# NTSB LAX97LA283: Cessna 195, N9328A, Santa Ana, CA, August 11, 1997 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 11, 1997, 11:39 local (18:39 UTC) - Place: Santa Ana, CA - Coordinates: 33.670402, -117.900573 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6704&lon=-117.9006&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report April 10, 1998 - Report: Approved by Office Director - ADs cited in the narratives: [AD 84-10-01 R1](https://openairdocs.org/ad/84-10-01-R1) (OpenAirDocs) - NTSB case key (mKey): 29871 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX97LA283 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29871/pdf - Page: https://openairdocs.org/ntsb/LAX97LA283 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - nonmechanical, approach - faf/outer marker to threshold (ifr) - fluid,fuel - contamination,water (cause) - maintenance,compliance with ad - not complied with, company maintenance personnel (cause) - aircraft preflight - inadequate, pilot in command (cause) - Forced landing, emergency descent/landing - On ground/water collision with object, landing - 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](https://openairdocs.org/deregistered/N9328A-2001-01-26), registration cancelled 2001-01-26, S/N 7407 (OpenAirDocs) - Reported make and model: Cessna 195 - Registry model: [Cessna 195](https://openairdocs.org/model/cessna-195) (registry code 2073102) (OpenAirDocs) - Category: Airplane - Serial number: 7407 - Airframe hours: 4700 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; 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 (OpenAirDocs). - [Accident 19970811021669A](https://openairdocs.org/incident/19970811021669A), Aug 11, 1997: Cessna 195, Santa Ana, CA, Substantial damage. Engine quit on final. Hit light poles and fence. Water rust in fuel. Leaky rusted fuel caps. Bad o ring corrosion. 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.