# NTSB LAX98FA068: Cessna 182P, N8158M, Salinas, CA, January 10, 1998 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 9, 1998, 17:56 local (Jan 10, 1998, 01:56 UTC) - Place: Salinas, CA - Coordinates: 36.670986, -121.609191 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.6710&lon=-121.6092&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 31, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 29934 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX98FA068 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/29934/pdf - Page: https://openairdocs.org/ntsb/LAX98FA068 ## Probable cause A loss of engine power due to a missing valve keeper. Also causal was the failure by engine maintenance personnel during engine top overhaul to install the second valve keeper in the No. 3 cylinder exhaust valve and the failure of inspection personnel to detect the improper assembly. ## 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, cruise - engine assembly,valve keeper - missing - engine assembly,valve keeper - not installed - engine assembly,valve,exhaust - disconnected - maintenance,top overhaul - improper, other maintenance personnel (cause) - maintenance,inspection - inadequate, other maintenance personnel (cause) - Loss of engine power(total) - mech failure/malf, descent - emergency - engine assembly,valve,exhaust - fractured - engine assembly,piston - fractured - engine assembly,connecting rod - fractured - engine assembly,crankcase - fractured - Forced landing, descent - emergency - In flight collision with object, emergency descent/landing - object - utility pole ## Analysis During a night-time flight in marginal VFR conditions, the pilot radioed approach control that his aircraft's engine had begun running rough, losing power, and he was having difficulty maintaining altitude. Approach control vectored the pilot 14 miles back to the airport where he had previously completed an instrument approach. The pilot reported the runway in sight, however, the aircraft crashed on final approach 2 miles from the runway. A witness reported hearing the aircraft's engine as it approached, followed by 5 seconds of silence, and then the sound of impact. An annual inspection was completed on the aircraft about 2 weeks before the accident and this was believed to be the owner's first flight after the inspection. During the inspection, the Nos. 1, 3, and 4 cylinders were removed from the engine and repaired. Postaccident examination of the engine revealed that one of the two valve keepers had not been reinstalled on the No. 3 cylinder exhaust valve resulting in asymmetric loading of the remaining keeper. When that keeper fractured, the exhaust valve was released and entered the combustion chamber of the No. 3 cylinder where it contacted the piston. The consequential damage fractured the Nos. 3 and 4 pistons, the Nos. 3 and 4 connecting rods, and the crankcase. ## Factual narrative HISTORY OF FLIGHT On January 9, 1998, at 1756 hours Pacific standard time, a Cessna 182P, N8158M, impacted a power transmission pole and a greenhouse 2 miles southeast of the Salinas, California, airport during a night emergency landing approach. The aircraft was destroyed and the private pilot was fatally injured. Visual meteorological conditions prevailed for the personal flight, which was operated by the owner under the provisions of 14 CFR Part 91. The flight departed from San Carlos, California, about 1730, on an instrument flight plan; however, the pilot had canceled the flight plan before the accident. According to the Federal Aviation Administration (FAA) Western Region Quality Assurance Office, the pilot completed an instrument approach to Salinas without landing and departed the Class D airspace under special VFR flight rules, destined for the Chalone Vineyard private airport 21 miles east. When 14 miles southeast of Salinas, the pilot contacted Monterey TRACON and reported that the aircraft's engine was running rough, losing power, and he was having difficulty maintaining altitude. The pilot was being radar vectored back to Salinas at the time of the accident and he had reported the airport in sight. On-scene examination of the aircraft's engine revealed a hole in the top of the crankcase and internal damage to the Nos. 3 and 4 pistons and connecting rods. There was additional damage in the No. 3 cylinder rocker box cover. A witness who observed the accident from the second story bedroom of his home, which is approximately 200 feet east of the accident site, reported that he saw the aircraft briefly before the initial impact. He saw a white and a green light that were unusually low for aircraft approaching the airport. As he watched there was a flash, then a trail of fire on the ground, and then an explosion and large fire in the far end of an adjacent greenhouse. Another witness, who resides in a mobile home immediately adjacent to the power transmission pole that the aircraft first struck, reported that he heard the engine of the aircraft as it approached. There was silence for about 5 seconds, then he heard the initial impact with the pole outside his home. He said that it was very dark under cloudy skies outside his house, and that the only lights in the area were those inside his home and another nearby residence. The owner of the property where the accident occurred reported that he and several of his employees rushed to the accident scene and used approximately 10 portable fire extinguishers to put out the largest fire which was in the cabin area of the aircraft. They essentially had the fire extinguished when the fire department arrived. He said that it was very dark outside because the lights inside the greenhouses do not come on until 10:00 PM. PERSONNEL INFORMATION The pilot's logbook was not located after the accident. On an insurance application dated March 11, 1996, the pilot reported total flying time of 4,000 hours with 250 hours in the previous 12 months and 60 hours in the previous 90 days. The application reported that the pilot had 2,000 hours