# NTSB LAX04LA170: Cessna 188B, N478Q, Planada, CA, March 25, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 25, 2004, 09:45 local (17:45 UTC) - Place: Planada, CA - Coordinates: 37.221668, -120.311668 - Nearby events: https://openairdocs.org/map.md?lat=37.2217&lon=-120.3117&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 31, 2006 - Report: Approved by Office Director - Parties: Federal Aviaiton Administration - NTSB case key (mKey): 58973 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX04LA170 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58973/pdf - Page: https://openairdocs.org/ntsb/LAX04LA170 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, maneuvering - aerial application - maintenance - inadequate, company maintenance personnel (cause) - fuel system,line fitting - not secured (cause) - fuel system,line - separation (cause) - Forced landing, emergency descent/landing - Loss of control - in flight, emergency descent/landing - airspeed(vs) - not maintained, pilot in command (contributing factor) - stall - encountered, pilot in command - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N478Q-2006-02-23), registration cancelled 2006-02-23, S/N 18802315T, built 1975 (OpenAirDocs) - Reported make and model: Cessna 188B - Registry model: [Cessna A188B](https://openairdocs.org/model/cessna-a188b) (registry code 2073005) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18802315T - Airframe hours: 5330 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: minor; 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 (OpenAirDocs). - [Accident 20040325003619A](https://openairdocs.org/incident/20040325003619A), Mar 25, 2004: Cessna A188B, Le Grand, CA, Destroyed. (-23) On March 25, 2004 N478Q a Cessna A188B ser. No. 18802315T was destroyed by fire following an emergency landing in an agricultural field. The aircraft was… 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.