LAX94FA289

NTSB accident investigation · Cessna 172M · Sacramento, CA · July 17, 1994

Accident · FatalField investigationFinal report
Date
July 17, 1994, 11:15 local (18:15 UTC)
Place
Sacramento, CA
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N1259UCessna 172M
Weather
Visual (VMC) · Day
Status
Completed · report December 7, 1994
Report
Approved by Office Director
FAA report
19940717018499A
Case key
28542

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 failure of the pilot to maintain adequate airspeed while maneuvering after takeoff and his failure to retract the flaps prior to departure. A factor in this accident was the pilot's lack of recent experience.

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 control - in flightTakeoff - initial climb
Raising of flaps - not performedPilot in commandCause
Airspeed(vs) - not maintainedPilot in commandCause
Stall/spin - inadvertentPilot in commandCause
Lack of recent experiencePilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The pilot began his takeoff roll, and during the takeoff roll the nose wheel was raised, then lowered back to the runway. A few seconds later, the aircraft again rotated, climbed about 2 feet, and then settled back onto the runway. On the next attempt, the pilot initiated a climb. The climb performance was described as 'wallowing,' with a slow rate of climb and a steep pitch attitude. The aircraft climbed to approximately 300 feet agl while making a shallow, left turn. During that time, the pitch attitude increased and then decreased. Witnesses described a second shallow, left turn. The pitch attitude increased to an estimated 30 degrees and then begin to decrease. The aircraft banked left and pitched down, descending toward the ground in a 70-degree nose-low attitude. The flap jackscrew was found extended, approximating full flaps. No evidence was found that the pilot had flown any aircraft within the last 4 months.

Factual narrative

History of flight

On July 17, 1994, at 1115 Pacific daylight time, a Cessna 172M, N1259U, crashed and burned while on a climb out from Natomas airport, Sacramento, California. The aircraft was owned and operated by American Aero Club, Inc., and was on a personal flight. Visual meteorological conditions were prevalent at the time and no flight plan had been filed for the local operation. The certificated private pilot and his three passengers were fatally injured. The flight was originating at the time of the accident.

The accident aircraft was scheduled to be flown on July 15 and had been subsequently rejected by another pilot due to what he described as an insufficient static power check. (The manufacturer states the maximum static rpm should be 2,350 rpm and the minimum should be 2,270 rpm.) That pilot stated that he reported the deficiency to a club mechanic. Since the aircraft was approaching a 50-hour inspection, the mechanic decided to go ahead and perform the inspection. Accordingly, the 50-hour inspection was performed and the aircraft was put back on the line.

The next day, on July 16, a second pilot rejected the aircraft for, what was again described as, an insufficient static power check. He reportedly was only able to develop between 1,900 and 2,000 rpms. The pilot stated that he described the deficiency to a club mechanic. The mechanic told investigators that to correct the problem he performed a run-up to clean the spark plugs and afterwards found no power deficiency. When interviewed by investigators, he was uncertain what the actual static rpm should be. He attributed the source of the problem to running the aircraft on the ground with a "rich idle" for too long, which had caused the spark plugs to foul, producing a power loss. After completing a power check, the mechanic again returned the aircraft to the line.

After being placed back on the line on July 16, the aircraft was flown twice during the remainder of the day. Both pilots found the aircraft performance to be normal.

On July 17, the pilot arrived at the airport and initially waited for his passengers to arrive. During his wait, he talked to another club member, who reported nothing unusual about the pilot or conversation. Witnesses stated that they then saw the pilot preflight the aircraft, enplane his passengers, and taxi from the flight line toward the active runway.

Witnesses who observed the aircraft's departure from runway 16 at Natomas airport described, what they concluded to be, several attempts to rotate the nose before the aircraft had obtained sufficient flying speed. One witness, who stated that he saw the aircraft early in the takeoff phase, reported that the aircraft was rolling down the runway on the main gear, but with the aircraft nose wheel off the runway. The pilot was then observed to lower the nose to the runway. A few seconds later, he was again observed attempting to rotate the aircraft. This time the aircraft climbed approximately 2 feet above the runway before settling back onto the runway. After both attempts, the pilot continued in his takeoff roll.

