WPR09LA098

NTSB accident investigation · Cessna 172S · Oceanside, CA · January 24, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
January 24, 2009, 10:42 local (18:42 UTC)
Place
Oceanside, CA
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N562ADCessna 172S
Defining event
Enroute-cruise: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report November 9, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Lycoming Engines, Federal Aviation Administration, Cessna Aircraft Company, California Flight Academy
FAA report
20090124003979A
Case key
73272

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

A defective alternator wire splice that resulted in an intermittent electrical system malfunction and erroneous fuel gauge readings, and, a loss of engine power for an undetermined reason.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Electrical power system: electrical pwr sys wiringAircraft › Aircraft systems · Damaged/degradedCessna 172S: 1 caseAll aircraft: 44 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedCessna 172S: 25 casesAll aircraft: 2,247 casesProbable cause
Fuel system: fuel quantity indicatorAircraft › Aircraft systems · MalfunctionCessna 172S: 1 caseAll aircraft: 35 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was on an instrument clearance in cruise flight at 6,000 feet mean sea level above a cloud layer. He said that while he did not see any fuel leaking, the fuel gauges were moving steadily toward zero at a higher rate than normal. He moved the fuel selector to the right tank position, yet the fuel gauges still kept moving rapidly toward zero. The pilot then attempted to make a radio call to declare an emergency; however, there was a complete electrical failure. He decided to make an emergency landing at a nearby airport, and as he started descending, the engine lost power. The pilot said that since the airplane was above clouds, he could not see the airport until the airplane was directly above it. As he approached runway 24, he realized he was too high and fast, so he overflew the runway and reversed course at the west end of the airport to attempt a landing on runway 06. He was too high and fast to land on runway 06 and did not have enough altitude or airspeed to make another attempt on runway 24. The airplane impacted the ground and obstacles about 0.5 miles east of the airport. During post-accident examination, fuel was found in both wing tanks and in the firewall-mounted fuel strainer. No evidence of significant fuel leakage was noted. No evidence was found of any mechanical malfunctions or failures that would have prevented the engine from producing power. The reason for the reported loss of engine power could not be determined. A defective splice repair to the alternator output electrical wire was observed, and when the wire was removed, the splice came apart and revealed evidence of electrical arcing. The alternator was bench tested and found to be functional. The defective splice likely resulted in the anomalous fuel gauge readings noted by the pilot. The fact that air traffic control reported the airplane’s transponder was broadcasting the codes for radio failure and then for emergency as the airplane descended indicates the airplane had not lost all electrical power. The pilot’s inability to communicate by radio during the descent likely resulted from his improper positioning of avionics bus 1 switch to the OFF position where it was found, which would have cut off power to communications radio 1.

