LAX97LA283

NTSB accident investigation · Cessna 195 · Santa Ana, CA · August 11, 1997

Accident · Serious injuriesLimited investigationFinal report
Date
August 11, 1997, 11:39 local (18:39 UTC)
Place
Santa Ana, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9328ACessna 195
Weather
Visual (VMC) · Day
Status
Completed · report April 10, 1998
Report
Approved by Office Director
FAA report
19970811021669A
Case key
29871

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

Water contamination in the fuel system due to the failure of the mechanic who performed the last annual inspection to adequately comply with the AD which required inspection of the fuel tank filler area for proper sealing, and the pilot's inadequate preflight inspection.

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(total) - nonmechanicalApproach - faf/outer marker to threshold (ifr)
Fluid,fuel - contamination,waterCause
Maintenance,compliance with ad - not complied withCompany maintenance personnelCause
Aircraft preflight - inadequatePilot in commandCause
Forced landingEmergency descent/landing
On ground/water collision with objectLanding - flare/touchdown
Terrain condition - none suitable
Object - other

Analysis

The aircraft lost engine power during an ILS approach, made an emergency landing in an auto parking lot, and collided with ground obstructions during the landing roll. During inspection of the aircraft, the contents of the carburetor were found to be approximately 1/3 water and grit deposits and 2/3 fuel. The inside of the top of the recessed wing fuel caps exhibited corrosion, and rust was present on the locking shaft. The O-rings around the shaft were deteriorated and the shaft had a side-to-side free play of about 1/16 inch. The bottom side of the fuel caps also exhibited corrosion and a pattern of scratches similar to the use of an abrasive material in the areas where corrosion was present. Corrosion was also present internally in the metal gascolator. An AD required an annual inspection of the fuel cap areas for evidence of water contamination. The AD was signed off by the mechanic at the last annual on 08/01/96. The aircraft is parked outside exclusively.

Factual narrative

On August 11, 1997, at 1139 hours Pacific daylight time, a Cessna 195, N9328A, collided with obstacles during a forced landing about 1 mile north of the John Wayne Airport, Santa Ana, California. The forced landing was precipitated by a total loss of engine power during an Instrument Landing System (ILS) approach to runway 19R. The aircraft was owned and operated by the pilot and was completing a personal cross-country flight that had begun at the San Bernardino, California, airport, around 1100. The aircraft sustained substantial damage in the collision sequence. The private pilot, the sole occupant, incurred serious injuries. Visual meteorological conditions prevailed beneath a broken cloud layer and an Instrument Flight Rules (IFR) flight plan was filed.

The pilot reported that at about 2 miles from the runway he noticed that he was a little low, so he advanced the throttle but nothing happened. He then told the tower that he was too low to make the runway and looked for a place to land. The pilot landed in an automobile parking lot and collided with light poles and a fence.

During inspection of the aircraft, the contents of the carburetor bowl were found to be approximately 1/3 water and grit deposits and 2/3 fuel. The wing fuel tank filler caps were examined and were noted to be a recessed-well type. Corrosion was observed on the inside of the recessed area on the top part of the cap. There was a pattern of scratches similar to the use of an abrasive material in the area where corrosion was present. The hole in both wing's filler caps for the locking handle shaft exhibited rust around the circumference, and 1/16-inch side-to-side play was noted on the shaft. The O-ring around each shaft was deteriorated. Corrosion was also noted on the underside of the fuel cap, as well as a similar pattern of abrasive marks. The metal gascolator showed internal corrosion. Photos are appended.

A complete engine examination was conducted with no other noted discrepancies.

The aircraft was equipped with a bladder fuel tank system for which Airworthiness Directive (AD) 84-10-01 R1 (07/05/88) was applicable. The heading on the AD is "To prevent power loss or engine stoppage due to water contamination of fuel system." Pertinent portions of the AD require an initial inspection of the fuel filler area for proper sealing, and that the inspection be repeated every 12 months. Review of the maintenance records revealed that the AD had been signed off by the airframe and powerplant mechanic on the last annual inspection dated 08/01/96.

In an interview, the aircraft owner stated that the aircraft is exclusively parked outside. He reported that during the preflight he obtained some water when the sumps were drained, and continued to drain until he got clear fuel.

Aircraft

Registration
N9328A
Reported as
Cessna 195
Category
Airplane
Serial number
7407
Airframe hours
4,700
Engine
Jacobs 755A2, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Norman L. Kreuder
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 7, 1996 · 30 hours before
Departed
SBD · San Bernadino, CA
Destination
SNA
Flight plan
IFR
Airport
SNA · Santa Ana, runway 19R, 5,700 × 150 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
70
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
2,492 total · 350 in this make and model · 8 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 5 knots
Visibility
25 statute miles
Lowest ceiling
2,500 ft broken
Temperature
75 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
SNA

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.