FTW99FA261

NTSB accident investigation · Cessna 182A · Bryan, TX · September 18, 1999

Accident · FatalField investigationFinal report
Date
September 18, 1999, 18:59 local (23:59 UTC)
Place
Bryan, TX
Injuries
5 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N4803DCessna 182A
Weather
Visual (VMC) · Day
Status
Completed · report May 17, 2001
Report
Approved by Office Director
FAA report
19990918028449A
Case key
47420

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

the pilot's failure to maintain aircraft control resulting in an inadvertent stall. A factor was the loss of engine power as a result of fatigue cracking and separation of the #6 cylinder head.

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.

Loss of engine powerTakeoff - initial climb
Engine assembly,cylinder - fatigueFactor
Engine assembly,cylinder - separationFactor
Maintenance,recordkeeping - not requiredFaa(other/organization)
Loss of control - in flightTakeoff - initial climb
Aircraft control - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Witnesses reported that the single-engine airplane's takeoff and climb appeared to be normal. As the airplane climbed through 400 feet, a puff of black smoke was observed emanating from the right side of the engine compartment. The airplane nosed up slightly, then nosed down turning about 360 degrees before descending rapidly from view. One witness heard the engine start missing before the airplane turned and descended. Continuity was established to all flight controls. Examination of the engine revealed that the #6 cylinder head separated from its cylinder barrel as a result of fatigue cracking originating in the cylinder head threads. When the engine was overhauled about 353.86 hours prior to the accident, 6 Nu-chromed overhauled cylinders were installed. It could not be determined how many hours the cylinders had accumulated nor how many times they had been overhauled. There is no requirement to track cylinder hours or overhaul occurrences.

Factual narrative

History of flight

On September 18, 1999, at 1859 central daylight time, a Cessna 182A airplane, N4803D, was destroyed when it impacted terrain following a loss of engine power and a loss of control during takeoff from the Coulter Field Airport near Bryan, Texas. The airplane was registered to SMC Institute A Close Corporation of Wilmington, Delaware, and operated by Ags Over Texas of Bryan, Texas. The commercial pilot and four parachutists were fatally injured. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 parachute activity flight. The flight was originating at the time of the accident.

Witnesses reported to the NTSB investigator-in-charge (IIC) that the airplane departed runway 14 and the takeoff and climb appeared to be normal. As the airplane was climbing through approximately 400 feet, a witness observed a puff of black smoke emanating from the right side of the engine compartment. The airplane nosed up slightly and then nosed down descending rapidly. A witness, sitting outside in his yard, heard the "engine start missing." The airplane turned toward the runway, and "I thought it was going back to Coulter Field Airport. A few seconds later I saw it go straight down." Another witness (dove hunter), located about 1/2 to 3/4 mile from the accident site, observed the airplane heading east at about 300-400 feet agl. He stated that "the aircraft appeared to stall. The right wing dropped quickly and the aircraft spun in, nose down, spin[ning] to the right, making one complete revolution before impacting the ground." Subsequently, black smoke was observed in the area where the airplane descended from view.

Personnel information

According to FAA records, the pilot was issued a private pilot certificate on January 4, 1997, and on April 15, 1998, he was issued an instrument rating. On July 13, 1998, he obtained a commercial pilot certificate with an airplane single-engine land rating. On December 2, 1998, he was issued a multi-engine land rating, which also sufficed as a biennial flight review. The pilot held a first class medical certificate, which was issued September 10, 1998.

A review of the pilot's flight logbook revealed that on July 14, 1998, he received his first introductory flight for jump operations, and on July 18, 1998, he completed the jump operations training. The logbook showed that the pilot's first flight as pilot-in-command for jump operations was on July 18, 1998. The logbook also revealed that as of September 15, 1999, the pilot had logged a total flight time of 810.2 hours, of which 341.0 hours were logged in the same make and model as the accident aircraft. The pilot had logged 294.9 hours in jump operations.

