CHI02LA218

NTSB accident investigation · Cessna TR182 · Copemish, MI · July 27, 2002

Accident · Serious injuriesLimited investigationFinal report
Date
July 27, 2002, 12:30 local (16:30 UTC)
Place
Copemish, MI
Injuries
2 serious, 1 minor
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N756CSCessna TR182
Weather
Visual (VMC) · Day
Status
Completed · report April 28, 2004
Report
Approved by Office Director
Parties
Textron Lycoming Engines, Cessna Aircraft Company, Federal Aviation Administration: Grand Rapids FSDO
FAA report
20020727017299A
Case key
55355

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The in-flight engine and cabin fire caused by a fatigue fracture of the left exhaust stack assembly. An additional cause was the part's inadequate design by the aftermarket part manufacturer. A factor to the accident was the soft field in which the emergency landing was made.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionCruise - normal
Exhaust system,manifold/pipe - fatigueCause
Exhaust system,manifold/pipe - fracturedCause
Acft/equip,inadequate designManufacturerCause
FireCruise - normal
Engine compartment - fireCause
Fuselage,cabin - fireCause
Forced landingEmergency descent/landing
Nose overEmergency descent/landing
Terrain condition - softFactor

Analysis

The airplane was destroyed during an on-ground fire following an emergency descent/landing due to an in-flight fire. The pilot reported that he smelled smoke followed by the cabin filling with heavy black smoke. The pilot stated flames began to enter the cockpit as he maneuvered the airplane for a landing in an agricultural field. The airplane nosed over during the landing. The left exhaust stack assembly contained a fatigue fracture adjacent to the main collector welded joint. The fracture was in both the heat affected zone and parent material. The fracture initiated in multiple locations on the outside surface of the tube and progressed through a fatigue mechanism. Energy dispersive spectroscopy (EDS) confirmed that both the weld and tube material met design specifications. The weld profile contained no apparent flaws. The left exhaust stack assembly had accumulated approximately 100 hours since new. The design of the Cessna supplied left exhaust stack assembly differs from the comparable Knisley PMA assembly. The Cessna assembly has a two-piece main collector. The two halves are stamped-out and joined together with a seam weld. The weight of the turbocharger assembly is supported in part by the left exhaust stack assembly. The Knisley main collector is manufactured by welding several tube sections together. Knisley issued a mandatory service bulletin that called for the removal of their left exhaust stack assembly and its replacement with the current Cessna assembly or FAA approved equivalent. The service bulletin states that the replacement was instituted because the Knisely assembly was not designed to carry the load of the turbocharger and compressor.

Factual narrative

History of flight

On July 27, 2002, at 1230 eastern daylight time, a Cessna TR182, N756CS, piloted by a private pilot, was destroyed during an on-ground fire following an emergency descent and landing due to an in-flight fire near Copemish, Michigan. Visual meteorological conditions prevailed at the time of the accident. The personal flight was operating under the provisions of 14 CFR Part 91 without a flight plan. The pilot and front-seat passenger sustained serious burn injuries. The rear-seat passenger sustained minor injuries. The flight departed from Mason County Airport, Ludington, Michigan, at 1215 and was en route to Cherry Capital Airport, Traverse City, Michigan.

According the pilot's written statement, during the accident flight he smelled smoke, which was followed by the cabin filling with a "heavy black smoke". The pilot stated flames began to enter the cockpit as he maneuvered the airplane for a landing in an agricultural field. The pilot reported that he opened the left cockpit window due to the smoke filled cabin and unlatched the cockpit door just prior to landing. The pilot stated that during landing the airplane flipped over.

Personnel information

The pilot held a private pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. The FAA issued the pilot certificate on June 19, 2002.

FAA records indicate his last medical examination was completed on April 24, 2002, and that he was issued a third-class medical certificate with limitation "must wear corrective lenses."

The pilot had accumulated a total flight time of 753.6 hours, of which 624.5 hours were as pilot-in-command. The pilot reported that 691.8 hours were in single-engine airplanes and 61.8 hours were in multiengine airplanes. He flew 78.3 hours during the previous 3 months, including 47.3 hours in the same make/model as the accident airplane. He had flown 44.1 hours during the prior 30 days and 9.0 hours during the last 24 hours.

