# NTSB CEN10LA572: Cessna 172RG, N5145U, Tulsa, OK, September 28, 2010

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: September 28, 2010, 10:38 local (15:38 UTC)
- Place: Tulsa, OK
- Coordinates: 36.039722, -95.984725 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=36.0397&lon=-95.9847&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern final: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150)
- Highest injury: Serious injuries
- Injuries: 1 serious, 1 minor
- Status: Completed, report May 16, 2011
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA Flight Standards District Office
- NTSB case key (mKey): 77428
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA572
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77428/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77428
- Page: https://openairdocs.org/ntsb/CEN10LA572

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Hydraulic power system](https://openairdocs.org/ntsb-findings/01022900): Aircraft › Aircraft systems · Malfunction (probable cause); cases with it: [Cessna 172RG, 1 case](https://openairdocs.org/ntsb-findings/01022900/cases.md?model=2072438), [All aircraft, 22 cases](https://openairdocs.org/ntsb-findings/01022900/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Other (probable cause); cases with it: [Cessna 172RG, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072438), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Approach-VFR pattern final: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Cessna 172RG, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=2072438), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172RG, 10 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072438), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172RG, 9 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072438), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/deregistered/N5145U-2011-09-26), registration cancelled 2011-09-26, S/N 172RG0258, built 1980 (OpenAirDocs)
- Reported make and model: CESSNA 172RG
- Registry model: [Cessna 172RG](https://openairdocs.org/model/cessna-172rg) (registry code 2072438) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 172RG0258
- Airframe hours: 15026
- Engines: 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.

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 28; injuries: serious; 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
- Pilot; age 26; injuries: minor; 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

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20100928046809A](https://openairdocs.org/incident/20100928046809A), Sep 28, 2010: Cessna 172RG, Tulsa, OK, Destroyed. Instructor pilot acting as student for CFI training was at the controls and was approx. 4 miles west of jones riverside airport (rvs). Within a few seconds of…

## Docket (4 files)

The files NTSB released with the investigation on January 19, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77428. 5.3 MB in all.

- NTSB Form 6120.1-2, Pilot-Operators Aircraft Accident Report (Instructor) (item 1, .PDF, 589 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341753&FileExtension=.PDF&FileName=NTSB%20Form%206120.1-2,%20Pilot-Operators%20Aircraft%20Accident%20Report%20(Instructor)-Redacted.PDF
- NTSB Form 6120.1-2, Pilot-Operators Aircraft Accident Report (Pilot) (item 2, .PDF, 643 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341754&FileExtension=.PDF&FileName=NTSB%20Form%206120.1-2,%20Pilot-Operators%20Aircraft%20Accident%20Report%20(Pilot)-Redacted.PDF
- Weather Reports and Records (item 3, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338986&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF
- Accident Report Photographs (item 4, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40341767&FileExtension=.PDF&FileName=Accident%20Report%20Photographs-Master.PDF

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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