# NTSB SEA04FA003: Cessna 177B, N30921, Chinook, MT, October 9, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 9, 2003, 17:20 local (23:20 UTC) - Place: Chinook, MT - Coordinates: 48.510276, -109.274169 - Nearby events: https://openairdocs.org/map.md?lat=48.5103&lon=-109.2742&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed, report September 1, 2004 - Report: Approved by Office Director - Parties: Textron Lycoming, Helena FSDO - NTSB case key (mKey): 58124 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA04FA003 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58124/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=58124 - Page: https://openairdocs.org/ntsb/SEA04FA003 ## Probable cause The total loss of engine power in cruise flight due to the separation of the carburetor from its mounting bolts, and the pilot's failure to adequately compensate for strong crosswinds while attempting the subsequent forced landing. Additional factors include strong crosswinds, a tree immediately adjacent to the gravel road that the pilot chose to land on, and the pilot's impairment due to recent use of Marihuana. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - fuel system,carburetor - separation (cause) - Forced landing, descent - emergency - In flight collision with object, emergency descent/landing - impairment(drugs), pilot in command (contributing factor) - compensation for wind conditions - inadequate, pilot in command (cause) - object - tree(s) (contributing factor) - weather condition - crosswind (contributing factor) ## Analysis While in cruise flight the aircraft suddenly lost all engine power, and after unsuccessfully attempting to get the engine restarted, the pilot attempted a forced landing on a nearby gravel road. During that attempt, the pilot failed to adequately compensate for strong crosswinds, and therefore inadvertently clipped the top of a tree that was located immediately adjacent to the approach end of the section of road he was trying to land upon. A post-accident inspection of the engine determined that the carburetor had separated from the engine in cruise flight, due to the fact that there were no longer any nuts on any of the four carburetor mount retaining lug bolts. The carburetor mounting flange holes all remained intact, and none of the four mounting bolts showed any signs of damaged or distorted threads. Recent use of Marihuana was determined to have impaired the pilot's judgment at the time he was attempting the forced landing. ## Factual narrative HISTORY OF FLIGHT On October 9, 2003, approximately 1720 mountain daylight time, a Cessna 177B, N30921, collided with a tree during an attempted engine-out forced landing about five miles south of Chinook, Montana. The private pilot and one of his passengers received fatal injuries, and a second passenger received serious injuries. The aircraft, which was owned and operated by the pilot, was destroyed by a post-impact fire. The 14 CFR Part 91 personal cross-country flight, which departed Great Falls, Montana, about 50 minutes earlier, was being operated in visual meteorological conditions. No flight plan had been filed. There was no report of an ELT activation, and the ELT itself was destroyed by the fire. According to family members, the pilot and his front seat passenger flew from Poplar, Montana, to Great Falls earlier that morning in order to attend court proceedings that involved a member of their extended family. While in Great Falls, the pilot offered another individual, who had come to Great Falls from Poplar, in order to attend the same event, the opportunity to fly back to Poplar in his aircraft. This person eventually became the back seat passenger. The pilot and his two passengers returned to the Great Falls Airport around 1545, and according to Great Falls Tower personnel, the aircraft took off for Poplar at 1621. Recorded radar data shows that after takeoff, the aircraft made a left downwind departure and headed northeast, paralleling Highway 87. While en route, the pilot climbed to about 6,000 feet, and stayed within a couple hundred feet of that altitude until 1608:42. At that time the aircraft's mode C beacon indicated that it was at 5,800 feet, and located at 48 degrees, 28.07 minutes north, 109 degrees, 22.33 minutes west, and traveling at a ground speed of 132 knots. This was the last recorded radar hit. According to the surviving passenger (rear seat), the aircraft was in cruise flight when the engine suddenly quit without any warning. There were no unusual noises, vibrations, or smells prior to the loss of power. She also said that there had been no smoke, or comment from the pilot, or anything else that would have alerted her to the fact that the engine was about to stop producing power. She further stated that initially the pilot seemed to be very excited or a little panicky, but soon thereafter seemed to become calm, and began trying to restart the engine. Reportedly, the pilot attempted a number of times to get the engine restarted, but was unable to do so. As the aircraft descended, the pilot told the other occupants that he was going to land on a gravel road that he had noticed below. As the aircraft got closer to the ground, the pilot maneuvered toward the north end of a straight stretch of the road he had selected for the emergency landing. He then tried one more time to get the engine restarted, but after being unsuccessful, appeared to turn his attention totally toward landing on the gravel road. He ultimately entered a shallow left turn that brought