CEN10LA572

NTSB accident investigation · Cessna 172RG · Tulsa, OK · September 28, 2010

Accident · Serious injuriesLimited investigationFinal report
Date
September 28, 2010, 10:38 local (15:38 UTC)
Place
Tulsa, OK
Injuries
1 serious, 1 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5145UCessna 172RG
Defining event
Approach-VFR pattern final: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report May 16, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards District Office
FAA report
20100928046809A
Case key
77428

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A shorted terminal lug on the landing gear hydraulic pump which resulted in a cabin fire. Contributing to the accident was the lack of clear installation procedures for the hydraulic pump.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Hydraulic power systemAircraft › Aircraft systems · MalfunctionCessna 172RG: 1 caseAll aircraft: 22 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · OtherCessna 172RG: 1 caseAll aircraft: 371 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

According to the certified flight instructor (CFI), the landing gear was lowered once during the instructional flight while practicing a slow flight maneuver. When the pilots returned to the airport and lowered the landing gear in preparation for landing, flames erupted from under the instrument panel and the carpet on the floor caught fire. The pilots declared an emergency before the radio failed. They pulled the mixture control to the idle cutoff position, but the fuel selector could not be turned off due to the flames. The cabin filled with smoke, the instruments were unreadable, and the pilots had difficulty breathing. The CFI opened his (left) door, causing the airplane to yaw to the left, and he used right rudder to compensate, while the rudder pedals were engulfed in flames. In the ensuing forced landing, the instructor was able to avoid power lines but was unable to clear a fence. The airplane struck the fence and came to a stop suddenly. Examination of the airplane revealed that the terminal lug on the hydraulic pump was improperly covered and had shorted. Additionally, the installation procedures for the hydraulic pump did not provide clear guidance on the proper method to cap the terminal lug.

Factual narrative

On September 28, 2010, at 1038 central daylight time, a Cessna 172RG, N5145U, registered to and operated by Spartan Aviation Industries, Inc., was destroyed when a fire broke out in the engine compartment while returning to the Richard Lloyd Jones, Jr., Airport (RVS), Tulsa, Oklahoma. The instructor pilot attempted a forced landing and impacted terrain 2 miles west of the airport. Visual meteorological conditions (VMC) prevailed at the time of the accident. The instructional flight was being conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The flight instructor was seriously injured, and the certified flight instructor (CFI) candidate received minor injuries. The local flight originated from RVS approximately 0930. According to the flight instructor's accident report, the landing gear was lowered only once during the flight when they practiced slow flight in the landing configuration. They returned to RVS and lowered the landing gear in preparation for landing. The instructor wrote, “Within seconds of lowering the gear, flames started pouring out from under the instrument panel and up the front of the panel. The carpet on the floor also caught fire quickly.” An emergency was declared, and then the radio failed. The mixture control was pulled to idle cutoff, but the fuel selector could not be turned off due to the flames. The cabin filled with smoke, the instruments became unreadable, and the pilots were having trouble breathing. The instructor opened his (left) door, causing the airplane to yaw to the left, and he used right rudder to compensate. The rudder pedals were “fully covered in flames.” The instructor’s right foot was on fire and his shoe was melting to his foot. The CFI candidate, who was in the right seat, was able to remove the instructor’s shoe but the instructor's calf was also on fire. In the ensuing forced landing, the instructor was able to avoid power lines but was unable to clear a fence. The airplane struck the fence and came ”to a stop suddenly.” Both occupants evacuated the airplane. The CFI candidate's report corroborated the instructor’s report. According to the Federal Aviation Administration (FAA) inspector who responded to the accident site, he found evidence that the terminal lug on the hydraulic pump was improperly installed and had shorted. There was no evidence that the exposed lug had been properly covered. The inspector examined six other Cessna 172RG’s at the airport and found two airplanes had exposed terminal lugs, three airplanes had a rubber boot (part number MS25171-2S) installed to cover the lug, and only one airplane was equipped with the proper cover (part number S1807-1). The inspector also discovered that the installation procedures for the hydraulic power package did not specifically mention the cover. Only the Cessna 172RG Illustrated Parts Catalog depicted the correct and proper installation.

Aircraft

Registration
N5145U
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0258
Airframe hours
15,026
Engine
Lycoming O-360-F1A6, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Spartan Aviation Industries, Inc.
Registered owner
Spartan Aviation Industries, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 3, 2010 · 24 hours before
Departed
RVS · Tulsa, OK
Destination
RVS · Tulsa, OK
Airport
RVS · Richard Lloyd Jones Jr.

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
28
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 1, 2010
Seat
Left
Flight hours
2,420 total · 100 in this make and model · 2,344 as pilot in command · 161 in the last 90 days · 31 in the last 30 days · 4 in the last 24 hours
Role
Pilot
Age
26
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
July 1, 2009
Seat
Right
Flight hours
378 total · 60 in this make and model · 312 as pilot in command · 14 in the last 90 days · 6 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 57 °F
Altimeter
29.92 inHg
Observed at
RVS, 2 nm away

Docket · 4

The files NTSB released with the investigation on January 19, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.