel pump maintained the fuel to the carburetor at an operating pressure of 23 to 25 psi.

If the electric pump fails below 10,000 feet pressure altitude, fuel drawn by the engine-driven pump is designed to bypass through the electric pump and sustain approximately normal fuel flow to the carburetor (with a slight drop in fuel pressure indication that may be noted). If the engine-driven fuel pump failed, fuel was forced by the electric pump to the carburetor to maintain normal engine operation.

The airplane’s take-off checklist stated that at 1,800 rpm “Place FUEL BOOST PUMP switch to TEST, check fuel pressure 21 to 25 psi.” AIRPORT INFORMATIONThe T-28B trainer was a two-place, single-engine, low-wing monoplane. The airplane was powered by a nine-cylinder R-1820-86 Wright engine developing 1,425 horsepower and driving a Hamilton Standard three-blade constant-speed propeller. Dual flight controls were installed in the tandem cockpit, and a speed brake was installed on the bottom fuselage aft of the main landing gear wheel wells. The tricycle landing gear was fully retractable.

The pilot owned the airplane for over 10 years. During that time, he never had any work done on the carburetor and never had issues with it. He estimated that at the time of the accident, the engine had just under 400 hours since major overhaul.

A review of the maintenance records revealed that they were incomplete, and it is unknown the full extent of maintenance the airplane and engine had undergone. The last conditional inspection was recorded as occurring on September 5, 2021, at an airframe total time of 14,772.3 hours and a Hobbs time of 362.3 hours. The rebuilt electric fuel pump was purchased in September 2015. The carburetor was last overhauled in February 2010, over 12 years before the accident. The engine-driven fuel pump was last overhauled in February 2010 and the paperwork indicated the reason for removal as “engine failure,” and normal wear was noted. There was no other indication of an engine failure. The last engine overhaul was recorded as being completed in April 2010.

Fuel System

The fuel system consisted of four bladder-type fuel cells, an aluminum alloy sump tank containing an electric boost pump, a fuel shutoff valve, a fuel strainer, an engine-driven fuel pump, check valves, and necessary fuel feed and vent lines. The system was controlled by the fuel shutoff valve handle in either cockpit.

The system is designed where fuel flows by gravity from all internal cells into the sump tank (located in the inboard right wing). A fuel shutoff control handle, located on the left console of each cockpit, has two positions: “ON” and “OFF”. Each position operates the fuel shutoff valve and the electric boost pump simultaneously. An electric fuel-boost-pump test switch was located on the electrical switch panel in the bottom forward right cockpit. The test switch was wired in series with the electric fuel pump switch on the fuel shutoff control handle. When held in the “TEST” position, the system was designed for power to the electric pump to be interrupted, allowing the pilot to confirm that the engine-driven fuel pump pressure is adequate.

The electric pump forced fuel under a pressure of 19 to 24 psi through the shutoff valve, strainer, and engine-driven fuel pump. When the engine started, the engine-driven fuel pump maintained the fuel to the carburetor at an operating pressure of 23 to 25 psi.

If the electric pump fails below 10,000 feet pressure altitude, fuel drawn by the engine-driven pump is designed to bypass through the electric pump and sustain approximately normal fuel flow to the carburetor (with a slight drop in fuel pressure indication that may be noted). If the engine-driven fuel pump failed, fuel was forced by the electric pump to the carburetor to maintain normal engine operation.

The airplane’s take-off checklist stated that at 1,800 rpm “...