MIA04FA128

NTSB accident investigation · Cessna R182 · Milton, FL · September 23, 2004

Accident · FatalField investigationFinal report
Date
September 23, 2004, 10:06 local (15:06 UTC)
Place
Milton, FL
Injuries
4 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N5157TCessna R182
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Teledyne Continental Motors, Inc., FAA Manufacturing Inspection District Office, Precision Airmotive Corporation, Textron Lycoming, FAA Flight Standards District Office, McCauley Propeller Systems
FAA report
20040923023359A
Case key
60221

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

The pilots operation of the airplane with known deficiencies in the equipment based on witness statements describing an excessive rpm drop and rough running engine after starting, during the engine run-up, and after becoming airborne, his failure to abort the takeoff after an excessive takeoff roll, and his failure to maintain airspeed resulting in an inadvertent stall, uncontrolled descent, and in-flight collision with terrain. A factor in the accident was the loss of engine power due to undetermined reasons.

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 powerTakeoff - roll/run
Reason for occurrence undeterminedFactor
Operation with known deficiencies in equipmentPilot in commandCause
Forced landingDescent - emergency
Loss of control - in flightManeuvering - turn to reverse direction
Aborted takeoff - not performedPilot in commandCause
Airspeed(vs) - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

During a checkout flight by a certified flight instructor (CFI) with the operator in the accident airplane the day before, an excessive (200 rpm) decrease was noted when checking the right magneto. Maintenance cleaned the spark plugs, performed an engine run-up, and returned the airplane to service. The pilot passed the check out flight and was provided the airplane. The CFI reportedly advised the pilot that if there was any maintenance problem to have the airplane worked on and the maintenance cost would be deducted. The day before the accident the pilot flew the airplane to Milton, Florida, and landed uneventfully where the airplane remained overnight. No maintenance was performed or requested, and no fuel was purchased. The pilot and three passengers boarded the airplane for a local flight and three witnesses, one of whom is an A & P mechanic, reported hearing the pilot having trouble starting the engine. The engine ran rough after starting, and the airplane was taxied to the approach end of runway 36 where the pilot performed an engine run-up. Several witnesses including the A & P mechanic reported hearing a discrepancy during the magneto check. The pilot was heard increasing the engine rpm while at the engine run-up area. During the takeoff roll one witness reported that the engine was, "making sounds as if it was not developing power." Several witnesses noted the airplane did not become airborne until approximately 3/4 down the 3,700 foot-long runway, or approximately 2,828 feet down the runway. Conservative takeoff distances for ground roll and distance to clear a 50 foot obstacle per the airplane "Information Manual" were 910 and 1,745 feet, respectively. The airplane began climbing to an estimated height of 100 feet, and the landing gear was noted to retract. One witness reported the airplane flew over her position and the engine was heard to be running rough. A pilot who was flying in the area at the time observed the airplane turn onto the downwind leg, stall, then pitch straight down. The airplane crashed in the side yard of a residence located approximately .30 nautical mile and 303 degrees from the departure end of runway 36. Examination of the flight controls and power section of the engine revealed no evidence of preimpact failure or malfunction. The ignition harness was impact damaged which precluded testing. Examination of the heat damaged magneto revealed the left capacitor was shorted to ground consistent with heat damage, while the right capacitor was functional. Heat damaged components were replaced, the magneto was placed on a test bench and operated with no discrepancies noted. Examination of the impact and heat damaged carburetor revealed the accelerator pump piston seal was badly worn exposing most of the sealing spring; the worn seal would reportedly not result in increased fuel flow. The as found setting of the economizer would result in a leaner fuel/air ratio. Rust was noted in the drain cavity below the float bowl, on the inner portion of the carburetor bowl drain plug, and a small amount of debris was noted in the main bowl chamber. Documents provided by the operator indicate a discrepancy related to excessive rpm decrease during a magneto check on August 27, 2004. The spark plugs were removed, cleaned, rotated, and reinstalled.

