ERA12LA440

NTSB accident investigation · Cessna 170 · Panama City, FL · July 11, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
July 11, 2012, 10:53 local (15:53 UTC)
Place
Panama City, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2561VCessna 170
Defining event
Initial climb: Fuel contamination
Weather
Visual (VMC) · Day
Status
Completed · report August 13, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20120711016939A
Case key
84274

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

A total loss of engine power due to water contamination of the fuel, the pilot/owner's inadequate preflight inspection of his airplane, and his failure to maintain airplane control after the engine failure.

Findings · 4

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.

Fluids: fuelAircraft › Fluids/misc hardware · Not serviced/maintainedCessna 170: 4 casesAll aircraft: 1,695 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 170: 4 casesAll aircraft: 551 casesProbable cause
Performance/control parameters: engine out controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 170: 1 caseAll aircraft: 35 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 170: 17 casesAll aircraft: 9,295 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 airplane was parked outdoors for an extended period of time. The pilot/owner spent 2 days alternately draining water-contaminated fuel and test running the airplane’s engine several times. The pilot stated that he drained one fuel tank completely because the fuel appeared to be “milky” and serviced that tank with 10 gallons of fuel, but he later amended his statement and said he drained both tanks completely before he serviced them with "a combination of Jerry cans and a friend's pickup-mounted fuel tank." He then departed. The airplane experienced a total loss of engine power immediately after takeoff. The pilot attempted to return to the airport but landed in a retention pond short of the runway. The pilot reported that he performed a “shallow” turn to return to the airport, but a witness described “an abrupt/steep left-hand turn” followed by a ''stall" and descent to water contact. No preimpact mechanical anomalies were noted that would have precluded normal operation. After the accident, the engine was placed in a test cell where it started immediately, accelerated smoothly, and ran continuously without interruption. The manufacturer and the FAA have published letters, bulletins, and advisories that provided guidance to prevent accidents due to water contamination of the fuel system. It is likely that the pilot did not drain all the water-contaminated fuel from the airplane before departure, which led to the loss of engine power after takeoff.