the aircraft to a position that was essentially a close-in left base for an approximately 1,000 foot long straight stretch of the gravel road he had selected for the forced landing. As the pilot was making the final turn to land in a southerly direction on the road, the aircraft collided with the upper branches of a 40 foot high deciduous tree growing just off the east side of the road. According to the passenger, after hitting the tree the aircraft slowed significantly, spiraled down into the surface of the road, and then slid into an adjacent ditch on the west side of the road. Immediately after the aircraft came to a stop, a small fire started under the instrument panel, in the area near the pilot's feet. At that time, the back seat passenger exited the aircraft and attempted to walk, but quickly found it necessary to crawl because she had broken her back. Soon thereafter, the aircraft was engulfed in flames and was eventually consumed by the fire. METEOROLOGICAL INFORMATION The 1655 aviation surface weather observation (METAR) at Havre, Montana, which is located about 20 miles west of the accident site, reported clear skies, 10 miles visibility, and winds of 260 degrees at 19 knots. A witness to the accident, who was working on a farm about one-half mile north of the accident site, reported that it was clear in the area, and that there were strong gusty winds coming out of the west at what he estimated was about 20 miles per hour. Law enforcement officials reported that when they arrived at the scene about ten minutes after the crash, there were strong winds blowing almost directly across the road from west to east. WRECKAGE AND IMPACT INFORMATION Two main branches on the east side of the initial impact tree had been sheared off approximately 10 feet below the top of the tree. These branches were about four inches in diameter at the point where they had broken off. A number of smaller branches were scattered across the road along the track the aircraft traveled after impacting the tree, with the two largest pieces being found where the aircraft came to rest. Ninety feet past the tree, near the middle of the hard-packed road, on a magnetic heading of 260 degrees from the tree, there was a two inch deep impact crater that measured about one foot across. Scattered around that crater were about a dozen pieces of the aircraft's windshield. The main wreckage came to rest about 110 feet past the tree, just off the west side of the road, at 48 degrees, 30.600 minutes north, 109 degrees, 16.42 minutes west. The engine and fuselage were setting upright in a shallow depression, and pointing almost directly back across the road to the east. The wings, which had ultimately come to rest inverted, were laying almost exactly perpendicular to the fuselage. The aluminum structure around the engine compartment, the inboard half of both wings, and the entire fuselage until just forward of the empennage, was almost entirely destroyed by the intense post-impact fire. The outboard half of the wings and the empennage itself were the only clearly discernable aluminum structure remaining. The empennage, which was partially elevated off the ground by the wires of a barbed-wire fence, showed very little evidence of impact damage, and significant fire damage was limited to the portion of the empennage that was laying on the ground. Both propeller blades were bent aft about 30 degrees, and the outboard one-third of one blade and the most outboard six inches of the other had melted from the intense heat. The nose of the propeller spinner was crushed almost straight back, with no indications of rotational twisting. The engine itself showed no significant evidence of impact damage, but the lower part of the exhaust system, including the muffler, had been pushed almost directly aft about four or five inches. The primary structure of all the engine accessories had melted away, and the carburetor was found laying on the ground directly below the engine. The components of the flight control system had come loose from the rest of the structure as that structure melted away in the fire, but all control cables were traced, and all torque tubes, pulleys, and bell cranks were located and identified, and there was no evidence of any anomaly or lack of continuity in the flight control system. Once the wreckage was moved to an enclosed work space, the engine was subjected to a further teardown inspection. During that inspection the top spark plugs were removed from each cylinder, and they were determined to have normal electrode wear patterns, normal grayish-white coloration, and no evidence of mechanical damage to their electrodes or insulators. Compression was created in each cylinder by placing a thumb over the spark plug hole and rotating the crankshaft. The number two and three cylinders were bore scoped, and there was no evidence of detonation or excessive oil accumul ## Aircraft - Registration: [N30921](https://openairdocs.org/deregistered/N30921-2018-01-17), registration cancelled 2018-01-17, S/N 17701546, built 1970 (OpenAirDocs) - Reported make and model: Cessna 177B - Registry model: [Cessna 177B](https://openairdocs.org/model/cessna-177b) (registry code 2073708) (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: 17701546 - Airframe hours: 3083 - Engines: Lycoming O-360-A1F6 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Michael D. Kirn - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 5, 2003 - Departed: GTF, Great Falls, MT - Destination: 42S, Poplar, MT ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 997 total, 983 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 13 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 64 °F ## 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 20031009024959A](https://openairdocs.org/incident/20031009024959A), Oct 9, 2003: Cessna 177B, Chinook, MT, Destroyed, 2 fatal. (-23) After departing great falls (gtf), Montana, for poplar (42S), Montana, the pilot received a weather briefing from gtf flight service station for light to… ## Docket (19 files) The files NTSB released with the investigation on June 23, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=58124. 