Factual narrative

History of flight

On September 23, 2004, about 1006 central daylight time, a Cessna R182, N5157T, registered to PropCo, Inc., operated by MC Aviation, Inc., experienced an in-flight loss of control and crashed in a residential area located .30 nautical mile west-northwest from the departure end of runway 36 at Peter Prince Field Airport, Milton, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 local, personal flight from Peter Prince Field Airport. The airplane was destroyed by impact and a postcrash fire and the commercial-rated pilot and three passengers were fatally injured. The flight originated about 5 minutes earlier from Peter Prince Field Airport.

An acquaintance of the pilot reported the purpose of the flight was to survey damage to the church in which he and the passengers were members of, to survey damage to the homes of church members, and to survey the area in general as a result of Hurricane Ivan to see where assistance from the church was needed.

One witness reported seeing four adults board the airplane and three separate witnesses reported hearing the pilot have a difficult time starting the engine, then after it was started, all three reported hearing the engine running "rough." One of the witnesses is a FAA certificated airframe and powerplant (A & P) mechanic. The airplane was observed taxiing to the approach end of runway 36 and one of the three witnesses reported, "During the run up his mag check sounded like it had excessive drop. He increased rpm's and held it there." The witness who is an A & P mechanic reported, "They taxied to the run-up area and in my opinion had an unsatisfactory pre-flight run-up/test. Evidently they chose to take off with the poorly running engine." The third witness reported, "...Got to the runway to do a run up. [Magneto] check sounded rough...."

The airplane was taxied onto the 3,700 foot long runway and began the takeoff roll but one of the witnesses reported the engine was, "making sounds as if it was not developing power." The A & P mechanic and one other witness reported the airplane became airborne when it was approximately 3/4 down the runway. The A & P mechanic stated, "The aircraft used 3/4 of the runway trying to get airborne and never developed full power. I would estimate they achieved 100 feet of altitude...." One witness reported seeing the landing gear retract after the airplane became airborne, while another witness reported hearing a rough running engine when the airplane flew overhead her position.

A pilot-rated witness who was airborne at the time of the accident reported seeing the flight depart from runway 36. The pilot-rated witness further reported that, "after he had turned downwind the airplane appeared to stall, then pitch straight down." He discontinued his approach, circled the crash site, observed fire, and advised FAA air traffic control of the accident.

Personnel information

The pilot was the holder of a commercial pilot certificate with airplane single engine land, airplane multi-engine land, and instrument airplane ratings. His commercial pilot certificate was first issued on January 27, 1999. The certificate issued on that date had airplane single engine land and instrument airplane ratings. He was issued a first class medical certificate on March 23, 2004, with the restriction, "must wear corrective lenses."

A review of copies of his pilot logbooks that contained entries from his first flight on December 14, 1996, to the last entry dated March 7, 2002, revealed no logged flights in the accident make and model airplane. He logged a total time of 2,046.6 hours, 519.1 hours in airplane single engine land airplanes, and 1,482.4 in airplane multi-engine land airplanes. He also logged 647.6 hours as pilot-in-command, and 1,357.8 hours as second-in-command. Further review of his pilot logbook revealed the remarks section of an entry dated January 5, 2001, indicating "Hired at Continental [Express] Part 121." From that date (January 5, 2001), to the last entry in the logbook (March 7, 2002), he logged only 1 flight in a general aviation airplane. That flight occurred on August 3, 2001, the duration was 1.0 hour, and the remarks section for that entry indicates, "Aircraft [check] out PA28-161."

According to FAA records, the right front seat occupant was not a certificated pilot.

Aircraft information

The airplane was manufactured in 1981 by Cessna Aircraft Company as model R182, and was designated serial number R18201826. It was certificated in the normal category and was equipped with a Textron Lycoming O-540-J3C5D engine rated at 235 horsepower when operated at 2,400 rpm. The airplane was also equipped with a McCauley B3D32C407-B constant speed propeller.

Review of the airplane maintenance records revealed the airplane was last inspected in accordance with a 100-Hour inspection on August 16, 2004. At that time the airplane had accumulated 3,150.0 hours total time. The airplane had accumulated 40.3 hours since the inspection at the time of the accident.

