LAX04LA170

NTSB accident investigation · Cessna 188B · Planada, CA · March 25, 2004

Accident · No injuriesLimited investigationFinal report
Date
March 25, 2004, 09:45 local (17:45 UTC)
Place
Planada, CA
Injuries
1 uninjured
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N478QCessna 188B
Weather
Visual (VMC) · Day
Status
Completed · report January 31, 2006
Report
Approved by Office Director
Parties
Federal Aviaiton Administration
FAA report
20040325003619A
Case key
58973

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

the partial loss of engine power due to the separation of the number 5 cylinder fuel injector supply line. The fuel line separation was due to company maintenance personnel's failure to secure the b-nut fitting following maintenance. Factors in the accident were the unsuitable nature of the terrain where the engine problem developed and the pilot's failure to maintain airspeed while attempting to reach a suitable forced landing spot, which led to an inadvertent stall.

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 power(partial) - mech failure/malfManeuvering - aerial application
Maintenance - inadequateCompany maintenance personnelCause
Fuel system,line fitting - not securedCause
Fuel system,line - separationCause
Forced landingEmergency descent/landing
Loss of control - in flightEmergency descent/landing
Airspeed(vs) - not maintainedPilot in commandFactor
Stall - encounteredPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - crop
Terrain condition - open field
Terrain condition - none suitable

Analysis

The airplane experienced a partial loss of engine power and impacted flat terrain while maneuvering over farm fields. The pilot was applying fertilizer to an agriculture field. He was in a climbing turn, about 150 feet above ground level (agl), when he felt the airplane shake as if it was approaching a stall. He advanced the throttle. The engine did not sound normal, and the airplane was not able to maintain altitude. He was over an orchard and directed the airplane towards one of the fields he was working. The pilot said he was over that field, fighting the stall buffet, when the airplane gave up flying, spun over to the right inverted, and nosed down to the ground 50 feet below. The pilot exited, and the airplane was subjected to a post impact fire. A Federal Aviation Administration (FAA) inspector performed a post accident examination of the airplane's engine at the operator's facility. He reported that the engine was a Continental IO-520-D that had folded under the wreckage against the ground, which provided protection from the post accident fire. Extensive heat damage was identified around cylinder number 5, which included local melting of the aluminum around the rocker cover and intake manifold. The number 5 cylinder fuel injector line was free of the fuel injector nozzle. The number 5 cylinder injector fuel line b-nut was found to be only finger tight. Examination of the airplane's maintenance logbook revealed that the engine oil cooler had been removed and replaced on March 12, 2004, approximately 36 flight hours prior to the accident. The FAA inspector said that a common practice used by mechanics was to move or adjust the number 5 cylinder fuel injector line in order to install or uninstall the engine oil cooler.

Factual narrative

On March 25, 2004, at 0945 Pacific standard time, a Cessna 188B, N478Q, collided with terrain during a forced landing following a loss of engine power in the vicinity of Planada, California. T-Craft, Inc., was operating the airplane under the provisions of 14 CFR Part 137. The pilot was not injured, and a post crash fire destroyed the airplane. Visual meteorological conditions prevailed, and a flight plan had not been filed. The flight originated at Chowchilla, California, about 0900.

The pilot stated in his written report that he was applying fertilizer to an agriculture field. He was in a climbing turn after making a pass, and the engine began to run rough. He said that it sounded like the propeller was surging. He was unable to maintain altitude, and he was only about 150 feet above ground level (agl). He said that manifold pressure and rpm seemed good at 25 inches and 2,500 rpm, respectively. He advanced the throttle, but did not feel or hear the engine respond. He did not recall the fuel pressure, oil pressure, or cylinder head temperature.

He was over an orchard, fighting the stall buffet, and directed the airplane towards one of the fields he was working. The pilot said that he was over that field when the airplane gave up flying, spun over to the right inverted, and nosed down to the ground 50 feet below. The airplane flipped back onto the gear upon ground contact. The pilot observed fire on the right side in the fuel tank area, and expedited his egress.

A Federal Aviation Administration (FAA) inspector performed a post accident examination of the airplane's engine at the operator's facility. He reported that the engine was a Continental IO-520-D that had folded under the wreckage against the ground, which provided protection from the post accident fire. The propeller had been completely sheared from the propeller hub retaining bolts. The engine's crankshaft rotated freely and the valve train operated in conjunction with compression on all cylinders. The magnetos were removed and examined. Extensive heat damage was identified around cylinder number 5, which included local melting of the aluminum around the rocker cover and intake manifold. The number 5 cylinder fuel injector line was broken free of the fuel injector nozzle and the fuel distribution manifold. The number 5 cylinder injector fuel line b-nut was finger tight.

Examination of the airplane's maintenance logbook revealed that the engine oil cooler had been removed and replaced on March 12, 2004, approximately 36 flight hours prior to the accident. The FAA inspector said that a common practice used by mechanics was to move or adjust the number 5 cylinder fuel injector line in order to install or uninstall the engine oil cooler.

Aircraft

Registration
N478Q
Reported as
Cessna 188B
Category
Airplane
Serial number
18802315T
Airframe hours
5,330
Engine
Continental IO-520-D, 285 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Aerial application · Part 137
Operator
T-Craft Inc.
Registered owner
Thiel AirCare, Inc
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · January 1, 2004 · 116 hours before
Departed
K2O6 · Chowchilla, CA
Destination
K2O6
Airport
K2O6 · Chowchilla

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
33
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
October 1, 2003
Seat
Front
Flight hours
459 total · 45 in this make and model · 389 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 5 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 45 °F
Altimeter
30.10 inHg
Observed at
KMCE, 5 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.