NYC95FA027

NTSB accident investigation · Cessna 195A · Broadview Hts, OH · November 17, 1994

Accident · FatalField investigationFinal report
Date
November 17, 1994, 10:20 local (15:20 UTC)
Place
Broadview Hts, OH
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N1527DCessna 195A
Weather
Visual (VMC) · Day
Status
Completed · report October 13, 1995
Report
Approved by Office Director
FAA report
19941117038369A
Case key
38842

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

the improper installation of a cabin heater system, resulting in an in-flight fire and subsequent loss of control and collision with trees.

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.

FireCruise - normal
Cabin heater - fire
Fluid,fuel - leakCause
Air cond/heating/pressurization,safety valve - not installedCause
Maintenance,installation - improperOther maintenance personnelCause
Forced landingDescent - emergency
Loss of control - in flightDescent - emergency
Fuselage,cabin - fire
In flight collision with objectDescent - uncontrolled
Object - tree(s)

Analysis

The pilot was flying his 40-year-OLD airplane to another airport to have routine maintenance performed. About 10 minutes after takeoff, while level at 5,000 feet, the pilot reported a cabin heater fire. Witnesses to the accident, reported the airplane circled low to the ground, as if the pilot was looking for a place to land. After several minutes the airplane was observed to make an abrupt left turn and collide with trees. Examination revealed that a cabin fire centered around the cabin fuel heater (cfh) located below the aft passenger seat. The most severe fire damage appeared to be in the vicinity of the heater fuel control unit that was largely melted away. There was no evidence of a fuel safety valve installed in the supply line to the cfh. The use of vibration loops and flexible lines was also not evident.

Factual narrative

History of flight

On November 17, 1994, at 1020 eastern standard time, a Cessna 195A, N1527D, owned and piloted by Jan Shaffer, was destroyed when it struck trees during a forced landing near Broadview Heights, Ohio. The pilot received fatal injuries. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight operating under 14 CFR 91.

The airplane was based at the Cleveland-Hopkins International Airport (CLE), Cleveland, Ohio. The purpose of the flight was to fly N1527D to the Salem Airpark, Salem, Ohio, for routine maintenance. Mr. Shaffer filed his flight plan with the Cleveland Automated Flight Service Station and received his IFR clearance from CLE clearance delivery.

About 1014, N1527D was cleared for takeoff by the CLE tower. After takeoff, N1527D contacted CLE departure control and was directed to maintain 5,000 feet and proceed direct to the Akron VOR navigational fix. About 1021, N1527D asked the CLE departure controller to confirm that the radar showed the airplane level at 5,000 feet, which the controller verified.

At 1022:59, N1527D reported that he had a problem. After a response from the CLE controller, N1527D replied at 1023:09, "We've got some kind of fire on board...I think it's a heater (thing)..." The Cleveland controller suggested to N1527D that he return to CLE and provided a heading to the airport. There was no response to the transmission, and at 1023:54 the controller stated, "Ah, two seven delta, you're cleared to Cleveland-Hopkins, fly heading, ah if you can three zero zero, and it's ten miles, report the airport in sight."

The pilot of N1527D responded, "Ah, we can't make it." No further transmissions were received.

Several witnesses observed the airplane on fire, flying low to the trees in a southwesterly direction. One witness, a police officer, stated:

"...I observed a small single engine plane coming from the south, banking left then going in a southwesterly direction, losing altitude. Fire was visible on the right side of the aircraft and black smoke was trailing from the tail area..."

Another witness traveling east along a highway stated:

"...My wife and I saw a plane...[with] fire coming from the back half of the plane. The plane was 100 feet in the air directly over Route 82, then all of a sudden it took a direct left into the valley...As soon as it hit the woods, the plane blew up..."

The accident occurred during the hours of daylight about 41 degrees, 19 minutes north latitude, and 81 degrees, 39 minutes west longitude.

Personnel information

The pilot, Mr. Jan Shaffer, held an Air Transport Pilot Certificate, with ratings for airplane single and multiengine land and sea. He held type ratings in several jet aircraft. He also held a Flight Instructor Certificate for airplane single and multiengine land, and instrument airplane.

His most recent Federal Aviation Administration (FAA) First Class Medical Certificate was issued on July 12, 1994.

Mr. Shaffer's current pilot log book was consumed in the airplane post crash fire; however, the most recent available log book from April 1987, indicated that he had accumulated about 23,600 hours of flight experience. On his last FAA medical application he indicated that he had approximately 26,025 hours.

