# NTSB WPR15LA146: Cessna 172M, N12842, Hilo, HI, April 14, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 14, 2015, 13:45 local (23:45 UTC) - Place: Hilo, HI - Coordinates: 19.724721, -155.053329 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=19.7247&lon=-155.0533&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed, report November 28, 2017 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 91027 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA146 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91027/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91027 - Page: https://openairdocs.org/ntsb/WPR15LA146 ## Probable cause Water contamination in the fuel system due to the flight instructor’s and pilot receiving instruction’s failure to drain all the water from the system during the preflight inspection, which resulted in a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Cessna 172M, 12 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072418), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Cessna 172M, 5 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072418), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 172M, 5 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072418), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [Cessna 172M, 2 cases](https://openairdocs.org/ntsb-events/193/sequence.md?model=2072418), [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172M, 28 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072418), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The flight instructor and pilot receiving instruction reported that, during the preflight inspection before the local instructional flight, they drained water from the fuel tanks. After departure, they flew for about 1 hour and then returned to the airport to practice touch-and-go landings. During the approach for landing, the pilot receiving instruction accomplished a no-flap "slip to landing." After touchdown, he applied power for the takeoff, and the airplane then reached between about 75 and 100 ft above ground level, at which point the engine began to run irregularly, and subsequently, it lost power. The flight instructor took control of the airplane and executed a left turn away from buildings located at the end of the runway. Subsequently, the airplane impacted a grassy area northeast of the departure end of the runway. During the postaccident examination of the airplane, water was found in the fuel sump strainer and the carburetor, which likely led to the loss of engine power. It is likely the flight instructor and pilot receiving instruction failed to ensure that all the water was drained from the tank during the preflight inspection. ## Factual narrative On April 14, 2015, about 1345 Hawaiian standard time, a Cessna 172M, N12842, experienced a loss of engine power during initial climb from Hilo International Airport (ITO), Hilo, Hawaii. The certified flight instructor, the student pilot undergoing instruction (PUI), and one passenger sustained serious injuries. The airplane was substantially damaged during the forced landing on the grassy area near the departure end of the runway. Hawaii Flight Academy was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The local instructional flight departed Hilo about 1245. Visual meteorological conditions prevailed, and no flight plan had been filed.The operator reported that the FI was instructing the student pilot in preparation for his private pilot practical examination. The passenger was another student pilot who was observing the training flight. The flight crew reported that they had drained water out of the fuel tanks prior to the flight. The flight departed and flew for about 1 hour before returning to ITO to practice touch-and-go landings. The flight instructor instructed the student to perform a no flap "slip to landing" and go-around. After the aggressive slip and landing, power was applied for the takeoff. The airplane became airborne and when about 75-100 feet above ground, the engine began to run irregular and subsequently lost power. The FI took control of the airplane and executed a left turn away from buildings, which were located at the end of the runway. The airplane impacted onto the grass area northeast of the departure end of runway 03. During an examination of the airplane, about 8 ounces of fluid was drained from the fuel sump strainer, and 5 ounces of the fluid appeared to be water. The carburetor was removed from the engine and an unmeasured amount of fluid was drained from the carburetor; about 90% of it appeared to be water. A water paste test was utilized, and the indication was positive for water. The operator commented that examination of the inside of the fuel tanks revealed that the sump drain valves protruded up about 1/2 inch above the bottom of the tanks. The operator suggested that pilots drain the engine sump completely, rock both wings vigorously during preflight, and drain fuel from the engine and wing sumps again. ## Aircraft - Registration: [N12842](https://openairdocs.org/deregistered/N12842-2018-02-08), registration cancelled 2018-02-08, S/N 17262306, built 1973 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17262306 - Year built: 1973 - Airframe hours: 8251 - Engines: LYCOMING O-320-D2J 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Departed: ITO, Hilo, HI - Destination: ITO, Hilo, HI - Airport: ITO, Hilo Intl, runway 03, 5,600 × 150 ft, asphalt - Equipment: Stall warning system, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 63; injuries: serious; medical: class 2, with waivers/limitations; last flight review February 24, 2015; seat: right - Student pilot; age 21; injuries: serious; student; medical: class 1, without waivers/limitations; seat: left; flight hours: 48 total, 33 in this make and model, 10 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 340° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 2,600 ft broken - Temperature: 77 °F, dew point 68 °F - Altimeter: 30.07 inHg - Observed at: PHTO ## 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 20150414004939A](https://openairdocs.org/incident/20150414004939A), Apr 14, 2015: Cessna 172M, Hilo, HI, Destroyed. 4/14/2015- N12842, a Cessna 172-M, serial number 17262306, was operating as a FAR part 61 instructional flight at the Hilo Airport, Hilo Hawaii. After… ## Docket (4 files) The files NTSB released with the investigation on October 19, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91027. 4.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457161&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457162&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457163&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457164&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.