LAX99LA182

NTSB accident investigation · Cessna T188C · Stovepipe Wells, CA · May 11, 1999

Accident · Serious injuriesLimited investigationFinal report
Date
May 11, 1999, 16:30 local (23:30 UTC)
Place
Stovepipe Wells, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9603JCessna T188C
Weather
Visual (VMC) · Day
Status
Completed · report November 30, 2000
Report
Approved by Office Director
FAA report
19990511040819A
Case key
46322

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

fuel exhaustion resulting from the pilot becoming lost and disoriented on a cross-country flight.

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) - nonmechanicalCruise
Fluid,fuel - exhaustionCause
Became lost/disoriented - inadvertentPilot in commandCause
Forced landingEmergency descent/landing
Nose overLanding - flare/touchdown
Terrain condition - soft

Analysis

The pilot/mechanic who overhauled the accident airplane engine was to remove it from the airplane, located on a highway in a remote desert area, to correct some discrepancies, which had caused the owner's pilot to make a precautionary landing. The mechanic chose to fly the airplane to another state where his shop is located. En route to a fuel source he landed on a road for directions. Subsequently, he arrived at the fuel source and had less than a gallon remaining. His next planned fuel stop was about 75 miles away. In the pilot's written statement he said he remembered noticing the fuel gauges reading low as he was flying low over sand dunes. The engine lost power, he turned on the boost pump, and the engine regained power momentarily. The aircraft then collided with sand dunes in the Death Valley National Park. The pilot reported that there were no mechanical problems with the airplane and he had run it out of fuel. The accident site is about 195 miles from the departure point on a heading about 90 degrees from the pilot's intended course line.

Factual narrative

History of flight

On May 11, 1999, about 1630 hours Pacific daylight time, a Cessna T188C, N9603J, operated by the pilot was substantially damaged during an off-airport landing at Stovepipe Wells, Death Valley National Park, California. The commercial pilot received serious injuries. Visual meteorological conditions prevailed for the personal flight operated under the provisions of 14 CFR Part 91 and no flight plan was filed. The flight originated at Overton, Nevada, about 1430, and was destined for a fuel stop in Jean, Nevada, with an ultimate destination of Corona, California.

An operator in Carson City, Nevada had recently sold the aircraft to an agricultural operator located in Alabama. The buyer sent a ferry pilot to reposition the aircraft to Alabama. The engine had about 2.5 hours since overhaul, which according to the engine logbook, was done February 28, 1996.

About 30 minutes into the flight, the ferry pilot experienced high oil temperature and made a precautionary landing at Yerington, Nevada. The seller was contacted at Carson City and came to Yerington and replaced the Vernitherm oil temperature sensor and checked the oil cooler for restrictions. The ferry pilot performed a satisfactory flight check and departed for Tonopah, Nevada, for a fuel stop.

After departure from Tonopah and en route to the next fuel stop, the ferry pilot experienced a loss of engine oil pressure with an increase in temperature and engine roughness. He landed at Alamo, Nevada. The seller was again contacted for assistance, and replaced the oil pressure bypass valve, changed the oil and filter, and inspected the engine. The ferry pilot departed Alamo southbound following Highway 93 and again experienced a loss of oil pressure. He landed on Highway 93, about 100 miles north of Las Vegas, Nevada.

Again the seller was contacted, and, unable to resolve the oil pressure issue, he suggested contacting the engine shop that overhauled it. The ferry pilot left the aircraft parked on Highway 93 and returned to Alabama. About 2 days later, the engine shop owner (accident pilot) flew the aircraft to Overton for fuel. Prior to reaching Overton, the pilot landed on a road at Moapa for directions. The airplane arrived at Overton about 1026, and was refueled with 53.3 gallons. According to a placard on the instrument panel, the airplane has 52 usable gallons of fuel from the 54-gallon tank system.

The manager of the refueling facility stated that after he fueled the airplane the pilot flew the airplane around the pattern for a test flight. Then with a friend helping, the pilot pulled the engine cowling off and appeared to be working on it. They left the airport for some time in the friend's pickup truck. The airport manager left the airport for some errands and when he returned, about 1500, the plane and pilot were gone.

According to the pilot, his intended destination after departing Overton was Jean. After departing Overton, he stated that he flew the airplane hard in the vicinity of the airport to check temperatures and oil pressure. He then planned a route to Corona with fuel stops as necessary. He had no explanation as to how he arrived at Stovepipe Wells. In his written statement, he said he remembered seeing the fuel gauges reading very low as he was flying low over some sand dunes. He also recalled the engine losing power and his turning on the boost pump, which momentarily restored power. The airplane contacted the sand dunes and nosed over. In his written report, the pilot stated that there were no mechanical problems with the airplane. He stated verbally to the Safety Board that the airplane had run out of fuel.