Aircraft information

The accident airplane was a 1979 Cessna TR182, serial number R18201041. The Cessna TR182 is a single engine, high-wing airplane. The Cessna TR182 is equipped with a retractable tricycle landing gear, electrically actuated wing flaps, and is powered by a single reciprocating engine. The fuselage and empennage are of an all-metal semimonocoque design. The metal wings are externally braced and have two integral tanks. The airplane was equipped with dual controls and could accommodate four occupants. The accident airplane had a certified maximum takeoff weight of 3,100 lbs.

The airplane was issued a Standard Airworthiness Certificate on April 21, 1979, and was certified as a standard category airplane. According to aircraft maintenance logbooks and the owner's pilot logbook, the accident airplane had accumulated a total flight time of 3,394.2 hours since new.

The last annual inspection was completed on January 3, 2002, and the airplane had accumulated 88.6 hours since the inspection. According to the aircraft maintenance logbooks, all applicable FAA Airworthiness Directives had been complied with as of the last annual inspection.

The engine was a turbocharged 235 horsepower Lycoming O-540-L3C5D, serial number L-21306-40A. The engine had accumulated 194.6 hours since the last overhaul, which was completed on September 29, 2000. The engine was installed on the accident airplane on December 11, 2000, and the last engine inspection was completed on January 3, 2002.

The propeller was a two-bladed McCauley B2D34C217/90DHB-8, hub serial number 791777.

Meteorological information

A weather observation station, located at the Manistee County Airport (MBL), 21 nautical miles (nm) southwest of the accident site, recorded the weather as:

At 1255: Wind 280 degrees true at 12 knots; 10 statute mile visibility; broken clouds at 2,300 above ground level (agl); temperature 28 degrees Celsius; dew point of 21 degrees Celsius; altimeter 29.79 inches of mercury.

Wreckage and impact information

An inspector with the Federal Aviation Administration performed the initial on-scene investigation. Representatives from Cessna Aircraft Company and Textron Lycoming Engines performed an additional on-scene investigation under the direct supervision of the Michigan State Police.

The landing gear had collapsed rearward during the landing attempt and the airplane nosed-over after traveling forward approximately 50 feet. The airplane was found resting inverted and the entire cabin area was consumed during the post-accident fire. Both wings remained intact and only the inboard portions were affected by fire. The engine remained attached to the firewall and both were damaged by fire. The turbocharger exhaust waste gate was found fully closed and the carburetor was consumed by fire. The lower right engine cowling was more affected by fire than the lower left side.

The fiberglass cabin heat valve body (p/n: 2253006-3) was consumed during the fire. The cabin heat valve door (p/n: 1253067-8) was found open and the torsion spring (p/n: 1253070-1) that normally forces the door shut was found disengaged from the control arm (p/n: 1253069-4). The valve seal (p/n: 1253067-9) that is normally attached to the aft portion of the valve door was consumed during the fire. The steel hinge rod, which is welded to the valve door, remained indexed to the control arm by safety wire. The cabin heat control cable remained attached to the control arm. The cabin heat control cable housing is secured by an aluminum bracket (p/n: 2253008-1) and steel clamp (p/n: S2226-1). The bracket is attached to a firewall stiffener plate (p/n: 0753102-9) by aluminum rivets. The bracket had separated from the stiffener plate and was destroyed by fire.

The left exhaust stack assembly (p/n: K2254012-2, s/n: 106419) contained an approximately four-inch fracture around the main collector welded joint.

Selections from the Cessna TR182 Illustrated Parts Catalog (IPC) that diagram the cabin heat valve assembly and left exhaust stack assembly are included with the docket material associated with this factual report.

Tests and research

According to the TR182 Type Certificate Data Sheet, Cessna Aircraft Company modified the supplied Lycoming O-540-L3C5D engine to include a turbocharger system. The installation of the turbocharger system was completed in accordance with Cessna drawing no. 2250065.

According to the Cessna TR182 IPC, the turbocharger installed on the accident airplane (s/n: R18201041) is supported by the engine exhaust system and a brace/support (p/n: 2250110-2) that is attached to the engine.

The TR182 Type Certificate Data Sheet and selections from the TR182 IPC that depict the turbocharger installation are included with the docket material associated with this factual report.

The left exhaust stack assembly (p/n: K2254012-2, s/n: 106419) was manufactured by Knisley Welding, Inc. (Knisley), Loomis, California. Knisley obtained a Parts Manufacturer Approval (PMA) for the production of the assembly on November 15, 2001. The assembly was listed on Knisley PMA supplement no. 23, which was effective on November 15, 2001.

