# NTSB FTW95FA277: Bellanca 17-31A, N39875, Hot Springs, AR, July 10, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 10, 1995, 00:46 local (05:46 UTC) - Place: Hot Springs, AR - Coordinates: 34.449531, -93.099777 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.4495&lon=-93.0998&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report December 19, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 19235 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95FA277 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19235/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=19235 - Page: https://openairdocs.org/ntsb/FTW95FA277 ## Probable cause THE PARTIAL LOSS OF ENGINE POWER AS A RESULT OF THE DISENGAGEMENT OF THE THROTTLE CABLE HOUSING DUE TO IMPROPER MAINTENANCE. FACTORS WERE THE NIGHT CONDITION AND THE LACK OF SUITABLE TERRAIN. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, takeoff - initial climb - maintenance - improper, other maintenance personnel (cause) - throttle/power lever,cable - disengaged (cause) - In flight collision with object, maneuvering - object - tree(s) - light condition - night (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - none suitable (contributing factor) ## Analysis WITNESSES TO THE INITIAL DEPARTURE OBSERVED THE AIRPLANE TAKEOFF, AND RETURN TO THE AIRPORT. THE PILOT TOLD A LINEMAN AT THE AIRPORT THAT HE EXPERIENCED A DROP OF 6 TO 7 INCHES OF MANIFOLD PRESSURE DURING TAKEOFF. THE PILOT WAS OBSERVED TO REMOVED THE ENGINE COWLINGS AND WORK ON THE ENGINE FOR APPROXIMATELY AN HOUR. AFTER REPLACING THE COWLINGS, THE PILOT DID SEVERAL RUNUPS AND HIGH SPEED TAXIS DOWN THE RUNWAY FOLLOWED BY ONE FLIGHT AROUND THE PATTERN WHILE HIS PASSENGERS WAITED AT THE TERMINAL. THE PASSENGERS WERE REBOARDED AND THE AIRPLANE DEPARTED. THE PILOT LANDED AT HIS INTERMEDIATE REFUELING STOP TWENTY MINUTES BEFORE MIDNIGHT. AFTER REFUELING, THE AIRPLANE DEPARTED FOR THE FINAL LEG OF THEIR NIGHT CROSS COUNTRY FLIGHT. DURING TAKEOFF CLIMB, THE ENGINE LOST PARTIAL POWER. THE AIRPLANE IMPACTED TREES 600 FEET PRIOR TO GROUND IMPACT. EXAMINATION OF THE AIRPLANE REVEALED THAT THE THROTTLE CABLE HOUSING HAD DISENGAGED FROM THE SWAGED END OF THE THROTTLE PUSH ROD ASSEMBLY. THE THROTTLE CABLE HOUSING WAS ALSO FOUND TO BE FRAYED. ## Factual narrative HISTORY OF FLIGHT On July 10, 1995, at 0046 central daylight time, a Bellanca 17-31A, N39875, was destroyed while maneuvering near Hot Springs, Arkansas. The non-instrument rated private pilot and his three passengers were fatally injured. The aircraft was being operated by the owner/operator, under Title 14 CFR Part 91. Visual meteorological conditions prevailed for the personal night cross country flight and no flight plan was filed. A lineman at the airport in Destin, Florida, the airplane's initial departure point, reported that the airplane was topped off with fuel before departure. Three passengers and the pilot boarded, and the airplane departed at approximately 1755 for their flight to Hot Springs. The lineman added that approximately 5 minutes after departing Destin, the airplane returned to the airport. The pilot complained of "low manifold pressure." He stated that he had experienced a loss of engine power and a "drop of 6 to 7 inches of manifold pressure" during takeoff. The pilot asked to borrow a few hand tools to remove the engine cowlings. The lineman further stated that he observed the pilot inspecting and working on the engine for approximately one hour. After reinstalling the cowlings, the pilot "did several run-ups and high speed taxis down the runway followed by one flight around the pattern while his passengers waited at the terminal." The passengers reboarded the airplane and departed Destin, at 1944 en route to the Johnson County Executive Airport near Olathe, Kansas. The lineman overheard one of several pilots watching the departing aircraft comment that it "sounded O.K." The flight made an intermediate stop at the Hot Springs Memorial Field at approximately 2340 to refuel and departed from Runway 23 at 0045. PERSONNEL INFORMATION The private pilot was part owner (1/2 interest) of the airplane. His pilot logbooks were not located. It was determined from Federal Aviation Administration (FAA) records and the co-owner of the airplane, that the pilot had logged approximately 1,300 hours of flight time. The pilot was not a licensed airframe and powerplant mechanic. The co-owner of the airplane reported that neither he nor the pilot customarily worked on their airplane. AIRCRAFT INFORMATION The wing tanks were topped off with 45.2 gallons of 100LL Avgas prior to his departure from Hot Springs. A review of the airframe and engine records by the FAA inspector did not reveal any anomalies or uncorrected maintenance defects prior