Aircraft information

The 1956-model Cessna was a high-wing, single-engine airplane, which had fixed tricycle landing gear. The airplane was equipped with a Continental O-470-L engine rated at 230-horsepower, and was modified to drop skydivers. Modifications included the removal of the right control wheel, and all seats were removed except for the left front. A jump seat (solid plate backrest) was installed against the instrument panel next to the pilot. A jump door, jump light, droop wing tips, and a jump step were also installed.

The airplane had been fueled with 14 gallons of 100LL aviation gasoline, two flights prior to the accident. One flight was to drop parachutists and the other was a "short" flight to locate a parachutist that landed off the airport. The pilot had flown the airplane several times earlier in the day prior to the accident flight.

The Ags Over Texas operations officer suggested to the NTSB IIC that the student static line parachutist would sit next to the pilot. One parachutist would sit behind the pilot, and the tandem parachutist would sit next to that parachutist near the door. The other parachutist would sit aft of the middle two parachutist. This seating arrangement could not be confirmed, and the weight of the static line parachutist was not obtained, therefore, an accurate weight and balance could not be determined. However, using the suggested seating arrangement and 120 pounds for the static line parachutist, the NTSB IIC, using the aircraft owner's manual, calculated that the airplane would be within weight and balance limits.

A review of the aircraft's maintenance records revealed that the engine was overhauled on October 25, 1997, at a total aircraft time of 6,572.41 hours and engine total time of 4,464.29 hours. During the engine overhaul, 6 Nu-chromed overhauled cylinders were installed. The aircraft underwent its last annual inspection on October 15, 1998. The last 100-hour inspection was completed on January 28, 1999, 248.84 hours since engine overhaul, at which time the engine received its last compression check before the accident. The compression check did not reveal any anomalies in cylinder head compression. As of September 12, 1999, the engine had accumulated 353.76 hours since its overhaul.

According to the facility that overhauled the cylinders, the cylinder heads were not removed from the cylinder barrels during overhaul. Each cylinder was Nu-chromed and the head was then ultrasonically inspected for cracks. It could not be determined how many hours the cylinders had accumulated nor how many times the cylinders had been overhauled, nor is it required to track cylinder time or overhaul periods.

Wreckage impact information

The accident site was located about 1/4 mile from the departure end of runway 14, at latitude 30 degrees 42.6 minutes north and longitude 096 degrees 19.6 minutes west. The airplane impacted the terrain on a magnetic heading of 115 degrees. The fuselage and engine came to rest upright on a heading of 120 degrees magnetic. The empennage was separated and adjacent to the fuselage but was facing 090 degrees. The fuselage and portions of the wings and control surfaces were consumed by fire.

The empennage and outboard sections of the wings remained intact; however, they were fire damaged. Both wings tips appeared to be swept forward. Both wing leading edges were damaged, but neither wing leading edge was crushed aft. The right wing outboard of the fuel tank was curved upward, and its tip separated. The ailerons were found intact and remained attached to the wings. Both ailerons sustained impact and fire damage. The inboard sections of the left and right flaps were destroyed by fire. The flap actuator was found to be in a position consistent with a 40 degree extension of flaps. The left horizontal stabilizer was wedged between two small mesquite trees. The right elevator was deflected upward and the rudder was deflected to the right. Control continuity was confirmed to all flight control surfaces.

A portion of the #6 cylinder head had separated from the barrel and was found laying next to the engine. The engine sustained some fire damage. The propeller was attached to the engine, and both propeller blades were secured in the propeller hub. One blade was bent aft under the engine, and its tip sustained fire damage. The other propeller blade had a slight forward bend and it had some chordwise scratching. The #6 cylinder head was sent to the NTSB Materials Laboratory in Washington, D.C., for further examination. The engine was removed and sent to the engine manufacturer's facility in Mobile, Alabama, for a detailed examination.

Medical and pathological information

An autopsy was performed on the pilot at the Bexar County Forensic Science Center.

The FAA Civil Aeromedical Institute toxicology laboratory detected 36.16 (mg/dl, mg/hg) of salicylate and 39.02 (mg/dl, mg/hg) of acetaminophen in the pilot's urine.