Aircraft information

All of the maintenance records were on board the airplane, and were destroyed during the in-flight, and post crash fires. No annual or maintenance history could be documented.

Wreckage and impact information

The airplane wreckage was examined at the accident site on November 18 and 19, 1994. The examination revealed that all major components of the airplane were accounted for at the scene.

The airplane came to rest on an approximate magnetic bearing of 060 degrees, in a valley about 90 feet below the top of the ridge line.

Initial tree impact scars started at the top of the ridge line, approximately 175 feet from the main fuselage wreckage. Tree impact scars became progressively lower on the trees in the direction of the wreckage. Several trees displayed burned areas near their respective impact scars. The tree scars indicated a general direction of 225 degrees magnetic.

Several components from the airplane were found along the path to the main wreckage. These included the left and right wings, left and right flaps sections, left and right ailerons, control cables, both main landing wheels, the elevator and the tail cone.

A ground impact hole was observed about 150 feet from the initial tree impact scar. The main fuselage rested upright, about 25 feet beyond the impact hole, facing in the opposite direction of the descent path through the trees. Located next to the fuselage was a fire burned tree, about 2 feet in diameter.

The upper 2/3 of the cabin area and ceiling were burned away forward of the tail section. The interior of the cabin was burned down to the floor. The left forward fuselage side and fuel selector area showed minimum signs of fire and smoke damage. The fuel selector was selected to the right wing tank. The right forward area was destroyed by fire; however, the right cabin entrance door was found several feet from the main wreckage intact with only impact and smoke damage. Examination of the cockpit instruments produced no useful information due to impact and fire damage.

The lower fuselage of the cabin area was intact except for an area in the vicinity of the cabin fuel heater (CFH). In this area, the fuselage floor was burned through, and the CFH was resting on the ground.

The 1/8 inch fuel line for the CFH was found attached to the "T" fitting of the left wing 5/8 inch main fuel supply line to the engine. The "B" nut at the opposite end of the line was burned off at the end and unattached. A fuel filter assembly, minus the glass bowl, was located in the fire debris between the pilot's seat and the CFH. The CFH fuel control regulator was partially melted and not attached to any fuel lines or the CFH. The fuel inlet elbow on the CFH assembly was intact without any "B" nut attached. The heat exchanger and the heatercase were fire damaged; however, there was no evidence of cracks, or of a burn through in the case. Components of the CFH fuel delivery system were removed from the wreckage and sent to the NTSB Materials Laboratory in Washington, D.C., for further analysis.

The engine was separated from the fuselage and found 20 feet beyond the main fuselage. The propeller and hub remained attached to the engine. The engine case was intact and not fractured. The propeller hub displayed rotational twisting and scratches. Both propeller blades displayed chord wise twisting. The propeller hub, blades, and engine received similar post accident fire damage.

Medical and pathological information

An autopsy was performed on Mr. Jan Shaffer, on November 18, 1994, by Dr. Elizabeth K. Balraj,M.D., Office of the Coroner, Cuyahoga County, Ohio.

The toxicological testing report, from the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for Mr. Jan Shaffer.

Tests and research

The NTSB Metallurgist's Factual Report was able to confirm the components identification and their respective connection locations. The specific location of the initial source of the fire on the CFH could not be determined.

Additional information

The CFH used in this airplane was the Model 979-B1, manufactured by the South Wind Division of the Stewart-Warner Corporation. According to a receipt supplied by Mr. Shaffer's family, the CFH in N1527D was replaced in February 1992, by Lorain County Aviation Inc., Elyria, Ohio.

The CFH is a 18,000 BTU/hour heater. All flames and products of combustion occur within a sealed,

Aircraft

Registration
N1527D
Reported as
Cessna 195A
Category
Airplane
Serial number
7749
Airframe hours
3,776
Engine
Jacobs R755-S, 245 horsepower, reciprocating
Damage
Destroyed
Fire
In-Flight
Flight
Personal · Part 91
Registered owner
Jan Shaffer
Airworthiness certificate
Standard, Normal
Departed
CLE · Cleveland, OH
Destination
38D · Salem, OH
Flight plan
IFR

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
66
Certificates
Airline transport, Commercial, Flight instructor
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land, Multi-engine sea
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
26,025 total

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 13 knots, gusting 23
Visibility
10 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 39 °F
Altimeter
30.00 inHg
Observed at
CLE, 10 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.

Other investigations on N1527D · 3

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