WPR09LA117

NTSB accident investigation · Cessna 152 · Turlock, CA · February 18, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
February 18, 2009, 10:00 local (18:00 UTC)
Place
Turlock, CA
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N48761Cessna 152
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 9, 2009
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20090218001179A
Case key
73365

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 loss of engine power due to carburetor icing resulting from the pilot's failure to apply carburetor heat. Contributing to the accident was the instructor's inadequate supervision of the flight.

Findings · 4

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.

Engine controlsAircraft › Aircraft power plant · Not used/operatedCessna 152: 1 caseAll aircraft: 51 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · PilotCessna 152: 11 casesAll aircraft: 792 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationCessna 152: 7 casesAll aircraft: 435 cases
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotCessna 152: 3 casesAll aircraft: 200 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 flight instructor and student were performing a series of touch-and-go pattern operations. The instructor reported that the engine lost power during the initial climb. He took control of the airplane from the student and verified that the mixture was fully enriched and the fuel shut off valve was in the "on" position. These actions had no effect, so he executed a forced landing in a nearby field. During the landing roll, the nosewheel sunk into the soft ground and the airplane nosed over and came to rest inverted. A postaccident examination of the engine by a licensed airframe and powerplant mechanic revealed that the bottom spark plugs of the number one and four cylinders exhibited evidence of water. Water was observed within the fuel sump; however, no water contamination was found in the fuel drained from the airplane's tanks. The engine was successfully run at various speeds with no anomalies noted. Review of the carburetor ice probability chart revealed that the temperature and dew point near the time of the accident were conducive to serious icing at any power setting. The instructor did not report applying carburetor heat following the engine failure.

Factual narrative

On February 18, 2009, about 1000 Pacific standard time, a Cessna 152, N48761, was substantially damaged during a forced landing shortly after takeoff from the Turlock Municipal Airport, Turlock, California. The flight instructor was not injured, and the student pilot received minor injuries. The airplane was registered to, and operated by, KS Aviation, Inc., Atwater, California. Visual meteorological conditions prevailed for the local instructional flight conducted under Title 14 Code of Federal Regulations Part 91. No flight plan was filed. The flight instructor reported that he and the student pilot were conducting a series of practice touch-and-go landings. During takeoff initial climb following the fourth landing, about 100 feet above ground (agl), the engine lost power. The flight instructor took control of the airplane and verified the mixture was fully enriched and the fuel shut off valve was in the on position. He executed a right turn of about 50 degrees and initiated a forced landing in a rough, soft field. During the landing roll, the nose wheel dug into the soft terrain. Subsequently, the airplane nosed over and came to rest inverted. Examination of the airplane by operator revealed that the vertical stabilizer and rudder were crushed, the firewall was bent, and the propeller was damaged. The airplane was recovered from the accident site to a hangar at the Turlock Airport and examined by an Airframe and Powerplant (A&P) mechanic employed by the operator. The mechanic reported that the wings were removed during recovery, but the fuel lines were capped. The mechanic drained the fuel from the airplane's wing tanks, and found no water. During examination of the engine, he noted that the bottom spark plugs of the number one and four cylinders exhibited "evidence of water." Additionally, the mechanic found water and fuel in the fuel sump, although the water "was not high enough to reach the screen." In order to perform an engine run, the mechanic replaced the damaged propeller and jury-rigged a fuel supply using fuel drained from the airplane. The mechanic stated that the engine was started and run at various speeds with no anomalies noted. The nearest weather reporting station at the Merced Municipal Airport (MCE), located 15 nautical miles southeast of the accident site, reported at 0953, temperature 9 degrees Celsius and dew point 6 degrees Celsius. Plotting these values on a carburetor ice probability chart indicated that the conditions were conducive to serious icing at any power setting. The operator's chief pilot stated that the company believed "the engine stoppage was the result of carb ice." He further stated that their "procedures for operations include the proper application of carb heat," and these procedures would be reviewed with their instructors and students.

Aircraft

Registration
N48761
Reported as
Cessna 152
Category
Airplane
Serial number
15283368
Airframe hours
8,823
Engine
Lycoming O-235-L2C, 110 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
KS Aviation Inc.
Registered owner
KS Aviation Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · February 11, 2009
Departed
O15 · Turlock, CA
Destination
O15 · Turlock, CA
Airport
O15 · Turlock Municipal, runway 30, 2,985 × 50 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
25
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
January 10, 2009
Seat
Right
Flight hours
369 total · 49 in this make and model · 314 as pilot in command · 117 in the last 90 days · 84 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
24
Injuries
Minor
Certificate
Student
Medical
Class 2, Without waivers/limitations
Seat
Left
Flight hours
33 total · 33 in this make and model · 0 as pilot in command · 33 in the last 90 days · 28 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 43 °F
Altimeter
30.29 inHg
Observed at
MCE, 15 nm away

Docket · 4

The files NTSB released with the investigation on June 23, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.0 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.