The straight-line distance from Overton to Jean is about 75 miles, and from Overton to Stovepipe Wells it is about 195 miles on a heading 90 degrees from the course line between Overton and Jean.

Examination of the logbooks and the recording tachometer by the Safety Board revealed 10.9 hours had accrued since the overhaul at the time of the accident. According to the seller, the shop owner was to remove the engine and transport it to Santa Ana, California, for examination and repairs, and the seller was to pick the engine up and reinstall it.

Personnel information

According to the Federal Aviation Administration (FAA) Airman and Medical Records, the pilot held a commercial pilot certificate with ratings for single engine land, multiengine land and instruments. In his written report to the Safety Board, the pilot reported a total flight time of 1,625 hours, with 62 flown in the preceding 90 days. The last FAA medical certificate of record was a second-class issued on June 28, 1995.

Aircraft information

According to aircraft logbook information the last documented annual inspection occurred on December 10, 1998, at 318.3 recording tachometer hours. The inspection documented the replacement of the right wing with a repaired wing.

The engine logbook documented a major overhaul dated February 28, 1996, at 2,260.7 total hours and zero hours since major overhaul. At the December 10, 1998 annual inspection, the total time was 2,261.2 hours and 318.3 tachometer hours. According to the records, the engine had accrued about 10.9 hours since the February 28, 1996 major overhaul.

Tests and research information

The oil pressure, oil temperature, cylinder head temperature, and fuel gauges were removed and taken to an FAA approved repair station for functional testing and examination.

The oil pressure gauge was properly calibrated and range marked.

A marine type water temperature gauge was installed in the instrument panel and marked as oil temperature. The gauge was calibrated in both Fahrenheit and Centigrade. It was not range marked, and on the glass face of the instrument was found the word "OIL" taped over the instrument face marking "water temp." The gauge was wired to a Rochester probe installed in an engine oil galley. Detailed examination of the wire from the gauge to the probe revealed that it was made up of three wires spliced together to form the necessary length; a yellow wire was spliced to a red wire then spliced to a black wire with a wire nut to reach the probe. The black portion of the wire was routed over the No. 5 engine cylinder push tube seal retainer springs. At that point, the wire was found severed and had the appearance of chafing or wearing at the spring area. Testing revealed that grounding of the wire would cause a full high needle deflection and breaking it without grounding would cause a full low needle deflection.

Testing of the gauge and probe combination revealed higher indicated temperatures than actual temperatures. The actual temperature of 160 degrees Fahrenheit indicated 192 degrees Fahrenheit, and 280 degrees Fahrenheit indicated 290.

The cylinder head temperature gauge was in calibration and without range marking. Embossed on the back of the instrument case it states use 2-OHM C.C. leads (copper/constantan). The installation leads used on the aircraft were found to be iron and constantan (I.C.). Functional testing with C.C. leads revealed indicated temperatures 10-degrees low over their entire range of readings. With I.C. leads, 100 degrees Centigrade indicated 120 degrees Centigrade, and 300 degrees Centigrade indicated 350 degrees centigrade.

The fuel quantity transmitters and gauges were removed as pairs and functionally tested. There were no manufacturer recommended test procedures available. The gauges and transmitters were tested using normal shop procedures. Each pair functioned normally.

After a postaccident examination of the engine, it was shipped to Teledyne Continental Motors in Mobile, Alabama. The engine was installed in a test cell and functionally test run in accordance with a normal engine acceptance test run procedure. Running it during the test was necessary to make some operational ad

Aircraft

Registration
N9603J
Reported as
Cessna T188C
Category
Airplane
Serial number
T18803826T
Airframe hours
2,291
Engine
Continental TSIO-520-T, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Richard G. Snover, doing business as One Stop Aviation, Inc.
Registered owner
Chisenhall Ag Service, Inc.
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · December 10, 1998 · 10 hours before
Departed
0L9 · Overton, NV
Destination
0L7 · Jean, NV

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
52
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Expired
Seat
Center
Flight hours
1,625 total · 1,545 as pilot in command · 62 in the last 90 days · 4 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Visibility
20 statute miles
Lowest ceiling
None
Temperature
90 °F

FAA reports on this event · 1

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