Factual narrative

On January 24, 2009, about 1042 Pacific standard time, a Cessna 172S, N562AD, collided with the ground following a loss of engine power during a go-around at Oceanside Municipal Airport, Oceanside, California. The commercial pilot and the passenger sustained serious injuries. The airplane sustained substantial damage. The airplane was registered to, and operated by, California Flight Academy, El Cajon, California. Visual meteorological conditions prevailed at Oceanside. An instrument flight plan was filed and activated for the 14 Code of Federal Regulations Part 91 personal cross-country flight, which departed El Cajon at 1021, with a destination of Torrance, California. According to information provided by Federal Aviation Administration (FAA) Air Traffic Control (ATC) personnel, the airplane departed from Gillespie Airport, El Cajon, and established contact with approach control. The flight was cleared to climb to 6,000 feet mean sea level (msl). At 1028, the pilot reported that he was climbing through 4,400 feet for 6,000 feet. No further transmissions were received from the airplane. At 1038, the controller called the airplane and received no response. He noticed the airplane was descending and made several more attempts at contact with no response. The airplane squawked the transponder codes for radio failure and then for emergency as it descended towards Oceanside Airport. During an interview conducted by an FAA inspector on February 19, 2009, the pilot reported that the airplane was in cruise flight near Oceanside, when he determined that the airplane was "leaking fuel at a very high rate." He said that he did not see any fuel leaking, but that the fuel gauges were moving steadily toward zero at a higher rate than normal. At this time, the airplane's radios were working, and the pilot does not recall seeing any indication of an alternator malfunction. He moved the fuel selector handle to the right tank position, and the fuel gauges kept moving "steadily toward zero after he did so." The engine then lost power, so the pilot began descending directly toward Oceanside for an emergency landing. He was unable to contact air traffic control during the descent, as the airplane's radios had now failed. As he approached runway 24, he realized he was "too high and fast," so he overflew the runway and reversed course at the west end of the airport to attempt a landing on runway 06. However, he was "still too high and fast" to land on runway 06 and did not have enough altitude or airspeed to make another attempt at landing on runway 24. In a written statement submitted to the NTSB on July 9, 2009, the pilot provided additional information about the sequence of events. He stated that after switching to the right fuel tank, he attempted to make a radio call to declare an emergency; however, as he tried to make the call, there was a "complete electrical failure." He turned towards Oceanside to make an emergency landing, and as he started descending, theengine lost power. The pilot said that since the airplane was above clouds, he could not see the Oceanside Airport until the airplane was directly above it. He “tried to land by circling from midfield but couldn’t touch down at the runway, landed long and crashed.” During an interview conducted by an FAA inspector on January 26, 2009, the passenger, who was a student pilot, reported a similar sequence of the events to that reported by the pilot. The passenger's report differed in that he did not report the loss of engine power following the pilot's movement of the fuel selector valve. The passenger stated that as the airplane neared the end of runway 06, the pilot pulled up to initiate a go-around, and “he did not recall hearing the engine come back to full power as the plane pitched up to a climb attitude.” Additionally, in a written statement submitted to the Safety Board on February 12, 2009, the passenger stated that upon reaching 6,000 feet msl, the pilot engaged the autopilot. When the pilot attempted to disengage the autopilot and descend to Oceanside, it would not disengage, and so he switched the avionics master switch off and back on. The passenger further stated that the pilot then “squawked [a transponder code] and told me to look out for traffic.” According to witness statements obtained by the Oceanside Police Department, the airplane was observed flying eastbound at a low altitude about .5 miles east of the Oceanside airport. One witness reported that the airplane was "bobbling" in the air and that she knew from this unsteady flight pattern that it was going to crash. Another witness reported that the airplane was "very quiet and he was unsure if the engine was running." This witness observed the airplane impact the ground, slide forward, collide with and sever a sewer valve. The airplane then struck a wood pole and came to a stop. The right wing and the engine separated from the fuselage during the impact sequence. During recovery of the airplane by salvage personnel, about 10 gallons of fuel were drained from the right tank and 15 gallons from the left tank. When the airplane was examined at the salvage yard under the supervision of an FAA inspector by representatives from Cessna Aircraft Company, Lycoming Engines, and California Flight Academy, the firewall-mounted fuel strainer contained blue colored fuel that tested negative for water contamination. The right fuel tank cap was loose when installed, and there were fuel stains noted on the upper wing surface in the immediate area of the cap. There were no fuel stain streaks leading aft from the cap towards the wing trailing edge. The left fuel tank cap was tight when installed. The fuel selector handle was in the right tank position and the fuel shutoff valve handle was in the open (forward) position. The fuel selector valve was removed and examined. It was determined to be near, but not in, the right tank detent. If the fuel valve had been in this position in flight, fuel flowto the engine would have been partially restricted. However, impact damage to the fuel valve, including the input shaft being bent, precluded determination of the exact in-flight position of the fuel selector valve. The propeller remained attached at the crankshaft flange. One propeller blade was undamaged, and the other blade displayed leading edge gouging, torsional twisting, and chordwise scratches. Examination of the Lycoming IO-360-L2A engine revealed no evidence of any pre-impact mechanical malfunctions. A splice repair to the alternator output electrical wire was observed, and when the wire was removed, the splice came apart and revealed evidence of electrical arcing. Evidence of electrical arcing was also observed on the engine baffling and cowling in the area of the wire splice. The alternator was retained for testing. The airplane’s avionics switch is a two-pole rocker-type switch that controls electrical power to avionics bus 1 and bus 2. Placing either side of the rocker switch in the ON position supplies power to the corresponding avionics bus. During examination of the airplane, the avionics bus 1 switch was found in the OFF position and the bus 2 switch was found in the ON position. Power is supplied to communications radio 1 by avionics bus 1 and to the transponder by avionics bus 2. On April 3, 2009, under the supervision of an FAA inspector, the alternator was bench tested and found to be functional. It produced 40 amps at 4,000 rpm with no abnormal indications. The pilot held a commercial pilot certificate with ratings for airplane multi-engine land and instrument airplane. He also held a private pilot certificate with a rating for airplane single-engine land. According to the pilot, he received all of his flight training from California Flight Academy under their Part 141 program. Examination of the pilot’s flight logbook indicated that he satisfactorily completed the practical test for his commercial certificate in a multi-engine land airplane on April 20, 2008. After this date, there were no further entries in the logbook until December 18, 2008. From December 18 to December 21, 2008, the pilot logged 11 flights with 3.0 hours flown in a multi-engine airplane and 13.0 hours flown in the accident airplane. There were no further logbook entries. The logbook indicated the pilot had accumulated a total flight time of 298.6 hours, of which 154.8 hours were in the accident make and model airplane.

Aircraft

Registration
N562AD
Reported as
Cessna 172S
Category
Airplane
Serial number
172S9549
Airframe hours
4,760
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
California Flight Academy
Registered owner
Fly Cfa LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 23, 2009 · 2 hours before
Departed
SEE · El Cajon, CA
Destination
OKB · Oceanside, CA
Flight plan
IFR
Airport
OKB · Oceanside Municipal Airport, runway 06, 2,712 × 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
24
Injuries
Serious
Certificates
Commercial, Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 20, 2008
Seat
Left
Flight hours
299 total · 155 in this make and model · 16 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 5 knots
Visibility
10 statute miles
Lowest ceiling
1,800 ft broken
Temperature
63 °F, dew point 54 °F
Altimeter
30.20 inHg
Observed at
OKB, 1 nm away

Docket · 9

The files NTSB released with the investigation on August 31, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 MB in all.

FAA reports on this event · 1

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