NTSB Identification: WPR13LA098
14 CFR Part 91: General Aviation
Accident occurred Saturday, January 19, 2013 in Marysville, CA
Probable Cause Approval Date: 09/24/2014
Aircraft: CESSNA 172F, registration: N5208F
Injuries: 2 Minor.
NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
The airplane had recently undergone an annual inspection, and the accident flight was the first flight since that maintenance was performed. After departure, the pilot made a 6-nautical-mile flight to another airport, at which point, he decided to perform several practice touch-and-go landings. Following a smooth landing, he configured the airplane for takeoff by confirming the fuel selector was positioned to both wing tanks and then applied full power. The airplane climbed to about 150 feet above ground level, and, then the engine suddenly experienced a total loss of power. The pilot could not restart the engine, and the airplane touched down in a muddy field and came to rest inverted.
The airplane’s fuel selector handle was designed to be affixed to its shaft via a spring pin that slides through a hole on the handle and shaft only when the handle is properly aligned with the shaft; the spring pin prevents the handle from being installed incorrectly. A postaccident examination revealed that the fuel selector handle had been installed 180 degrees out of alignment, which was only possible because the spring pin attaching the handle to the shaft had been modified. Disassembly of the fuel valve also revealed excessive wear to the internal mechanism.
The mechanic who conducted the airplane’s annual inspection reported that he had taken off the fuel selector handle to remove the panel and check for leaks. He checked the “off” position when receiving the airplane, but he did not check it after finishing the annual inspection. During postaccident examinations, the fuel flowed freely through the valve when the fuel selector handle was near the “off” position, and the fuel stopped flowing when the handle was in the “both” position consistent with the handle indicating an opposite selection. Although one of the magnetos had worn beyond service limits and was not producing an adequate spark, its failure was unlikely related to the total loss of engine power. It is likely that the mechanic improperly installed the fuel selector handle after taking it off during the annual inspection, which was only possible due to the incorrectly modified fuel selector handle assembly.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
A total loss of engine power during initial climb due to fuel starvation, which resulted from maintenance personnel’s improper installation of the fuel selector handle. Contributing to the accident was an incorrectly modified fuel selector handle assembly.
HISTORY OF FLIGHT
On January 19, 2013, about 1605 Pacific standard time, a Cessna 172F, N5208F, made a forced landing into a muddy field following a total loss of engine power during the initial climb from the Yuba County Airport, Marysville, California. Beale Aero Club was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certified flight instructor (CFI) and passenger sustained minor injuries; the airplane sustained substantial damage. The local positioning flight departed from Beale Air Force Base, Marysville, California at 1553 with a planned destination of Yuba County Airport. Visual meteorological conditions prevailed and a military visual flight rules (VFR) flight plan had been filed.
The CFI stated that the airplane had recently undergone an annual inspection and this flight was the first since that maintenance was performed. The CFI intended to reposition the airplane at the Yuba County Airport where it was normally based. After departure, he made the approximate 6 nautical mile flight to the destination, at which point he decided to perform several touch-and-go practice takeoff and landings. Following a smooth landing, he configured the airplane for takeoff by confirming the fuel selector was positioned on "BOTH" wing tanks, the carburetor heat was off, the flaps were retracted, and the fuel mixture was "RICH." He applied full power and the airplane climbed about 150 feet, during which time he noted the oil pressure and temperature were showing normal indications.
Shortly thereafter, the engine suddenly experienced a total loss of power. He lowered the nose and configured the airplane for its best-glide airspeed. Despite his efforts, the CFI could not restart the engine and the airplane touched down in a muddy field. The main landing gear dug into the soft terrain and the airplane flipped over coming to rest inverted. The wreckage was located about 50 feet from the first impact location and about 0.5 miles from the edge of the runway.
AIRCRAFT INFORMATION
The Cessna 172F, serial number 17253209, was manufactured in 1965. The engine's data plate indicated it was a Teledyne Continental Motors O-300-D engine, serial number 25471-D-73-D-R.
Fuel System Design
The airplane's fuel system was a gravity-fed design where fuel flowed from metal tanks in the inboard section of each wing, through a selector valve, and continued to a fuel strainer before entering the carburetor.
