# NTSB CEN18LA278: Aero Commander S2R, N5553X, Vinton, IA, July 17, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 17, 2018, 13:45 local (18:45 UTC) - Place: Vinton, IA - Coordinates: 42.21934, -92.03833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.2193&lon=-92.0383&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 97815 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA278 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97815/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97815 - Page: https://openairdocs.org/ntsb/CEN18LA278 ## Probable cause Loss of throttle control input due to a failure in the throttle control system. Contributing to the accident was the inadequate inspection and reinstallation of worn parts by maintenance personnel. ## 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 · Fatigue/wear/corrosion (probable cause); cases with it: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=0143022), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Aero Commander S2R, 1 case](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=0143022), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Aero Commander S2R, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=0143022), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) ## Analysis The pilot stated that on final approach, he slowed the airplane for landing. When the airplane crossed the end of the runway, he reduced the throttle back, but the airplane would not slow, so he executed a go-around. During the go-around, the engine lost partial power and would not respond to the pilot’s throttle inputs. The pilot then executed a forced landing in a cornfield, and the airplane sustained substantial damage to the fuselage and empennage. Examination of the throttle control system revealed that the interlocking teeth mechanisms between the carburetor lever stop assembly and the throttle control lever were worn and lost integrity to interconnect. The teeth on the lever stop assembly were severely worn. Thus, it is likely that during the accident flight, when the pilot actuated the throttle control lever, the throttle control system failed when the worn-down teeth on the lever stop would not engage the teeth on the mating throttle control lever. This caused a loss of the throttle lever input, which allowed the engine to enter a low rpm condition. The material examination also noted a mismatch in hardness of the associated parts; although the hardness values were typical for the respective part compositions and microstructures, the mismatch in hardness lent itself to higher wear rates. A review of the airplane’s maintenance records revealed that the carburetor had been removed for overhaul and reinstalled 135 hours before the accident. It is likely that maintenance personnel reinstalled the worn parts without thoroughly inspecting them. ## Factual narrative On July 17, 2018, about 1345 central daylight time, an Aero Commander S2R airplane, N5553X, was substantially damaged when it was involved in an accident near Vinton, Iowa. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 137 aerial application flight. The pilot stated he departed about 1254 from Vinton Veterans Memorial Airpark (VTI), Vinton, Iowa, with a load of fungicide. He sprayed two fields and had emptied all the fungicide in the airplane’s hopper. He reported that the takeoff, flight to and from the fields, and flight while spraying the fields were uneventful. He then headed back to VTI for a straight-in approach for runway 9. At 1/2 mile out on short final, he slowed the airplane for landing, and when the airplane crossed the end of the runway, he reduced the throttle back to the normal landing position. After a couple of seconds, the pilot realized the airplane was not slowing down. He then reduced the throttle back more, and the engine rpms did not drop. At that point, the airplane was almost halfway down the runway, and the pilot decided to go around. The pilot stated that he advanced the throttle, the airspeed increased, and he proceeded to go around. The pilot flew the pattern back around and was almost abeam the landing threshold when he had to increase the throttle to maintain engine rpms. He stated that when he turned to final, he reduced power “just a little bit” and the engine lost “most” of its power. The pilot stated he pushed the throttle full forward and moved it back and forward again with no response from the engine. The pilot chose to conduct a forced landing in a sandy cornfield to the right of the approach end of runway 9, and the airplane sustained substantial damage to the fuselage and empennage. Examination of the throttle control system revealed that teeth on the carburetor lever stop assembly and throttle control lever were worn out and no longer interconnected (see Figure 1); the lever stop assembly teeth were noted to be severely worn. When the throttle control lever was actuated, the worn-down teeth of the mating parts would glide over each other with no respective response from the carburetor lever stop assembly. The castellated hex retaining nut was found properly cotter pinned. Upon removal of the cotter pin, the nut could not be tightened to the next accessible castellation. The lever stop assembly roll pin was tight and had to be removed with a drift punch. Both levers fit tight on the throttle shaft. A logbook review indicated that a carburetor overhaul and installation was completed 135 hours before the accident. The associated parts were removed and sent to the National Transportation Safety Board Materials Laboratory for further examination, which revealed that the lever stop assembly had a composition consistent with aluminum alloy, while the composition of the throttle control lever was carbon steel. The hardness of the steel throttle control leveraveraged 52 HRA and the hardness of the aluminum lever stop averaged 34 HRA; these data were typical for the respective part compositions and microstructures. Figure 1: Diagram of Throttle Control Lever and Lever Stop from Accident Airplane with Inset Photo of Worn Teeth The carburetor was removed for examination and bench testing. The carburetor passed the bench test, and no anomalies were found that would have precluded normal operation. ## Aircraft - Registration: [N5553X](https://openairdocs.org/deregistered/N5553X-2021-12-17), registration cancelled 2021-12-17, S/N 1753R, built 1973 (OpenAirDocs) - Reported make and model: AERO COMMANDER S2R - Registry model: [Aero Commander S2R](https://openairdocs.org/model/aero-commander-s2r) (registry code 0143022) (OpenAirDocs) - Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1753R - Year built: 1973 - Airframe hours: 15680 - Engines: Pratt and Whitney R-1340-S3H1-G 600 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Noe Aviation Llc - Registered owner: Noe Aviation LLC - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Condition, May 12, 2018, 92 hours before - Departed: KVTI, Vinton, IA - Destination: Same as departure - Airport: KVTI, Vinton Veterans Memorial Airport, runway 09, 4,000 × 70 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 4, 2018; seat: single; restraint: 4-point; flight hours: 1,141 total, 201 in this make and model, 1,139 as pilot in command, 45 in the last 90 days, 40 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Temperature: 84 °F, dew point 57 °F - Altimeter: 30.11 inHg - Observed at: KVTI, 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 20180717011459A](https://openairdocs.org/incident/20180717011459A), Jul 17, 2018: Aero Commander S2R, Vinton, IA, Substantial damage. Upon landing runway 9, pilot was unable to reduce engine power so a go-around was initiated. During the downwind approach throttle input was needed to maintain… ## Other investigations on N5553X (2) 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. - [NTSB SEA84LA199](https://openairdocs.org/ntsb/SEA84LA199), Aug 14, 1984: Rockwell Thrush SR2 (N5553X), Nampa, ID, substantial damage - [NTSB SEA74FYA02](https://openairdocs.org/ntsb/SEA74FYA02), Jul 7, 1973: Aero Comdr 600S2R (N5553X), Homedale, ID, substantial damage ## Docket (5 files) The files NTSB released with the investigation on April 19, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97815. 15.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11756216&FileExtension=pdf&FileName=CEN18LA278%20completed%206120%20w%20blocks%20filled2_Redacted-Rel.pdf - Materials laboratory factual report (item 2, PDF, 17 pages, 27 photos, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8140019&FileExtension=pdf&FileName=19-034%20-%20Materials%20Lab%20Factual%20Report%20(CEN18LA278)2-Rel.pdf - Carburetor bench testing and exam notes (item 3, PDF, 1 page, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11755186&FileExtension=pdf&FileName=Carb%20Bench%20Testing%20Notes_redacted-Rel.pdf - Memorandum of record for FAA exam (item 4, PDF, 1 page, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11756226&FileExtension=pdf&FileName=Memorandum%20of%20Record%20for%20FAA%20Exam-Rel.pdf - Photographs of accident airplane (item 5, PDF, 3 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12163471&FileExtension=pdf&FileName=Photos%20for%20Docket-Rel.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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.