Factual narrative

HISTORY OF FLIGHT On July 11, 2012, at 1053 central daylight time, a Cessna 170, N2561V, was substantially damaged during a forced landing after takeoff from Sandy Creek Airpark (75FL), Panama City, Florida. The certificated airline transport pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was originating at the time of the accident. The ferry flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. According to a witness acquainted with the pilot, the airplane was departing on the first leg of a cross-country flight to Alaska. The witness helped the pilot/owner prepare the airplane for flight, as it had not flown for several months. Fuel samples were taken from each fuel tank sump, and several successive samples contained water. In a telephone interview with a Federal Aviation Administration (FAA) inspector, the pilot/owner said he found water in several fuel samples, and ultimately drained the right fuel tank completely. He further stated that he serviced the right tank with 10 gallons of automotive gasoline to match the 10 gallons contained in the left tank. The pilot later amended his statement, and said that he drained all of the contaminated fuel from the airplane before he filled the tanks from "a combination of Jerry cans and a friend's pickup-mounted fuel tank." After completion of a 15-minute engine run to ensure that there was "no water in the carburetor," the pilot departed, and experienced a loss of engine power immediately after takeoff. He turned the airplane to return to the airport, but landed in a retention pond short of the runway. The pilot reported that he performed a “shallow” turn to return to the airport, but the witness described “an abrupt/steep left-hand turn” followed by a ''stall" and descent to water contact. PERSONNEL INFORMATION The airline transport pilot held multiple pilot certificates and ratings. His most recent FAA second-class medical certificate was issued in September 2010. The pilot reported 10,000 total hours of flight experience, of which 40 hours were in the accident airplane make and model. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 1948. The most recent annual inspection was completed 17 months prior to the accident, on February 11, 2011, at 1,508.0 aircraft hours. At the time of the accident, the tachometer displayed 1540.9 hours. An Airworthiness Directives compliance listing was not made available for review. An entry in the engine logbook dated January 6, 2012, indicated the number 2 cylinder was removed for valve work. There was no return-to-service entry following the reinstallation of the cylinder. METEOROLOGICAL INFORMATION The 1456 weather observation at Greenwood County Airport (GRD), located approximately 18 miles north of the accident site, included calm winds, clear skies below 10,000 feet, temperature 31 degrees C, dew point 16 degrees C, andan altimeter setting of 29.94 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane was examined at the scene on July 12, 2012. The airplane came to rest upright in the retention pond on the west end of the runway, with the engine partially submerged in water. Five (5) five-gallon plastic gas cans floated in the pond; of which four were full of auto fuel and one was empty with remnants of auto fuel inside. One two-gallon plastic gas can full of fuel was located inside the aircraft cabin area. The airplane was recovered from the pond, and control continuity was established from the flight controls to all flight control surfaces. The propeller was undamaged, but the carburetor was broken at its mount. A preliminary examination of the engine was performed, but then suspended. The engine was then removed for a detailed examination at a later date. On November 6, 2012, the engine was examined in Mobile, Alabama. The engine was flushed to remove mud and water from the cylinders, and the magnetos were removed, dried, and reinstalled. The carburetor, exhaust stacks, and the starter were all replaced due to impact damage. The engine was placed in a test cell where it started immediately, accelerated smoothly, and ran continuously without interruption. While the engine ran, the carburetor and its mount flange were repaired with a “metal-set” adhesive. The engine was stopped, the replacement carburetor was removed, and the original carburetor was reinstalled. Once again, the engine started immediately, accelerated smoothly, and ran continuously without interruption. ADDITIONAL INFORMATION Fuel System The fuel tanks were metal, and undamaged. On October 23, 1970, Cessna issued Service Letter SE70-28, “Fuel tank filler neck sealing”. This Service Letter addressed fuel tank filler neck sealing on 100 series aircraft with metal fuel tanks. It stated, in part, “Because the fuel tank filler neck assembly of the type illustrated… is recessed into the upper wing surface, it is possible for water (rain, snow, etc.) to collect in this area while the aircraft is parked. For this reason it is important a waterproof condition of the assembly be maintained on in-service aircraft to prevent water from seeping into the fuel tank.” On October 27, 1980, Cessna issued Service Information Letter SE80-87, “Fuel contamination” and its associated Owner’s Advisory. This Service Information Letter addressed fuel contamination. The letter recommended that fuel samples be obtained before the first flight of the day and after each refueling. It stated, “If contamination is detected continue draining from all fuel drain points, including drain plugs, until all contamination has been removed… Do not fly the aircraft with contaminated or unapproved fuel." On July 30, 1982, Cessna issued Service Information Letter 82-36, “Fuel contamination” and its associated Owner’s Advisory. The purpose of this Service Information Letter was, “To stress to owners and operators the importanceof routine fuel system inspection and maintenance… to detect, eliminate, and prevent fuel contamination.” The associated Owner’s Advisory stated, “If contamination is detected, it then becomes the pilot’s responsibility to see that the contaminants are removed from the fuel system prior to further flight.” The Owner’s Advisor also discusses elimination and prevention of contamination. On July 11, 1986, Cessna issued Service Bulletin SEB86-5, titled, “Special “Seat Locked” and “Fuel Contamination” Warning Placards” and its associated Owner’s Advisory. This mandatory Service Bulletin called for the installation of a fuel contamination warning placard on the instrument panel in view of the pilot. The placard stated, “WARNING: ASSURE THAT ALL CONTAMINANTS, INCLUDING WATER, ARE REMOVED FROM FUEL AND FUEL SYSTEM BEFORE FLIGHT. FAILURE TO ASSURE CONTAMINANT FREE FUEL AND HEED ALL SAFETY INSTRUCTIONS AND OWNER ADVISORIES PRIOR TO FLIGHT CAN RESULT IN BODILY INJURY OR DEATH.” FAA Advisory Circular AC 20-125, “Water in aviation fuels” stated that the information contained “should be reviewed by maintenance personnel, fuel servicing organizations, and especially the pilots of the aircraft to assure that all precautions and inspections to prevent or eliminate water in fuel are accomplished.”Sub-section D “Flight Personnel”, paragraph (1) stated, “The pilot-in-command has the final responsibility to determine that the aircraft is properly serviced. An important part of the preflight inspection is to drain aircraft fuel tank sumps, reservoirs, gascolators, filters, and other fuel system drains to assure that the fuel supply is free of water. A review of National Transportation Safety Board Briefs of Aircraft Accidents involving 114 accidents due to fuel contamination with water occurring between January 7, 1980, and September 11, 1981, showed that the probable cause in 85 of those accidents was ‘Pilot-in-Command – Inadequate Preflight Preparation and/or Planning.’ Since water in fuel accounts for a major share of fuel quality accidents, pilots should make it a practice to include this check beginning with the next preflight inspection.” Section 7, sub-section C, paragraph 4 discussed preflight fuel samples. It stated, in part, “Continue to drain fuel from the contaminated sump until certain the system is clear of all water.” Lastly, Section 9 stated, “Normally, upon finding water-contaminated fuel the procedures for removal of water outlined in this advisory circular should suffice. Should contamination persist or any doubt exists as to water contamination, the advice is to have the aircraft fuel system inspected by a qualified person.” On July 30, 2010, the FAA issued Special Airworthiness Information Bulletin CE-10-40R1, “Aircraft fuel system; water contamination of fuel tank systems on Cessna single engine airplanes.” On November 2, 2011, the FAA issued Special Airworthiness Information Bulletin (SAIB) CE-12-06, “Aircraft fuel system; water contaminationof fuel tank systems.” Both SAIB documents recommended similar steps for identifying water in fuel systems as those listed above.

Aircraft

Registration
N2561V
Reported as
Cessna 170
Category
Airplane
Serial number
18066
Airframe hours
1,541
Engine
Cont Motor C145 SERIES, 145 horsepower, reciprocating
Damage
Substantial damage
Flight
Ferry · Part 91
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · February 11, 2011 · 33 hours before
Departed
75FL · Panama City, FL
Destination
Andalusia, AL
Airport
75FL · Sandy Creek Airpark

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
40
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Flight hours
10,000 total · 40 in this make and model · 7,500 as pilot in command · 65 in the last 90 days · 25 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 7 knots
Visibility
10 statute miles
Lowest ceiling
18,000 ft broken
Temperature
86 °F, dew point 77 °F
Altimeter
30.04 inHg
Observed at
KPAM, 5 nm away

Docket · 14

The files NTSB released with the investigation on July 9, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.6 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.