LAX04LA166

NTSB accident investigation · Globe GC-1B · Placerville, CA · March 18, 2004

Accident · Serious injuriesLimited investigationFinal report
Date
March 18, 2004, 14:30 local (22:30 UTC)
Place
Placerville, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N369BZGlobe GC-1B
Weather
Visual (VMC) · Day
Status
Completed · report January 31, 2006
Report
Approved by Office Director
Parties
Federal Aviation Administration, Teledyne Continental
FAA report
20040318005209A
Case key
58921

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 loss of engine power due to an improperly sized and installed set of sealing gaskets in the gascolator, which resulted in fuel starvation. A factor to the accident was the unsuitable terrain for the forced landing.

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
Fluid,fuel - starvationCause
Maintenance,installation - improperOwner/pilot mechanicCause
Fuel system,gascolator - leakCause
Forced landingEmergency landing after takeoff
In flight collision with objectEmergency landing after takeoff
Object - tree(s)
Terrain condition - mountainous/hilly

Analysis

The airplane collided with trees and terrain following a loss of engine power in the takeoff initial climb. The pilot reported that he had just dropped off a passenger and was repositioning the airplane to another airport. At 200 to 300 feet above ground level (agl) in the takeoff initial climb the engine lost power. He attempted to turn back to the runway but did not have enough altitude. He elected to stall the airplane into the trees on the south slope of the airport boundary. The accident was witnessed by personnel at the airport. The witnesses reported that the pilot was departing using runway 23, the airplane took off and did a steep, almost vertical ascent, and banked hard to the left (south). The pilot appeared to stall the airplane, as it went into the trees on the south side of the runway. The pilot held an airframe and powerplant mechanic certificate and was the primary maintainer of the airplane. Federal Aviation Administration inspectors examined the wreckage at the accident scene and Safety Board investigators later examined the wreckage following recovery. Disassembly of the gascolator revealed that both the upper and lower gaskets in the gascolator were 1/8 to 3/16 inches smaller in diameter than the gascolator canister and the top and bottom covers. The investigators observed that in order to affect a seal, both gaskets had to be centered when installed. Both gaskets were off center. No fuel was observed in the fuel lines and the manifold valve was disassembled and found to be dry and void of any fuel. The manifold valve body and screen were clean. No other discrepancies were found during the engine examination.

Factual narrative

History of flight

On March 18, 2004, about 1430 Pacific standard time, a Globe GC-1B, N369BZ, collided with trees and terrain following a loss of engine power in the takeoff initial climb at Placerville Airport (PVF), Placerville, California. The owner/pilot was operating the airplane under the provisions of 14 CFR Part 91. The airline transport pilot, the sole occupant, sustained serious injuries; the airplane sustained substantial damage. The personal local flight departed Placerville about 1430, en route to Cameron Airpark (O61) Cameron Park, California. Visual meteorological conditions prevailed and no flight plan had been filed. The primary wreckage was at 38 degrees 43.266 minutes north latitude by 120 degrees 45.509 minutes west longitude.

The pilot reported that he had just dropped off a passenger and was repositioning the airplane to Cameron. On the initial climb out, at 200 to 300 feet above ground level (agl), the engine quit. He attempted to turn back to the runway but did not have enough altitude. He elected to stall the airplane into the trees on the south slope of the airport boundary.

The accident was witnessed by personnel at the airport. The first responders to the accident site turned off the fuel selector switch. They assisted the pilot out of the airplane and transported him to the hospital.

The witnesses reported that the pilot was departing using runway 23; the airplane took off and did a steep, almost vertical ascent, and banked hard to the left (south). The pilot appeared to stall the airplane, as it went into the trees on the south side of the runway.

The pilot had refueled the airplane at Cameron with a total of 28 gallons. He had flown to Livermore Airport (LVK) and then to Placerville.

The airplane was recovered and transported for further investigation.

The pilot submitted a Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2). He stated that the airplane had no mechanical failures or malfunctions during the flight.

Personnel information

A review of Federal Aviation Administration (FAA) airman records revealed that the pilot held an airline transport pilot certificate with ratings for airplane single engine and multiengine land. The pilot held a certified flight instructor (CFI) certificate with ratings for airplane single engine and multiengine land, and instrument airplane. The pilot held an airframe and powerplant mechanic certificate.

The pilot held a first-class medical certificate issued on January 15, 2004. It had no limitations or waivers.

The pilot reported a total flight time of 9,060 hours. He logged 102 hours in the last 90 days, and 51 in the last 30 days. He had en estimated 750 hours in this make and model. He completed a biennial flight review on January 29, 2004.

Aircraft information

The airplane was a Globe GC-1B Swift, serial number 1302. A review of the airplane's logbooks revealed a total airframe time of 1,655 hours at the last annual inspection. The logbooks had an entry for an annual inspection dated October 01, 2003.

The engine was a Teledyne Continental Motors IO-360C engine, serial number 50643-6-C. Total time on the engine at the last annual inspection was 3,272 hours. The total time since overhaul was 980 hours.

The owner/pilot was the primary mechanic of record for the accident airplane.

Wreckage and impact information

Investigators from the FAA examined the wreckage at the accident scene. The airplane came to rest south of the runway on a hillside about 100 feet downslope from the runway elevation.

Tests and research

The FAA and Teledyne Continental Motors (TCM) were parties to the investigation.

Investigators examined the wreckage at Plain Parts, Sacramento, California, on March 23, 2004.

Investigators removed the top spark plugs. All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

Investigators manually rotated the engine with the propeller. The engine rotated freely and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

No fuel was observed in the fuel lines, and the manifold valve was disassembled and found to be dry and void of any fuel. The manifold valve body and screen were clean.

Investigators manually rotated the engine and both magnetos produced spark for all cylinders.

On April 19, 2004, investigators inspected the fuel system. They disassembled and inspected the gascolator. Both the upper and lower gaskets in the gascolator were 1/8 to 3/16 inches smaller in diameter than the gascolator canister and the top and bottom covers. They observed that in order to affect a seal, both gaskets had to be centered when installed. Both gaskets were off center.

Investigators attempted to start the engine, but were unsuccessful. The fuel line for the engine driven fuel pump was broken at the casting. An attempt to repair the damaged line was unsuccessful.

Additional information

The IIC released the wreckage to the owner's representative.

Aircraft

Registration
N369BZ
Reported as
Globe GC-1B
Category
Airplane
Serial number
1302
Airframe hours
1,655
Engine
Continental IO-360-C, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Miguel E. Nelson
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 1, 2003 · 35 hours before
Departed
PVF · Placerville, CA
Destination
O61 · Cameron Park, CA
Airport
PVF · Placerville, runway 23, 4,200 × 75 ft, asphalt

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
Certificates
Commercial, Flight instructor, Airline transport, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
January 1, 2004
Seat
Left
Flight hours
9,060 total · 750 in this make and model · 4,686 as pilot in command · 102 in the last 90 days · 51 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 45 °F
Altimeter
29.93 inHg
Observed at
AUN, 20 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.