The fuel selector valve was located near the floor of the fuselage between the pilot and copilot positions on the pedestal. The valve was coupled to a selector handle via a diagonally affixed shaft. The handle positions were labeled "OFF, LEFT, BOTH and RIGHT" with a placard. The handle could be rotated either direction, and was designed to settle into a detent located at one of four selected positions. Upon rotation of the handle, a cam lobe in the fuel valve applied pressure against a series of spring-loaded ball-bearing valve fittings. Depending on the position of the cam, fuel could pass through either the left or right tank fitting, or no fuel would be ported to the fitting that was routed to the carburetor.
The selector handle was designed to be affixed to its shaft via an offset spring-pin that slides through a hole on the handle and shaft when properly aligned (will only fit in one direction to prevent the handle from being installed incorrectly).
Maintenance
A review of the airplane maintenance logbooks revealed that the engine had accumulated 5,038.1 hours total time, and 1,563.1 hours since the last major overhaul. The last annual inspection was dated as having been completed January 18, 2013. The records indicated that during this maintenance the mechanic complied with Cessna Service Bulletin SB99-18R1A, which requires draining the fuel tanks to inspect the fuel gauge accuracy.
The mechanic that worked on the airplane was the director of maintenance, and maintained all of the operators' airplanes, which was a flight club that also provided training. He stated that the airplane's last annual inspection took longer to perform than was usual because he had been interrupted to do a 100 hour inspection for another airplane. He recalled that he had received the accident airplane for maintenance on October 31, 2012 with minimum fuel (since he had to check the fuel quantity indicator), and January 19 was when he returned the airplane back into service.
The mechanic further stated that his normal fuel system check during an annual inspection was as follows: Upon receiving and then releasing the airplane back into service, he would turn the selector to the "OFF" position and observe the amount of time the engine continues to run. This procedure would aid him in ensuring that the selector was shutting off the fuel and that the seals were intact. He would then test all the fuel selector positions. Subsequently, as part of the annual, he would remove the center console and the fuel selector cover in an effort to complete the checklist required item of cycling the selector and looking for leaks. He has had experiences in the past where he has seen selectors leaking or where the engine doesn't completely shut off.
The mechanic recalled that he had taken the selector handle off in an effort to remove the panel. He then checked to make sure the detents engaged into each position selected. If the shaft's alignment was slightly off it wouldn't feed from the correct tank, which he would be able to see from staining around the valve. The handle is usually indexed so that it can only be installed in the correct position. This is accomplished by an offset roll-pin that can only be inserted with proper alignment, but in the accident airplane, the handles offset hole had been drilled out to accommodate a bolt, which in turn enabled the handle to be able to be secured 180-degrees out of alignment. He was sure he had it in the correct position because during the post-inspection he put the selector in the both position and the engine ran normally. He ran the engine in the "LEFT," "RIGHT," and "BOTH" positions, though he didn't test "OFF"). He did check the "OFF" position when receiving the airplane, but did not do it after finishing the annual.
TEST AND RESEARCH
The engine and fuel system were examined following recovery of the wreckage; a detailed examination report with pictures is appended to the report in the public docket.
An external examination of the engine case revealed that it was intact with no holes or perforations observed. Investigators rotated the engine via the propeller. The engine's internal mechanical continuity was established during rotation of the crankshaft and upon attainment of thumb compression in all cylinders. Visual inspection of the engine revealed no evidence of foreign object damage or detonation, and no indication of excessive oil consumption. The valve train was observed to operate in proper order and equal lift action occurred at each rocker assembly. An oil film was present in the all six rocker box areas. The left magneto, Slick model 6364, serial number 04091034 was removed and function tested. The test revealed that the magneto did not produce adequate spark. The magneto was dissembled for further evaluation. It was determined the cam was worn causing the point gap to be out of the manufacture's tolerance.
The airplane had sustained damage to the wings during the accident sequence, however the fuel tanks appeared to be intact and no ruptures could be located. The fuel selector handle was positioned on the "RIGHT" selection, consistent with the pilot's statement of where it was at the time of the accident. The hardware attaching the handle to the shaft consisted of a bolt with a washer and nut securing it, rather than the spring-pin listed in the Cessna Illustrated Parts Catalogue. The handle appeared to have a smaller hole (slanted diagonal) machined below the larger hole that the bolt attached through.