Tests and research

On October 14, 1999, the Teledyne Continental O-470-L engine (serial number 67582-7-L) was examined at the Teledyne Continental Motors (TCM) facility at Mobil

Aircraft

Registration
N4803D
Reported as
Cessna 182A
Category
Airplane
Serial number
34903
Airframe hours
6,926
Engine
Continental O-470-L, 230 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Skydiving · Part 91
Operator
Ags Over Texas
Registered owner
Smc Institute A Close Corp.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 28, 1999 · 105 hours before
Departed
CFD
Airport
CFD · Coulter Field, runway 14, 4,000 × 75 ft

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
22
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
810 total · 341 in this make and model · 667 as pilot in command · 115 in the last 90 days · 75 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 55 °F
Altimeter
29.00 inHg
Observed at
CLL, 7 nm away

Docket · 39

The files NTSB released with the investigation on March 30, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.7 MB in all.

Supplement AItem 1 · .PDF · 268 KBSupplement BItem 2 · .PDF · 398 KBSupplement SItem 3 · .PDF · 52 KBWitness StatementsItem 4 · .PDF · 1.3 MBWreckage DiagramsItem 5 · .PDF · 122 KBWreckage DiagramItem 6 · .PDF · 56 KBMaterials Laboratory Factual ReportItem 7 · .PDF · 92 KBMaterials Laboratory Factual Report, Figure 1Item 8 · .PDF · 32 KBMaterials Laboratory Factual Report, Figure 2Item 9 · .PDF · 36 KBMaterials Laboratory Factual Report, Figure 3Item 10 · .PDF · 32 KBMaterials Laboratory Factual Report, Figure 4Item 11 · .PDF · 41 KBMaterials Laboratory Factual Report, Figure 5Item 12 · .PDF · 42 KBParty Report - CessnaItem 13 · .PDF · 682 KBParty Report - TeledyneItem 14 · .PDF · 1.9 MBParty Report, DiagramItem 15 · .PDF · 39 KBTeledyne Continental Motors Engine Examination ReportItem 16 · .PDF · 235 KBAircraft Flight ManifestItem 17 · .PDF · 735 KBFuel LogItem 18 · .PDF · 114 KBMaintenance Records ExcerptsItem 19 · .PDF · 1.2 MBExcerpts Airframe LogItem 20 · .PDF · 724 KBExcerpts Engine LogItem 21 · .PDF · 5.5 MBPropeller LogItem 22 · .PDF · 1.8 MBMajor Repair and Alteration - FAA Form 337Item 23 · .PDF · 120 KBPilot's Flight LogbookItem 24 · .PDF · 2.8 MBStatement of Party Representatives to NTSB InvestigationItem 25 · .PDF · 430 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 26 · .PDF · 160 KBToxicological ReportItem 27 · .PDF · 83 KBPhoto 1: View of Right Side of Airplane.Item 28 · .PDF · 65 KBPhoto 2: View of Left Side of Airplane.Item 29 · .PDF · 57 KBPhoto 3: View of Left Wing.Item 30 · .PDF · 74 KBPhoto 4: Top View of Right Wing.Item 31 · .PDF · 73 KBPhoto 5: Bottom View of Right Wing.Item 32 · .PDF · 61 KBPhoto 6: Right Side View of Empennage.Item 33 · .PDF · 49 KBPhoto 7: Left Side View of Empennage.Item 34 · .PDF · 57 KBPhoto 8: View of Cockpit & Cabin Area.Item 35 · .PDF · 64 KBPhoto 9: Right Side View of Engine. Note Position of Separated #6 Cylinder.Item 36 · .PDF · 62 KBPhoto 10: Left Side View of Engine. Note Position of Separated #6 Cylinder.Item 37 · .PDF · 65 KBPhoto 11: Close-Up View of the Engine. Note Portion of the #6 Cylinder is Separated.Item 38 · .PDF · 51 KBPhoto 12: Close-Up View of Separated #6 Cylinder.Item 39 · .PDF · 59 KB

FAA reports on this event · 1

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