# NTSB WPR09LA117: Cessna 152, N48761, Turlock, CA, February 18, 2009 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: February 18, 2009, 10:00 local (18:00 UTC) - Place: Turlock, CA - Coordinates: 37.489723, -120.702499 - Nearby events: https://openairdocs.org/map.md?lat=37.4897&lon=-120.7025&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 73365 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09LA117 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73365/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73365 - Page: https://openairdocs.org/ntsb/WPR09LA117 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine controls](https://openairdocs.org/ntsb-findings/01057600): Aircraft › Aircraft power plant · Not used/operated (probable cause); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-findings/01057600/cases.md?model=2071835), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/01057600/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 152, 11 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2071835), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna 152, 7 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2071835), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Cessna 152, 3 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=2071835), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 152, 30 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2071835), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 152, 35 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071835), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 152, 37 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071835), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N48761-2015-05-20), registration cancelled 2015-05-20, S/N 15283368, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 152 - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15283368 - Airframe hours: 8823 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 25; injuries: none; 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 - Student pilot; age 24; injuries: minor; 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 ## 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 20090218001179A](https://openairdocs.org/incident/20090218001179A), Feb 18, 2009: Cessna 152, Turlock, CA, Substantial damage. A forced landing following a total loss of engine power occurred while conducting touch-and-go landings for training. On the 3rd takeoff, the engine suddenly… ## Docket (4 files) The files NTSB released with the investigation on June 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73365. 1.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314937&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Mechanic's Statement (item 2, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314938&FileExtension=.PDF&FileName=Mechanic%27s%20Statement-Redacted.PDF - Weather Reports and Records (item 3, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314939&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Carburetor Icing Chart (item 4, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314940&FileExtension=.PDF&FileName=Carburetor%20Icing%20Chart-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.