# NTSB LAX04LA166: Globe GC-1B, N369BZ, Placerville, CA, March 18, 2004 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 18, 2004, 14:30 local (22:30 UTC) - Place: Placerville, CA - Coordinates: 38.721111, -120.758613 - Nearby events: https://openairdocs.org/map.md?lat=38.7211&lon=-120.7586&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report January 31, 2006 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Teledyne Continental - NTSB case key (mKey): 58921 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04LA166 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58921/pdf - Page: https://openairdocs.org/ntsb/LAX04LA166 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - fluid,fuel - starvation (cause) - maintenance,installation - improper, owner/pilot mechanic (cause) - fuel system,gascolator - leak (cause) - Forced landing, emergency landing after takeoff - In flight collision with object, emergency 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](https://openairdocs.org/aircraft/N369BZ), registered now, S/N 1302, built 1946 (OpenAirDocs) - Reported make and model: Globe GC-1B - Registry model: [Globe GC-1B](https://openairdocs.org/model/globe-gc-1b) (registry code 9230104) (OpenAirDocs) - Registry engine: [Continental C125 series](https://openairdocs.org/engine/continental-c125-series) (registry code 17011, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1302 - Airframe hours: 1655 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: serious; 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 (OpenAirDocs). - [Accident 20040318005209A](https://openairdocs.org/incident/20040318005209A), Mar 18, 2004: Swftms GC1B, Placerville, CA, Substantial damage. (-23) After taking off, pilot stated that the aircraft engine lost power. Pilot attempted to turn around and land on the runway. Aircraft crashed adjacent to… 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.