CEN16LA033

NTSB accident investigation · Cessna 120 · Gonzales, LA · November 6, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
November 6, 2015, 12:05 local (18:05 UTC)
Place
Gonzales, LA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2942NCessna 120
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 21, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20151106018349A
Case key
92298

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

Maintenance personnel’s improper installation of the carburetor during recent maintenance, including the omission of a required cotter pin, which resulted in a total 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.

Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceCessna 120: 1 caseAll aircraft: 103 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 120: 2 casesAll aircraft: 371 casesProbable cause
Maintenance/inspectionsAircraft › Aircraft handling/service · Incorrect service/maintenanceCessna 120: 1 caseAll aircraft: 103 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

The pilot reported that the airplane was on final approach to the airport when the engine started to lose power. He applied carburetor heat and switched fuel tanks, but engine power was not restored, so he made a forced landing to a field near the airport. An examination of the wreckage found that the castellated nut that connects the throttle arm to the carburetor had backed off, which allowed the engine to go to idle, and that the nut's associated cotter pin was missing. The pilot reported that the carburetor had been replaced the day before the accident flight. The accident is consistent with the throttle arm becoming disengaged from the carburetor as a result of a missing cotter pin and the accompanying nut subsequently backing off.

Factual narrative

On November 6, 2015, about 1205 central standard time, a Cessna 120 airplane, N2942N, impacted terrain shortly after departing the Louisiana Regional Airport (L38), Gonzales, Louisiana. The commercial rated pilot was seriously injured and the airplane was substantially damaged during the accident. The airplane was registered to and operated by Graham Aviation LLC, Baton Rouge, Louisiana, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time. The pilot reported that he had been airborne about 25 minutes and was on final approach to the runway. The engine began to lose power, so he applied carburetor heat and switched fuel tanks. The engine did not recover, so he made a forced landing in a field. The pilot added that the engine's carburetor had been replaced the day prior. The responding Federal Aviation Administration (FAA) inspector reported that the airplane had crashed in a field near the airport. A visual examination of the engine noted that fuel was present on site. The airplane came to rest upright, with the main landing gear collapsed. Heavy impact damage was noted to the airplane's fuselage. After the airplane was recovered, an examination of the wreckage was conducted by the FAA inspector. The examination found that the castellated nut holding the carburetor's throttle arm had backed off, allowing the engine to go to idle. Additionally, the nut was missing the associated cotterpin.

Aircraft

Registration
N2942N
Reported as
Cessna 120
Category
Airplane
Serial number
13203
Built
1947
Engine
Cont Motor C85 SERIES, 85 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Graham Aviation LLC
Registered owner
Graham Aviation LLC
Airworthiness certificate
Standard, Normal
Departed
L38 · Gonzales, LA
Destination
L38 · Gonzales, LA
Airport
L38 · Louisiana Regional Airport

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 15, 2015
Seat
Left
Restraint
Lap only
Flight hours
16,000 total · 220 in this make and model · 15,200 as pilot in command · 150 in the last 90 days · 30 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 3 knots
Visibility
10 statute miles
Lowest ceiling
1,100 ft broken
Temperature
81 °F, dew point 77 °F
Altimeter
30.06 inHg
Observed at
KL38, 3 nm away

Docket · 3

The files NTSB released with the investigation on December 1, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.3 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.

Other investigations on N2942N · 1

Matched to the same aircraft by N-number and date.