# NTSB WPR14CA197: Cessna 140, N2256N, Vacaville, CA, May 21, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: May 21, 2014, 09:14 local (16:14 UTC) - Place: Vacaville, CA - Coordinates: 38.373332, -121.956947 - Nearby events: https://openairdocs.org/map.md?lat=38.3733&lon=-121.9569&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report July 30, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 89244 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR14CA197 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89244/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89244 - Page: https://openairdocs.org/ntsb/WPR14CA197 ## Probable cause The pilot's use of excessive brakes during landing, which resulted in a nose over. Contributing to the accident was a partial loss of engine power during takeoff initial climb, likely due to carburetor ice. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 140, 56 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2071602), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 140, 8 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=2071602), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Cessna 140, 2 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=2071602), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/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 140, 4 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2071602), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/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 (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 140, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2071602), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 140, 49 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071602), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot was taking off for a personal local flight and about 150 feet in the air, the engine lost partial power. The pilot decided to land the airplane on the remaining runway. As the airplane approached the end of the runway, the pilot said he applied the brakes too hard, and the airplane nosed over. The airplane sustained substantial damage to the wings, fuselage, vertical stabilizer, and rudder. The pilot said he had replaced two engine cylinders, and during the previous days he had run the engine on the ground in accordance with the cylinder break-in procedure. The accident flight was the first flight after the engine repair. Prior to the flight, he had done an extended ground run without the use of carburetor heat. He said during the initial climb the engine lost power, acting like it might have had water in the fuel, but during the preflight inspection, he had sumped the tanks, and found no water. According to a carburetor icing chart, the weather conditions at the time of the accident bordered between serious icing at glide power and serious icing at cruise power. ## Factual narrative The pilot was taking off for a personal local flight and about 150 feet in the air, the engine lost partial power. The pilot decided to land the airplane on the remaining runway. As the airplane approached the end of the runway, the pilot said he applied the brakes too hard, and the airplane nosed over. The airplane sustained substantial damage to the wings, fuselage, vertical stabilizer, and rudder. The pilot said he had replaced two engine cylinders, and during the previous days he had run the engine on the ground in accordance with the cylinder break-in procedure. The accident flight was the first flight after the engine repair. Prior to the flight, he had done an extended ground run without the use of carburetor heat. He said during the initial climb the engine lost power, acting like it might have had water in the fuel, but during the preflight inspection, he had sumped the tanks, and found no water. According to a carburetor icing chart, the weather conditions at the time of the accident bordered between serious icing at glide power and serious icing at cruise power. ## Aircraft - Registration: [N2256N](https://openairdocs.org/deregistered/N2256N-2018-03-01), registration cancelled 2018-03-01, S/N 12492, built 1947 (OpenAirDocs) - Reported make and model: CESSNA 140 (G) - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 12492 - Year built: 1947 - Airframe hours: 3349 - Engines: CONT MOTOR C85 SERIES 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Mcdonald Kevin - Registered owner: Mcdonald Kevin - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 9, 2014 - Departed: KVCB, Vacaville, CA - Destination: KVCB, Vacaville, CA - Airport: KVCB, Nut Tree Airport, runway 2, 4,700 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; flight engineer, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review September 30, 2013; seat: left; restraint: 3-point; flight hours: 460 total, 56 in this make and model, 351 as pilot in command, 4 in the last 90 days, 1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 52 °F - Altimeter: 29.95 inHg - Observed at: KVCB ## 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 20140521007249A](https://openairdocs.org/incident/20140521007249A), May 21, 2014: Cessna 140, Vacaville, CA, Substantial damage. On may 21, 2014, at about 0930 pacific daylight time (PDT), a single-engine Cessna 140 airplane, N2256N, experienced a partial loss of engine power during… ## Other investigations on N2256N (2) 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. - [NTSB LAX82DA205](https://openairdocs.org/ntsb/LAX82DA205), May 29, 1982: Cessna 140 (N2256N), Phoenix, AZ, substantial damage - [NTSB LAX74DUJ29](https://openairdocs.org/ntsb/LAX74DUJ29), Nov 3, 1973: Cessna 140 (N2256N), Willcox, AZ, substantial damage ## Docket (2 files) The files NTSB released with the investigation on June 19, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89244. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413464&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Carburetor Icing Probability Chart (item 2, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413465&FileExtension=.PDF&FileName=Carburetor%20Icing%20Probability%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.