4.7 MB in all. - Supplement S (item 1, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214216&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Area Map (item 2, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214217&FileExtension=.PDF&FileName=Area%20Map-Master.PDF - Toxicological Report (item 3, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214218&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Digital Image 1. Looking south along road that pilot tried to land on. Impacted tree on left, and wreckage just off right side of road. (item 4, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214221&FileExtension=.PDF&FileName=Digital%20Image%201.%20%20Looking%20south%20along%20road%20that%20pilot%20tried%20to%20land%20on.%20%20Impacted%20tree%20on%20left,%20and%20wreckage%20just%20off%20right%20side%20of%20road.-Master.PDF - Digital Image 2. Looking north along road toward impacted tree. (item 5, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214223&FileExtension=.PDF&FileName=Digital%20Image%202.%20%20Looking%20north%20along%20road%20toward%20impacted%20tree.-Master.PDF - Digital Image 3. Engine and propeller. (item 6, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214224&FileExtension=.PDF&FileName=Digital%20Image%203.%20%20Engine%20and%20propeller.-Master.PDF - Digital Image 4. Cabin section of fuselage. (item 7, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214225&FileExtension=.PDF&FileName=Digital%20Image%204.%20%20Cabin%20section%20of%20fuselage.-Master.PDF - Digital Image 5. Empennage. (item 8, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214226&FileExtension=.PDF&FileName=Digital%20Image%205.%20%20Empennage.-Master.PDF - Digital Image 6. Carburetor mounting studs protruding from oil sump. (item 9, .PDF, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214228&FileExtension=.PDF&FileName=Digital%20Image%206.%20%20Carburetor%20mounting%20studs%20protruding%20from%20oil%20sump.-Master.PDF - Digital Image 7. Heat damaged carburetor mounting flange. (item 10, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214229&FileExtension=.PDF&FileName=Digital%20Image%207.%20%20Heat%20damaged%20carburetor%20mounting%20flange.-Master.PDF - Digital Image 8. Heat distorted left front carburetor flange mountng hole. (item 11, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214231&FileExtension=.PDF&FileName=Digital%20Image%208.%20%20Heat%20distorted%20left%20front%20carburetor%20flange%20mountng%20hole.-Master.PDF - Digital Image 9. Right front carburetor flange mounting hole. (item 12, .PDF, 274 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214233&FileExtension=.PDF&FileName=Digital%20Image%209.%20%20Right%20front%20carburetor%20flange%20mounting%20hole.-Master.PDF - Digital Image 10. Left rear carburetor flange mounting hole. (item 13, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214234&FileExtension=.PDF&FileName=Digital%20Image%2010.%20%20Left%20rear%20carburetor%20flange%20mounting%20hole.-Master.PDF - Digital Image 11. Right rear carburetor flange mounting hole with lip distortion. (item 14, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214235&FileExtension=.PDF&FileName=Digital%20Image%2011.%20%20Right%20rear%20carburetor%20flange%20mounting%20hole%20with%20lip%20distortion.-Master.PDF - Digital Image 12. Fuel filter cover cap. (item 15, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214236&FileExtension=.PDF&FileName=Digital%20Image%2012.%20%20Fuel%20filter%20cover%20cap.-Master.PDF - Digital Image 13. Carburetor body with heat distored left side. (item 16, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214240&FileExtension=.PDF&FileName=Digital%20Image%2013.%20%20Carburetor%20body%20with%20heat%20distored%20left%20side.-Master.PDF - Digital Image 14. Photo showing muffler displaced aft into area previously occupied by carburetor. (item 17, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214243&FileExtension=.PDF&FileName=Digital%20Image%2014.%20%20Photo%20showing%20muffler%20displaced%20aft%20into%20area%20previously%20occupied%20by%20carburetor.-Master.PDF - Digital Image 15. Indentations in muffler located directly in front of carburetor mounting lug bolts. (item 18, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214244&FileExtension=.PDF&FileName=Digital%20Image%2015.%20%20Indentations%20in%20muffler%20located%20directly%20in%20front%20of%20carburetor%20mounting%20lug%20bolts.-Master.PDF - Digital Image 16. Photo showing positional relationship between aft part of muffler shroud and forward carburetor mounting lug bolts. (item 19, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40214246&FileExtension=.PDF&FileName=Digital%20Image%2016.%20%20Photo%20showing%20positional%20relationship%20between%20aft%20part%20of%20muffler%20shroud%20and%20forward%20carburetor%20mounting%20lug%20bolts.-Master.PDF 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.