The Parts Exchange, Fort Mill, South Carolina, took an order from Victory Air Service, Ludington, Michigan, for a replacement left exhaust stack assembly on November 29, 2001. Victory Air Service was the maintenance facility where the accident airplane was maintained. The Parts Exchange received the replacement part from Knisley on December 7, 2001, and shipped the assembly to Victory Air Service the same day. Aircraft maintenance logbooks indicated the replacement assembly was installed on the accident airplane on December 14, 2001.

At the time of the accident, the replaced exhaust stack assembly had accumulated approximately 100 hours since installation.

The PMA supplement, work order document

Aircraft

Registration
N756CS
Reported as
Cessna TR182
Category
Airplane
Serial number
R18201041
Airframe hours
3,394.2
Engine
Lycoming O-540-L3C5D, 235 horsepower, reciprocating
Damage
Destroyed
Fire
Both
Flight
Personal · Part 91
Registered owner
James D. Davis
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 3, 2002 · 88.6 hours before
Departed
LDM · Ludington, MI
Destination
TVC · Traverse City, MI

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
43
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
April 3, 2002
Seat
Left
Flight hours
754 total · 105 in this make and model · 625 as pilot in command · 78 in the last 90 days · 44 in the last 30 days · 9 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 12 knots
Visibility
10 statute miles
Lowest ceiling
2,300 ft broken
Temperature
82 °F, dew point 70 °F
Altimeter
29.79 inHg
Observed at
MBL, 21 nm away

Docket · 30

The files NTSB released with the investigation on February 20, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.5 MB in all.

Materials Laboratory - Factual Report of Group ChairmanItem 1 · .PDF · 2.0 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 307 KBKnisley Design Print For P/N K2254012-2 Left Exhaust Stack AssemblyItem 3 · .PDF · 76 KBCessna TR182 Illustrated Parts Catalog (IPC) Depiction of Cessna P/N 2254012-2 Left Exhaust Stack AssemblyItem 4 · .PDF · 63 KBCessna TR182 Illustrated Parts Catalog (IPC) Depiction of the Turbo Charger InstallationItem 5 · .PDF · 141 KBCessna TR182 Illustrated Parts Catalog (IPC) Depiction of the Cabin Heat Control Valve & SystemItem 6 · .PDF · 116 KBCessna TR182 Service Manual Description of the Cabin Heating SystemItem 7 · .PDF · 219 KBSelections From N756CS Maintenance LogbookItem 8 · .PDF · 195 KBSelection From FAA Type Certificate Data Sheet for the Cessna TR182 AirplaneItem 9 · .PDF · 30 KBKnisley Welding, Inc. PMA Approval for P/N K2254012-2Item 10 · .PDF · 263 KBKnisley Supplied Documentation for the Sale of P/N K2254012-2 S/N 106419Item 11 · .PDF · 200 KBThe Parts Exchange Supplied Documentation on the Purchase of P/N K2254012-2 S/N 106419Item 12 · .PDF · 215 KBKnisley Welding, Inc. Mandatory Service Bulletin: 002Item 13 · .PDF · 359 KBChain-Of-Custody & Wreckage ReleasesItem 14 · .PDF · 115 KBPhoto 1. Main Wreckage OverviewItem 15 · .PDF · 741 KBPhoto 2. Wreckage - FrontItem 16 · .PDF · 693 KBPhoto 3. Wreckage - Front/RightItem 17 · .PDF · 716 KBPhoto 4. Wreckage - RightItem 18 · .PDF · 713 KBPhoto 5. Wreckage - LeftItem 19 · .PDF · 696 KBPhoto 6. Wreckage - Main CabinItem 20 · .PDF · 718 KBPhoto 7. Engine - FrontItem 21 · .PDF · 707 KBPhoto 8. Engine - RightItem 22 · .PDF · 748 KBPhoto 9. Engine - LeftItem 23 · .PDF · 712 KBPhoto 10. Cabin Heat Control ValveItem 24 · .PDF · 1.2 MBPhoto 11. Cabin Heat Control ValveItem 25 · .PDF · 1.1 MBPhoto 12. Cabin Heat Control ValveItem 26 · .PDF · 144 KBPhoto 13. Turbocharger SupportsItem 27 · .PDF · 210 KBPhoto 14. Exhaust Main CollectorItem 28 · .PDF · 714 KBPhoto 15. Main Collector FractureItem 29 · .PDF · 186 KBPhoto 16. Cessna P/N: 2254012-2Item 30 · .PDF · 293 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.