Investigators disconnected the carburetor and noted that with the fuel selector handle near the "OFF" position (just left of the detent), the fuel flowed freely through the valve. When the selector was positioned in the "BOTH" position the fuel stopped flowing, consistent with handle indicating an opposite selection.
Removal of the pedestal revealed that the fuel selector assembly and valve rotated when the handle was turned. Disassembly of the fuel valve disclosed that all four detent positions on the cover were worn and contained debris; the cam lobe appeared worn.
A Beale Air Force Base training pilot has sued the Beale Aero Club, blaming it for a plane crash two years ago.
Maj. James Grogan filed his case this week in Yuba County Superior Court against the club, its former mechanic, John Henry, and the former manager, Connie Schupe.
Grogan and a 17-year-old student pilot were in a Cessna 172F on Jan. 19, 2013, when it suddenly lost power and crashed into a field south of the Yuba County Airport.
Grogan was treated at Rideout Memorial Hospital for moderate injuries. The student pilot was not injured.
Grogan was earning more than $105,000 per year at the time of the accident, according to the lawsuit, but "as a result of the injuries sustained, (he) is unable to perform his regular duties."
In a statement to the National Transportation Safety Board a few days after the accident, Grogan wrote: "As the operator, I saw no way to prevent this mishap/accident ... There was no previous indication of maintenance problems and no indication motor was about to quit. All emergency checklists run to completion as time and circumstances allowed."
A Beale Aero Club spokesman declined to comment on the suit on Friday. The Aero Club is on Beale Air Force Base.
The NTSB, in a statement of probable cause last September, blamed the crash on "maintenance personnel's improper installation of the fuel selector handle. Contributing to the accident was an incorrectly modified fuel selector handle assembly."
The NTSB said the plane "had recently undergone an annual inspection, and the accident flight was the first flight since that maintenance was performed."
According to the report, the airplane's "fuel selector handle had been installed 180 degrees out of alignment, which was only possible because the spring pin attaching the handle to the shaft had been modified. Disassembly of the fuel valve also revealed excessive wear to the internal mechanism."
The NTSB said it was "likely that the mechanic improperly installed the fuel selector handle after taking it off during the annual inspection, which was only possible due to the incorrectly modified fuel selector handle assembly."
Source: http://www.appeal-democrat.com
14 CFR Part 91: General Aviation
Accident occurred Saturday, January 19, 2013 in Marysville, CA
Aircraft: CESSNA 172F, registration: N5208F
Injuries: 2 Minor.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.
On January 19, 2013, about 1605 Pacific standard time, a Cessna 172F, N5208F, collided into a muddy field following a total loss of engine power during the initial climb from the Yuba County Airport, Marysville, California. The Beale Aero Club was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certified flight instructor (CFI) and passenger sustained minor injuries; the airplane sustained substantial damage. The local position flight departed from Beale Air Force Base, Marysville, at 1553, with a planned destination of Yuba County Airport. Visual meteorological conditions prevailed, and a military visual flight rules (VFR) flight plan had been filed.
The CFI stated that the airplane had recently undergone an annual inspection and the accident flight was the first flight since that maintenance was conducted. The CFI intended to position it back at the Yuba County Airport where it was normally based. After departure, he made the short flight to the destination, at which point he decided to perform several touch-and-go practice takeoff and landings. Following a smooth landing, he configured the airplane for takeoff by confirming the fuel selector was positioned on "BOTH" wing tanks, the carburetor heat was off, the flaps were retracted, and the fuel mixture was "RICH". He applied full power and the airplane climbed to about 150 feet, during which time the CFI noted the oil pressure and temperature were showing normal indications.
The CFI further stated that at 150 feet above ground level (agl), the engine suddenly experienced a total loss of power. He lowered the nose and configured airplane for a best-glide airspeed. Despite his efforts, the CFI could not restart the engine and the airplane touched down in a muddy field. The main landing gear dug into the soft terrain and the airplane flipped over inverted. The wreckage was located about 50 feet from the first impact location and about 0.5 miles from the edge of the runway.
The wreckage was taken to a hangar for further examination.
No comments:
Post a Comment