to the flight. The last 100 hour inspection was completed on February 9, 1995, and approximately 16 hours of flight time had been accumulated up to the time of the accident. WRECKAGE AND IMPACT INFORMATION The airplane came to rest among trees at the base of a hill approximately one mile south of the airport in a nose down attitude. Numerous pine branches with slash marks and paint transfers were found on a measured heading of 120 degrees leading to the final resting site of the airplane. The first tree with broken branches and airplane debris in it, was on a ridge 600 feet from the main wreckage. The next tree with broken branches was 200 feet from the main wreckage. See the enclosed crash scene diagram for additional details. On-scene investigation revealed that the flaps were extended 23 degrees, and the landing gear was down. Examination of the engine control cables revealed that the throttle was full forward (maximum power), the propeller was full forward (high RPM), and the mixture was full forward (full rich). Engine continuity could not be established, fuel selector position could not be established, and flight control continuity could not be determined due to thermal damage from the post impact fire. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Arkansas State Crime Laboratory at Little Rock, Arkansas, on July 11, 1995. Toxicological tests were ordered and performed. Carbon monoxide, cyanide, and ethanol were all found in the blood. Dr. John Soper, Ph.D. of the Federal Aviation Administration Civil Aeromedical Institute at Oklahoma City, Oklahoma, attributes the ethanol to postmortem decomposition. FIRE A post-impact fire destroyed the airplane. No evidence of pre- impact fire was found during the investigation. TEST AND RESEARCH An examination of the engine and airframe revealed that the throttle cable housing had disengaged from the swaged end of the throttle push rod assembly. The enclosed photographs show that the cable housing had slipped out of position by 2 inches and the throttle push rod assembly shows 1/2 inch of displacement. According to the engine manufacturer representative, "this [slippage] would allow the engine power to decelerate even though the throttle was in the full power setting." According to the airframe log books, the throttle cable assembly had never been replaced. The airplane was manufactured in 1973. Examination of the throttle cable also revealed a frayed section of the throttle cable housing. Information provided by the throttle cable manufacturer established that the cable is a "condition" change item. Title 14 CFR, Part 43, Appendix D, Paragraph D, item 6, states that each person performing an annual inspection shall inspect the engine controls for defects, improper travel, and improper safetying. Fuel from the last refueling point was examined for contaminants and/or water. None was found. ADDITIONAL DATA The airplane was released to the owner's representative. ## Aircraft - Registration: [N39875](https://openairdocs.org/deregistered/N39875-1996-03-12), registration cancelled 1996-03-12, S/N 7332109 (OpenAirDocs) - Reported make and model: BELLANCA 17-31A - Registry model: [Bellanca 17-31A](https://openairdocs.org/model/bellanca-17-31a) (registry code 1220435) (OpenAirDocs) - Category: Airplane - Serial number: 73-32-109 - Airframe hours: 2514 - Engines: LYCOMING IO-540-K1E5 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Robert N. Weiler - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 9, 1995, 15 hours before - Departed: HOT - Destination: OJC, OLATHE, KS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,300 total, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/bright - Wind: 250° at 4 knots - Visibility: 7 statute miles - Lowest ceiling: 6,500 ft broken - Temperature: 79 °F, dew point 75 °F - Altimeter: 29.00 inHg - Observed at: LIT, 40 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 19950710017129A](https://openairdocs.org/incident/19950710017129A), Jul 10, 1995: Blanca 1731A, Hot Springs, AR, Destroyed, 4 fatal. Lost part power. Returned. Fixed. Departed lost power again. Struck trees. Throttle cable separated at push rod. ## Docket (20 files) The files NTSB released with the investigation on December 5, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=19235. 