Further review of the maintenance records revealed the engine was overhauled by Don George, Inc., in November 1992, and installed in the airplane following overhaul on December 11, 1992. The engine was removed from the airplane due to a propeller strike, disassembled and inspected in October 1993. The engine was reinstalled in the airplane on October 27, 1993, and remained installed until removed postaccident. On August 16, 2004, an entry in the engine logbook indicates in part, "all cylinders were removed and overhauled by John Jewel Aircraft CRS JUJR300L, due to exhaust flange erosion." At the time of the accident the engine had accumulated 920 hours since major overhaul, and approximately 40 hours since the overhauled cylinders were installed.

Meteorological information

A surface observation weather report taken at the Pensacola Regional Airport (KPNS), Pensacola, Florida, on the day of the accident at 0953, or approximately 13 minutes before the accident indicates the wind was from 080 degrees at 9 knots, clear skies existed, the temperature and dew point were 24 and 18 degrees Celsius, respectively, and the altimeter setting was 30.14 inHg. The accident site was located approximately 14 nautical miles and 045 degrees from KPNS.

Airport information

The Peter Prince Airport is equipped with one asphalt runway designated 36/18, which is 3,700 feet in length by 75 feet wide. The airport elevation is 82 feet, and the airport is equipped with a common traffic advisory frequency (CTAF)/UNICOM of 122.975 mHz, that is not recorded.

Wreckage and impact information

The airplane crashed in the sideyard of a house located at 7732 Erudition Avenue, Milton, Florida. The accident site was located at 30 degrees 38.721 minutes North latitude and 086 degrees 59.911 minutes West longitude, or approximately .30 nautical mile and 303 degrees magnetic from the departure end of runway 36. The accident site was located .61 statute mile and 333 degrees from the center of the airport.

Examination of the accident site revealed the wreckage was upright on a magnetic heading of 035 degrees magnetic near a lake. The engine assembly was beneath ground level with only the outer 10 inches of one propeller blade visible. The "backbone" of the engine was at an angle of approximately 40 degrees with respect to the nearly level ground. The smell of 100 low lead fuel was noted in the ground while digging the earth away from the engine. Fire damage to grass was noted surrounding the left wing, fuselage, empennage, aft portion of the right wing, and at the right wingtip resting location.

Examination of the airplane revealed the fuselage was consumed by the postcrash fire from the instrument panel aft to approximately 6 inches forward of the leading edge of the horizontal stabilizer, and fire d

Aircraft

Registration
N5157T
Reported as
Cessna R182
Category
Airplane
Serial number
R18201826
Airframe hours
3,190.3
Engine
Lycoming O-540-J3C5D, 235 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Operator
MC Aviation, Inc
Registered owner
PropCo, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 1, 2004 · 40.3 hours before
Departed
2R4 · Milton, FL
Destination
2R4
Airport
2R4 · Peter Prince Field Airport, runway 36, 3,700 × 75 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
26
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
3,666 total · 2 in this make and model · 649 as pilot in command · 140 in the last 90 days · 48 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
80° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 64 °F
Altimeter
30.13 inHg
Observed at
KPNS, 14 nm away