On his third attempt, with approximately 20 to 25 percent of the runway remaining, the pilot was successful in initiating a climb and remaining airborne. Witnesses described the aircraft's initial climb performance as "wallowing," with a slow rate of climb and an unusually steep nose attitude. A Federal Aviation Administration (FAA) inspector who observed the aircraft from his car concluded from what he observed that an instructor was probably demonstrating a short field takeoff.

After takeoff, the aircraft was described as climbing to approximately 300 feet agl while making a shallow, left 90- degree, crosswind turn. During that time, the pitch attitude of the aircraft was observed to increase and decrease in what, according to the opinion of witnesses, was an attempt to increase airspeed. Witnesses then described a second shallow, left 90-degree downwind turn. Again, the pitch attitude of the aircraft was observed to increase to an estimated 30 degrees, then decrease. However, as the pitch attitude of the aircraft decreased for the final time, the left wing dropped and the aircraft suddenly descended toward the ground in a 70-degrees nose-low attitude. One witness near the impact site reported what he heard as a "popping" sound coming from the engine just prior to the crash.

Personnel information

The pilot's logbook and the flying club's records were reviewed by investigators. There were no records reflecting a current biennial flight review (BFR).

There were no records reflecting that the pilot had flown any aircraft within the preceding 90 days. The last record for a flight in the same make and model was on October 17, 1993. The last record for a flight in any aircraft took place on March 13, 1994, in a Cessna 150.

Aircraft information

A review of the engine logbook revealed total engine time was 2,155.7 hours since major overhaul. The manufacturer recommends a major overhaul after 2,000 hours service.

A weight and balance computation was provided by the manufacturer's representative. Based on the occupant weights and their position in the aircraft provided by the Coroner, full fuel and the manufacturer's empty weight of the aircraft, the aircraft was at its maximum allowable gross weight and was near its aft center of gravity limit.

During the postcrash inspection of the engine, it was noted that the number 2 exhaust rocker arm was an incorrect part. The part installed was identified as an intake rocker arm.

According to club records, the aircraft was being operated with auto-gas under Patterson STC SA1948CE. It had been reportedly topped off with auto-gas mixed with 10 percent 100 low-lead aviation fuel before departure. The fuel capacity of both tanks totaled 42 gallons.

Wreckage and impact information

The aircraft impacted on level, dry, grassy terrain, about 1/2- mile south of the airport creating a ground scar approximately 6 feet in length, 3 feet in width, with an average depth of 4 inches. The final heading of the aircraft after impact was 195 degrees. The dry grass in an approximate 40-foot radius around the initial impact point was burned and blackened.

Control continuity was established for the ailerons, elevators, and rudder. The flap actuator was found extended 5.75 inches and, according to the manufacturer's charts, corresponds to a flap position of 37 to 38 degrees. The elevator trim actuator was found extended 1.5 inches and, according to the charts, corresponds to a 10-degrees tab up position.

The crush on the leading edges of the main wings was both rearward and upward at an approximate 45- to 50-degree angle. The leading edge crush was evident on the outboard portion of the left wing. Both wings showed evidence of scorching and fire involvement toward the wing roots.

The fuselage from the propeller aft to the vertical stabilizer had been consumed by fire. The empennage showed evidence of scorching, particularly on the left side.

The nose wheel was displaced and collapsed aft. Both main gear were separated from the aircraft. All three had evidence of fire damage.

Both main fuel tanks were ruptured and exhibited evidence of hydraulic deformation. There was no residual fuel in the right tank. In the left tank, there was approximately 1 quart of fuel with water contamination. Both tanks exhibited evidence of fire damage. The main fuel valve was not located in the debris. The gascolator was missing from its installed position and was not located in the wreckage debris.

The carburetor was removed from the engine and visually examined. It was equipped with a metal float and a single-piece venturi. No fuel was present in the carburetor bowl. The fuel inlet screen was clean and free of contaminants.

The ignition system exhibited evidence of exposure to fire an

Aircraft

Registration
N1259U
Reported as
Cessna 172M
Category
Airplane
Serial number
17266954
Airframe hours
7,525
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
Sacramento Aero Services, doing business as American Aero Club, Inc.
Registered owner
Sacramento Aero Services
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · June 9, 1994 · 52 hours before
Airport
Q96 · Natamos Field, runway 16, 2,700 × 30 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
40
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
146 total · 24 in this make and model · 94 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 4 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 66 °F
Altimeter
29.00 inHg
Observed at
SMC, 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.