3.0 MB in all. - Supplement A (item 1, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037862&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 382 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037863&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement K (item 3, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037864&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Supplement S (item 4, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037865&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Witness Statements (7) (item 5, .PDF, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411643&FileExtension=.PDF&FileName=Witness%20Statements%20(7)-Redacted.PDF - Wreckage Diagram (item 6, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037867&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Other Pertinent Forms and Reports (item 7, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411644&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411645&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411646&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: A slashed tree limb with paint transfer (no negative). Photo courtesy of Lycoming. (item 10, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037871&FileExtension=.PDF&FileName=Photo%201%3A%20%20A%20slashed%20tree%20limb%20with%20paint%20transfer%20(no%20negative).%20%20Photo%20courtesy%20of%20Lycoming.-Master.PDF - Photo 2: Slashed tree limbs with paint transfers (no negative). Photo courtesy of Lycoming. (item 11, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037872&FileExtension=.PDF&FileName=Photo%202%3A%20%20Slashed%20tree%20limbs%20with%20paint%20transfers%20(no%20negative).%20%20Photo%20courtesy%20of%20Lycoming.-Master.PDF - Photo 3: The aircraft accident site with the engine buried under debris. (item 12, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037873&FileExtension=.PDF&FileName=Photo%203%3A%20%20The%20aircraft%20accident%20site%20with%20the%20engine%20buried%20under%20debris.-Master.PDF - Photo 4: The aircraft accident site showing the airplane in a nose down position in trees. (item 13, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037874&FileExtension=.PDF&FileName=Photo%204%3A%20%20The%20aircraft%20accident%20site%20showing%20the%20airplane%20in%20a%20nose%20down%20position%20in%20trees.-Master.PDF - Photo 5: The throttle cable assembly with pushrod from the accident airplane. (item 14, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037875&FileExtension=.PDF&FileName=Photo%205%3A%20%20The%20throttle%20cable%20assembly%20with%20pushrod%20from%20the%20accident%20airplane.-Master.PDF - Photo 6: Throttle cable assembly. The arrow points to the 3/8 inch limit line showing how much of the cable housing was inside of the swaged end of the push rod assembly. (item 15, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037876&FileExtension=.PDF&FileName=Photo%206%3A%20%20Throttle%20cable%20assembly.%20%20The%20arrow%20points%20to%20the%203%2F8%20%20inch%20limit%20line%20showing%20how%20much%20of%20the%20cable%20housing%20was%20inside%20of%20the%20swaged%20end%20of%20the%20push%20rod%20assembly.-Master.PDF - Photo 7: The throttle cable assembly showing slippage of the cable housing from the accident airplane. (item 16, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037877&FileExtension=.PDF&FileName=Photo%207%3A%20%20The%20throttle%20cable%20assembly%20showing%20slippage%20of%20the%20cable%20housing%20from%20the%20accident%20airplane.-Master.PDF - Photo 8: The throttle cable assembly from the accident airplane showing the amount of push rod travel. The throttle setting in the cockpit was in full power position. (item 17, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037878&FileExtension=.PDF&FileName=Photo%208%3A%20%20The%20throttle%20cable%20assembly%20from%20the%20accident%20airplane%20showing%20the%20amount%20of%20push%20rod%20travel.%20%20The%20throttle%20setting%20in%20the%20cockpit%20was%20in%20full%20power%20position.-Master.PDF - Photo 9: An undamaged replica of a push rod assembly (not from the accident aircraft) in the full power position. (item 18, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037879&FileExtension=.PDF&FileName=Photo%209%3A%20%20An%20undamaged%20replica%20of%20a%20push%20rod%20assembly%20(not%20from%20the%20accident%20aircraft)%20in%20the%20full%20power%20position.-Master.PDF - Photo 10: An undamaged replica of a push rod assembly (not from the accident aircraft) in the power off (closed throttle) position. (item 19, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037880&FileExtension=.PDF&FileName=Photo%2010%3A%20%20An%20undamaged%20replica%20of%20a%20push%20rod%20assembly%20(not%20from%20the%20accident%20aircraft)%20in%20the%20power%20off%20(closed%20throttle)%20position.-Master.PDF - Photo 11: The throttle cable housing from the accident airplane showing the frayed section. (item 20, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40037881&FileExtension=.PDF&FileName=Photo%20%2011%3A%20%20The%20throttle%20cable%20housing%20from%20the%20accident%20airplane%20showing%20the%20frayed%20section.-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. --- 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.