CEN15LA284

NTSB accident investigation · Cessna TR182 · Casper, WY · June 27, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
June 27, 2015, 08:00 local (14:00 UTC)
Place
Casper, WY
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4751SCessna TR182
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report June 1, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Textron Aviation, Lycoming, FAA FSDO
FAA report
20150627010049A
Case key
91458

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

The improper repair of the carburetor heat cable sheath to clamp joint, which prevented the proper operation of the carburetor heat and resulted in the loss of engine power.

Findings · 3

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.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Incorrect service/maintenanceCessna TR182: 1 caseAll aircraft: 195 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceCessna TR182: 1 caseAll aircraft: 103 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationCessna TR182: 1 caseAll aircraft: 435 cases

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

The private pilot was conducting a cross-country personal flight. Immediately after takeoff, the engine lost power. The pilot and pilot-rated passenger attempted to restore engine power but were unsuccessful. The airplane was unable to return to the airport, and the pilot conducted a forced landing, during which the airplane impacted terrain beyond the airport perimeter fence. An examination of the engine revealed that the sheath for the carburetor heat cable was separated from the clamp. A black rubber adhesive was found at the joint between the sheath and the clamp, but it was not securing the clamp to the joint. The carburetor heat at the carburetor was partially on, and the position could not be changed when actuated by the control knob in the cabin. An examination of the airframe, engine, and related systems revealed no further anomalies. The weather conditions at the time of the accident were conducive to the accumulation of serious carburetor icing at glide power; however, it could not be determined whether carburetor icing played a role in the loss of engine power. Even if carburetor icing had not accumulated, the separation of the sheath from the clamp would have prevented the proper operation of the carburetor heat, and the partial carburetor heat would have resulted in the loss of engine power at takeoff.

Factual narrative

On June 27, 2015, about 0800 mountain daylight time, a Cessna TR182, N4751S, was substantially damaged when it impacted terrain west of the Natrona County International Airport (KCPR), Casper, Wyoming. Visual meteorological conditions prevailed at the time of the accident. The flight was conducted under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. The private pilot, pilot-rated passenger, and one additional passenger were seriously injured. The flight had just departed and was en route to Jackson Hole Airport, (KJAC), Jackson, Wyoming.The airplane was cleared for takeoff from runway 26. About 300 feet above ground level the engine began to run rough and lose power. The pilot and pilot-rated passenger attempted to restore engine power but were unsuccessful. The pilot-rated passenger "took control" of the airplane and attempted to return to the airport. The engine continued to run rough and lose power, and they were unable to return to a runway to land. The airplane impacted terrain beyond the airport perimeter fence, just off of the departure end of runway 26. The left wing was bent and buckled, the fuselage was crushed up and aft, and the firewall was buckled. A postaccident examination of the engine revealed that the sheath for the carburetor heat cable was partially separated. A black rubber adhesive was at the joint between the sheath and the clamp joint but was not securing the clamp to the joint. The carburetor heat at the carburetor was partially on and the position could not be changed when actuated by the control knob inside the cabin of the airplane. A blue liquid, consistent in smell with 100 low lead aviation fuel, was drained from the engine sump and left wing. The samples were clear of visible water or particle contamination. A quarter cup of a clear liquid was drained from the right wing. No other fuel or liquid was recovered from the right wing. The fuel samples were sent to a laboratory for further examination. The analysis of the chemical composition of the fuel samples was consistent with previously measured aviation gasolines. An examination of the airframe, engine, and related systems revealed no further anomalies. Temperature at the time of the accident was 18 degrees Celsius (C) (64 degrees Fahrenheit (F)) and a dewpoint of 10 degrees C (50 degrees F). A review of the carburetor icing probability chart, located in the Federal Aviation Administration's Special Airworthiness Information Bulletin CE-09-35, revealed that conditions at the time of the accident were conducive to the accumulation of serious carburetor icing at glide power.

Aircraft

Registration
N4751S
Reported as
Cessna TR182
Category
Airplane
Serial number
R18201413
Built
1979
Airframe hours
2,170.9
Engine
Lycoming O-540-L3C5D, 235 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 6, 2015
Departed
KCPR · Casper, WY
Destination
KJAC · Jackson, WY
Airport
KCPR · Natrona County Intl Airport, runway 26, 8,679 × 150 ft, asphalt
Equipment
Auto-pilot

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
Pilot
Age
67
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
July 17, 2013
Seat
Left
Restraint
3-point
Flight hours
1,143 total · 32 in this make and model · 4 in the last 90 days
Role
Pilot-rated passenger
Age
53
Injuries
Serious
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
June 17, 2015
Seat
Right
Restraint
3-point
Flight hours
5,390 total · 120 in this make and model · 4,990 as pilot in command · 28 in the last 90 days · 19 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Temperature
64 °F, dew point 50 °F
Altimeter
30.09 inHg
Observed at
KCPR, 1 nm away

Docket · 6

The files NTSB released with the investigation on April 12, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.8 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.