Docket · 47

The files NTSB released with the investigation on March 16, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 40.4 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 187 KBSupplement SItem 2 · .PDF · 340 KBMaterials Laboratory 15 - Factual Report 05-053 fuel pumpItem 3 · .PDF · 408 KBWitness StatementsItem 4 · .PDF · 255 KBReports from Local Agencies-Santa Rosa County Sheriff's OfficeItem 5 · .PDF · 255 KBReports from Parties to the Investigation-Cessna Aircraft CompanyItem 6 · .PDF · 463 KBReports from Parties to the Investigation-LycomingItem 7 · .PDF · 532 KBReports from Parties to the Investigation-McCauley Propeller SystemsItem 8 · .PDF · 5.9 MBReports from Parties to the Investigation-Precision Airmotive CorporationItem 9 · .PDF · 15 KBReports from Parties to the Investigation-Teledyne Continental Motors, Inc.Item 10 · .PDF · 48 KBFueling InformationItem 11 · .PDF · 372 KBDocuments provided by MC AviationItem 12 · .PDF · 581 KBStatement from Greg NeffItem 13 · .PDF · 100 KBRecord of NTSB ConversationsItem 14 · .PDF · 155 KBPilot Logbook (First)Item 15 · .PDF · 3.2 MBPilot Logbook (Second)Item 16 · .PDF · 12.5 MBE-mail correspondence related to imaging equipment found in the wreckage.Item 17 · .PDF · 56 KBExcerpts from Information ManualItem 18 · .PDF · 2.9 MBCarburetor Illustration and Parts ListItem 19 · .PDF · 135 KBCarburetor recordsItem 20 · .PDF · 138 KBEngine LogbookItem 21 · .PDF · 3.5 MBRecord of Conversation with Jay KingItem 22 · .PDF · 34 KBToxicological ReportsItem 23 · .PDF · 166 KBStatement of Party Representatives to NTSB InvestigationItem 24 · .PDF · 172 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 25 · .PDF · 65 KBPhoto 1: Digital photograph. View of the airplane at the accident site.Item 26 · .PDF · 487 KBPhoto 2: Digital photograph. View of the airplane at the accident site.Item 27 · .PDF · 451 KBPhoto 3: Digital photograph. View of the airplane at the accident site.Item 28 · .PDF · 485 KBPhoto 4: Digital photograph. View of the airplane at the accident site.Item 29 · .PDF · 477 KBPhoto 5: Digital photograph. View showing the tip of one propeller blade.Item 30 · .PDF · 443 KBPhoto 6: Digital photograph. View showing the top of the engine. Note the angle of the engine reference to the nearly level ground.Item 31 · .PDF · 469 KBPhoto 7: Digital photograph. View of the throttle quadrant.Item 32 · .PDF · 402 KBPhoto 8: Digital photograph provided by Cessna Aircraft Company. View of the ignition switch.Item 33 · .PDF · 1.1 MBPhoto 9: Digital photograph. View of the engine and attached propeller.Item 34 · .PDF · 457 KBPhoto 10: Digital photograph. View of the “Aircraft Time Sheet”Item 35 · .PDF · 381 KBPhoto 11: Digital photograph provided by Textron Lycoming. View of the spark plugs.Item 36 · .PDF · 690 KBPhoto 12: Digital photograph provided by Teledyne Continental Motors, Inc. View of the single-drive dual magneto.Item 37 · .PDF · 414 KBPhoto 13: Digital photograph provided by Teledyne Continental Motors, Inc. View showing the operation of the magneto on the test stand.Item 38 · .PDF · 84 KBPhoto 14: Digital photograph provided by Teledyne Continental Motors, Inc. View showing the operation of the magneto on the test stand.Item 39 · .PDF · 414 KBPhoto 15: Digital photograph provided by Precision Airmotive Corporation. View of the carburetor.Item 40 · .PDF · 66 KBPhoto 16: Digital photograph provided by Precision Airmotive Corporation. View showing the split float.Item 41 · .PDF · 62 KBPhoto 17: Digital photograph provided by Precision Airmotive Corporation. View showing the pump plunger assembly.Item 42 · .PDF · 57 KBPhoto 18: Digital photograph provided by Precision Airmotive Corporation. View showing an exemplar pump plunger assembly.Item 43 · .PDF · 735 KBE-mail Correspondence Related to Imaging EquipmentItem 44 · .PDF · 49 KBEvidence Control Form From 2012 For All Original Retained ItemsItem 45 · .PDF · 106 KBReturned Items NTSB Evidence Control FormItem 46 · .PDF · 80 KBUnreturned Items NTSB Evidence Control FormItem 47 · .PDF · 80 KB

FAA reports on this event · 1

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

Other investigations on N5157T · 1

Matched to the same aircraft by N-number and date.