CT1140071 Tutor - Epilogue

Report / June 26, 2020 / Project number: CT114071 - A Category

Location: 10 NM east of Peachtree City, Georgia, USA
Date: 13 October 2019
Status: Investigation Completed

The accident involved a CT114 Tutor aircraft from the Canadian Armed Forces Air Demonstration Team (Snowbirds) enroute to the Atlanta Air Show being held at the Atlanta Motor Speedway in Hampton, Georgia.

Following a routine check while inverted, the pilot then rolled level and applied full power to rejoin the formation. Shortly after, the pilot experienced a loss of thrust. Losing altitude and unable to recover engine power, the pilot elected to eject as the aircraft was too low to attempt a safe recovery to an airport. The pilot successfully ejected from the aircraft however reported anomalies with the ejection sequence and the parachute opening.

The aircraft was destroyed upon impact and the pilot received minor injuries as a result of the ejection sequence.

The investigation determined that the most probable cause of the CT114071 accident was a fuel delivery system failure within the engine. The precise location of the failure could not be identified with confidence, though given the evidence of pre-existing damage to the engine oil cooler fuel inlet port, the analysis suggests a potential fuel leak at that location.

The investigation also determined that the mostly likely cause of the parachute malfunction was the result of one or more parachute pack retaining cones having been released prior to the activation of the MK10B Automatic Opening Device. Entanglement of the suspension lines with parts of the ejection seat immediately followed ultimately disrupting the proper opening of the parachute canopy. Inspection of all related Tutor Aviation Life Support Equipment was subsequently carried out to ensure fleet airworthiness.

The investigation recommends that an inspection be carried out on CT114 engines to identify any damaged oil coolers that may be at risk of leaking at the fuel ports. In addition, the investigation recommends establishing a controlled verification process on the maintenance activities involving fuel transfer tubes in an effort to identify the cause of the damage to the oil cooler ports. Further recommended measures include improving the fitment of the fuel tubes and consolidating and improving on the maintenance instructions that involve the oil cooler and its components.