in the Cessna 182 make and model aircraft. On his medical examination application, dated 02/20/97, the pilot reported 4,500 total flying hours, and 100 hours in the prior 6 months. AIRCRAFT INFORMATION According to the pilot's brother, the aircraft logbooks were carried in a seat pouch in the aircraft. The seats, except for the frames, were consumed by fire and the logbooks were not located. FAA inspectors located records of a recent annual inspection performed on the aircraft by an area repair station. Among the records was shop work order 11074 dated November 19, 1997. The work order shows aircraft hours of 1,377.4 and includes, among other service items, an annual inspection and the removal, repair, and reinstallation of the Nos. 1, 3, and 4 cylinders due to low compression. An "Invoice for Services" for work order number 11074 shows that the work was completed on January 6, 1998. Representatives of the repair station, Victor Aviation Services, Inc. of Palo Alto, California, stated however, that the January 6 date was the date the invoice was prepared and that the work had been completed in mid-December. The repair station produced a copy of a logbook page showing the work performed during the inspection and repair and an approval for return to service (signoff) dated December 12, 1997. Following the annual inspection and engine repair, the aircraft was flown twice by Victor Aviation personnel; once for a maintenance check flight, and a second time to return the aircraft to the owner at San Carlos. The pilot's brother thought that the accident flight was the first flight of the aircraft by the owner since completion of the annual inspection. WRECKAGE AND IMPACT INFORMATION The aircraft impacted the perimeter of a complex of greenhouses in a level agricultural area. The wreckage was distributed along an approximate 135-foot-long path oriented approximately 300 degrees (magnetic). In the area to the left (southwest) of the wreckage path was an open, uncultivated field, and to the right (northeast) was the complex of several large greenhouses. The wreckage path was in line with a row of electrical power transmission lines, which supplied electrical power to the greenhouses. The poles supporting the lines are approximately 12 inches in diameter and 30 feet tall, and the open span between poles is approximately 120 feet. The accident site is at latitude 36 degrees 37.812 minutes north, and longitude 121 degrees 34.152 minutes west (GPS). From the accident site, the bearing and distance to the Salinas airport are 303 degrees magnetic and 2.68 miles (GPS). Adjacent to a mobile home at the southeast end of the wreckage path, there were burn marks and freshly exposed wood approximately 20 feet above ground level on a power transmission pole. Several power transmission lines were on the ground on both sides of this pole. Near the base of this pole was the root portion of the right-hand wing, the right-hand flap (separated at midspan) and the right-hand wing strut. The fuel cell in the inboard wing section was ruptured and the adjacent skins exhibited black sooting. To the left of the wreckage path in the next 50 feet was an area of widely scattered pieces from the right-hand main landing gear wheel fairing. Approximately 90 feet past the first power pole, the outboard section of the right wing hung suspended from the one remaining power transmission line, approximately 15 above the ground. The aileron was suspended from the power line by an aileron cable. In the upper skin of the wing was a spanwise tear in the skin which ran from the root to the area where the aileron cable exited. The white paint of the wing exhibited black sooting. Approximately 30 feet further along the wreckage path was the next power pole in the row which had freshly exposed wood approximately 4 feet above ground level. Beyond (northwest) the second power pole, approximately 15 feet and 10 feet right of the wreckage path centerline, was the fuselage with the empennage tail surfaces and the left wing. The left wing was on the ground oriented with the root end to the northwest and the tip to the southeast. The fuselage was on top of the left wing and was inverted. The fuselage was oriented with the engine and propeller to the northwest and the empennage to the southeast. The cabin section of the fuselage was destroyed by fire, as was a portion of the empennage. The engine, propeller, and nose landing gear were not involved in the fire. The cockpit instruments and switches were destroyed by fire. The engine tachometer and manifold pressure gauges were identified with their respective needles resting against the stops at the low end of their scales. The operating hour recording drums of the tachometer ## Aircraft - Registration: [N8158M](https://openairdocs.org/deregistered/N8158M-1998-07-11), registration cancelled 1998-07-11, S/N 18264550 (OpenAirDocs) - Reported make and model: Cessna 182P - Registry model: [Cessna 182P](https://openairdocs.org/model/cessna-182p) (registry code 2075816) (OpenAirDocs) - Category: Airplane - Serial number: 18264550 - Engines: Continental O-470-S 230 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Richard H. Graff - Airworthiness certificate: Standard, Normal - Departed: SQL, SAN CARLOS, CA - Destination: SOLEDAD, CA - Airport: SNS, Salinas Municipal, runway 31, 4,825 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 4,700 total, 2,700 in this make and model, 4,000 as pilot in command, 60 in the last 90 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 180° at 5 knots - Visibility: 5 statute miles - Lowest ceiling: 2,000 ft overcast - Observed at: SNS, 3 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 19980110000189A](https://openairdocs.org/incident/19980110000189A), Jan 10, 1998: Cessna 182P, Salinas, CA, Destroyed, 1 fatal. Engine power loss struck pole and green house. Inspection revealed hole in crank case number 3 and 4 rods damaged. (.4) during a night-time flight in marginal… 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.