# NTSB CEN15LA284: Cessna TR182, N4751S, Casper, WY, June 27, 2015

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: June 27, 2015, 08:00 local (14:00 UTC)
- Place: Casper, WY
- Coordinates: 42.907222, -106.48722
- Nearby events: https://openairdocs.org/map.md?lat=42.9072&lon=-106.4872&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: Serious injuries
- Injuries: 3 serious
- Status: Completed, report June 1, 2016
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Textron Aviation, Lycoming, FAA FSDO
- SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs)
- NTSB case key (mKey): 91458
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA284
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91458/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91458
- Page: https://openairdocs.org/ntsb/CEN15LA284

## 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

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

- [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=2072735), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md)
- [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=2072735), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md)
- [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2072735), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md)

## Sequence of events

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

- [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna TR182, 5 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2072735), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Landing-flare/touchdown: Landing gear not configured](https://openairdocs.org/ntsb-events/095); cases with it: [Cessna TR182, 11 cases](https://openairdocs.org/ntsb-events/095/sequence.md?model=2072735), [All aircraft, 584 cases](https://openairdocs.org/ntsb-events/095/sequence.md)
- [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna TR182, 4 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2072735), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md)

## 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](https://openairdocs.org/deregistered/N4751S-2016-06-07), registration cancelled 2016-06-07, S/N R18201413, built 1979 (OpenAirDocs)
- Reported make and model: CESSNA TR182
- Registry model: [Cessna TR182](https://openairdocs.org/model/cessna-tr182) (registry code 2072735) (OpenAirDocs)
- Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: R18201413
- Year built: 1979
- Airframe hours: 2170.9
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 67; injuries: serious; 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
- Pilot-rated passenger; age 53; injuries: serious; 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

## 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 20150627010049A](https://openairdocs.org/incident/20150627010049A), Jun 27, 2015: Cessna TR182, Casper, WY, Substantial damage. Aircraft lost full power after takeoff at around 300 feet, AGL. Engine would power up and then lose power.

## Docket (6 files)

The files NTSB released with the investigation on April 12, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91458. 6.8 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438735&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Aviation Fuel Examination Results (item 2, .PDF, 287 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438736&FileExtension=.PDF&FileName=Aviation%20Fuel%20Examination%20Results-Master.PDF
- Carburetor Icing Chart (item 3, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438737&FileExtension=.PDF&FileName=Carburetor%20Icing%20Chart-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438738&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438739&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF
- Photos (item 6, .PDF, 2 photos, 250 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40438740&FileExtension=.PDF&FileName=Photos-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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