# NTSB LAX99LA314: Cessna 177A, N39AE, Big Bear City, CA, September 20, 1999 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 20, 1999, 11:39 local (18:39 UTC) - Place: Big Bear City, CA - Coordinates: 34.259365, -116.839073 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2594&lon=-116.8391&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 6, 2001 - Report: Approved by Office Director - NTSB case key (mKey): 47479 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX99LA314 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47479/pdf - Page: https://openairdocs.org/ntsb/LAX99LA314 ## Probable cause A loss of engine power due to fuel system contamination, which resulted from the mechanic's failure to fully inspect and verify the serviceability of the fuel system before returning the aircraft to service for a maintenance ferry flight. The pilot's decision to attempt flight with unresolved discrepancies in the reliability of the engine to produce power was a factor in the accident. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - fuel system - contamination,other than water (cause) - maintenance,inspection - inadequate, other maintenance personnel (cause) - operation with known deficiencies in equipment - attempted, pilot in command (contributing factor) - Forced landing, emergency descent/landing - terrain condition - water - Ditching, emergency landing after takeoff ## Analysis The aircraft was parked outside on the ramp for several months, with the fuel drains removed and the tanks drained. An A&P mechanic replaced the fuel drain in the right tank and added fuel for a maintenance ferry flight. The pilot performed a preflight and before takeoff checks. The engine stalled once during taxi, then began to miss and run roughly after takeoff. After returning, the pilot drained the fuel sumps and found a 'small amount of water' in the gascolator. He then drained an additional gallon of fuel from the tank without finding any additional water or sediment. After takeoff on the second flight, the engine began surging and then quit. When attempts to restart the engine failed, he turned back toward the airport but could not reach the runway and ditched the airplane in the water. The mechanic did not perform or offer to perform any additional troubleshooting procedures between the first and second flight. The inside of the gascolator was coated with an insoluble greenish-brown film. The left wing fuel quantity transmitter was coated with material that was similar in appearance to a non-silicon sealant. The material was decomposing and readily flaked off when touched. About 10cc of liquid was recovered from the fuel reservoir; about half was water, with a heavier sediment that was similar in color and consistency as to the material coating the fuel quantity transmitter. The above noted discrepancies were located in areas that would not be accessible or serviceable by a pilot performing a preflight inspection. ## Factual narrative On September 20, 1999, about 1139 hours Pacific daylight time, a Cessna 177A, N39AE, ditched in Big Bear Lake after losing power near Big Bear City, California. The aircraft sustained substantial damage; however, the certificated airline transport pilot, the sole occupant, was not injured. The aircraft was being operated under the provisions of 14 CFR Part 91 by the pilot as a maintenance test flight when the accident occurred. The flight originated from the Big Bear City Airport about 1130. Visual meteorological conditions prevailed at the time and no flight plan was filed. The pilot reported that the aircraft had been parked outside, on the ramp, for nearly 7 months. The owner had reported that the left main tank had been "seeping." At the time the aircraft was parked, both fuel drains were removed and all fuel was drained from the tanks. At the end of the period of inactivity, an airframe and powerplant mechanic (A&P) replaced the fuel drain in the aircraft's right tank and added fuel to prepare the aircraft for a ferry flight to Corona, California. After sitting for most of a day, no leaks were noted. The mechanic then added enough additional fuel to bring the level up to 20 gallons. The pilot performed a preflight and before takeoff checks; however, the engine stalled once during taxi. On the first flight, the pilot had climbed to 8,000 feet msl when he found that the engine began to miss and run roughly. After returning, the pilot again drained the fuel sumps and obtained a "small amount of water" from the gascolator. He then drained an additional gallon of fuel from the tank, and at that time, did not find any additional water or sediment. The pilot's procedures were observed by the mechanic. Prior to takeoff on the accident flight, the pilot again performed the same preflight and before takeoff checks. This time the checks were performed without incident. The mechanic did not perform or offer to perform any additional troubleshooting procedures between the first and second flight. The pilot reported that he took off with about 18 gallons of fuel in the right main tank. After takeoff, he climbed to 7,500 feet msl heading east of the airport and over the lake. After reaching 7,500 feet, the engine began surging and then quit. He turned on the electric fuel boost pump, pushed the mixture handle into the "full rich" position, and "pumped" the throttle. When his attempts to restart the engine failed, he turned back toward the airport but was unable to reach the runway. He ditched the airplane in about 1.5 feet of water, 50 yards from the south shore of the lake, west of the Stanfield cutoff. After touching down, the aircraft nosed over and came to rest on its back. The pilot turned off the electric fuel pump and master switch, and crawled out of the cockpit and onto the wing. He waited there until rescued by boaters who had witnessed the accident. On November 1, 1999, a Safety Board investigator examined the engine and airframe at Action Towing and Recovery in Fresno, California. A cold compression check of the Nos. 1 through 4 cylinders revealed the following readings: 62, 61, 61, and 63 psi, respectively. All four top spark plugs were removed and examined. The tips of all four plugs were covered with a similar looking brownish substance consistent with the color and texture of rusted metal. The inside of the gascolator was found to be coated with an apparently insoluble greenish-brown film. The left wing fuel quantity transmitter was removed and examined. It was coated with material that was similar in appearance to silicon sealant. The material was decomposing and readily flaked off when touched. The fuel reservoir drain plug was removed and approximately 10cc of liquid was recovered. The liquid precipitated into a lower layer and upper layer in a manner similar to the precipitation that follows the mixture of water and gasoline. The sample also contained some heavier sediment that was similar in color and consistency as to the sealant-like material found on the fuel quantity transmitter. The above noted discrepancies were located in areas that are not accessible or serviceable by a pilot performing a preflight inspection or before takeoff checks. ## Aircraft - Registration: [N39AE](https://openairdocs.org/deregistered/N39AE-2012-09-04), registration cancelled 2012-09-04, S/N 177-01179, built 1968 (OpenAirDocs) - Reported make and model: Cessna 177A - Registry model: [Cessna 177A](https://openairdocs.org/model/cessna-177a) (registry code 2073706) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177-01179 - Airframe hours: 3381 - Engines: Lycoming O-360-A2F 180 horsepower reciprocating - Damage: Substantial damage - Flight: Part 91 - Operator: Michael Smith, doing business as Aero Haven, Inc. - Registered owner: Zavala Baudelio - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 17, 1998, 20 hours before - Departed: L35 - Airport: L35, Big Bear City ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 53; military, commercial, airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 13,099 total, 400 in this make and model, 12,494 as pilot in command, 120 in the last 90 days, 40 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 9 knots, gusting 16 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point -0 °F - Altimeter: 30.00 inHg - Observed at: L35 ## 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 19990920042639A](https://openairdocs.org/incident/19990920042639A), Sep 20, 1999: Cessna 177A, Big Bear, CA, Substantial damage. (.4)The aircraft was parked outside on the ramp for several months, with the fuel drains removed and the tanks drained. An A&P mechanic replaced the fuel drain… 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.