# NTSB WPR15LA153: Cessna 170B, N1296D, Centralia, WA, April 28, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 28, 2015, 11:45 local (18:45 UTC) - Place: Centralia, WA - Coordinates: 46.761665, -123.015556 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.7617&lon=-123.0156&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report November 29, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Lycoming, Textron Aviation, FAA SEA FSDO - ADs cited in the narratives: [AD 2004-10-14](https://openairdocs.org/ad/2004-10-14) (OpenAirDocs) - NTSB case key (mKey): 91095 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR15LA153 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91095/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91095 - Page: https://openairdocs.org/ntsb/WPR15LA153 ## Probable cause Maintenance personnel’s incorrect installation of the fuel selector valvehandle, which resulted in fuel starvation, a loss of engine power, and a forced hard landing. Contributing to the accident was the pilot's failure to follow the manufacturer's checklist. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system: fuel distribution](https://openairdocs.org/ntsb-findings/01022820): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Cessna 170B, 1 case](https://openairdocs.org/ntsb-findings/01022820/cases.md?model=2072306), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/01022820/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Related maintenance info (probable cause); cases with it: [Cessna 170B, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072306), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 170B, 5 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2072306), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 170B, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072306), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 170B, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2072306), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Cessna 170B, 2 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=2072306), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 170B, 6 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072306), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 170B, 4 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2072306), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) ## Analysis The airline transport pilot reported that he intended to accomplish the engine manufacturer-recommended break-in procedures after repair work was completed while he was en route to another airport to fuel the airplane. The repair work had required that the fuel tanks be drained. Upon completion of the work, the recovered fuel was put in the left fuel tank. The pilot reported that he did not have an exact measurement of fuel but that he estimated that it was about 15 gallons. He also added about 6 1/4 gallons of fuel to the right fuel tank as a backup reserve. The pilot took off with the fuel selector valve (FSV) in the "left" tank position. During the climb to cruise flight, about 2,000 ft above ground level, the airplane experienced a loss of engine power. The pilot's attempts to restart the engine were unsuccessful. During the descent, the pilot switched the fuel selector to the "both" position; however, the engine would not restart. The pilot subsequently conducted a forced landing in a field; he pulled the airplane's nose up to clear some tall trees, which resulted in a stall and a subsequent hard landing in the field. Postaccident examination of the wreckage revealed that the FSV was properly installed but that the selector handle was slightly right of the forward, or the "both," position. Further examination of the FSV handle revealed that it was incorrectly indexed to the drive shaft that coupled the handle to the FSV, which allowed the handle to be installed 180 degrees from its correct position. The observed handle orientation resulted in the FSV being closed (or off) when the FSV handle was in the "both" position, right when in the "left" position, and left when in the "right" position. The FSV was verified to be open when positioned in all three feed positions, and closed when positioned to "off." The FSV handle had a hole drilled in it at manufacture that was angled to prevent incorrect orientation of the handle. Another hole was observed drilled through the operating arm and handle, which allowed for the incorrect installation of the handle. The investigation could not determine when this hole was drilled. The pilot reported that, during takeoff, he believed that the fuel selector was positioned to the fuller left tank; however, due to the incorrect indexing to the drive shaft that coupled the handle to the FSV, the fuel selector was actually positioned and drawing fuel from the reserve right fuel tank, and the fuel in that tank was subsequently exhausted, which resulted in the loss of engine power. When the pilot positioned the fuel selector to the "both" position during the emergency procedures, the fuel selector valve was actually in the "off" position. The Pilot's Operating Handbook specified that the FSV should be in the "both" position during takeoff. ## Factual narrative The pilot stated that he took off with the LEFT tank selected. The Pilot Operating Handbook for this model airplane stated that the FSV should be in the BOTH position for takeoff. The airplane was a Cessna 170B, serial number 25424. Investigators examined the airframe and engine logbooks as well as the certified airplane airworthiness documents on file with the FAA. At the time of the accident, the airframe had accumulated a total time of 3,740.1 hours. The last documented annual inspection was performed on April 25, 2015, at a tachometer time of 371.1. During the wreckage examination, the recording tachometer read 371.5 hours. The engine was a Lycoming O-360-A1A, sn L20323-36A, rated for 180 hp at 2,700 rpm. The engine had been installed on the airplane in accordance with Avcon STC SA806CE Sept 3, 2002, at a recording tachometer time of 148.2. The engine had been field overhauled June 15, 2009, by persons and/or agencies unknown. The recording tachometer was 306.8 with a recorded engine total time (TTE) of 1,551.1 hours. Records indicated that the engine was removed, inspected, and repaired June 17, 2013, after a propeller strike-sudden stoppage IAW AD 04-10-14C1, at a tachometer time of 371.1. The engine had accumulated 64.3 hours since field overhaul. A Major Repair and Alteration Form 337 dated August 19, 2013, was filed with the FAA. It recorded repairs made to the airframe due to a hard landing incident. Numerous structural airframe members were replaced or repaired in the fuselage including the gear box; the form noted that the center console (tunnel) was removed for access, and then reinstalled. A search of the NTSB data base did not reveal an accident related to the hard landing, but did reveal a banner tow accident on July 4, 1998. At the time of the accident, the engine had accumulated 64.7 hours of operation since field overhaul and 0.5 hours since the repair. The propeller had been installed on the airplane in accordance with Hartzell STC SA01111CH April 25, 2015, at a recording tachometer time of 371.1. On April 28, 2015, about 1145 Pacific daylight time, a Cessna 170B, N1296D, made an off airport forced landing following a loss of engine power near Centralia, Washington. The pilot/owner was operating the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The airline transport pilot sustained serious injuries. The airplane sustained substantial damage during the accident sequence. The cross-country personal flight departed Shady Acres Airport, Spanaway, Washington, at an undetermined time with a planned destination of Chehalis, Washington. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot reported that repair work had required that the fuel tanks be drained. Upon completion of the work, the recovered fuel was installed in the left fuel tank. The pilot didn't have an exact measurement, but estimated that it was about 15 gallons. Although the pilot had takenwhat he believed reasonable precautions to insure that the fuel was not contaminated, he added an overfilled 5 gallon (estimated 6 1/4 gallons) can of new fuel to the right fuel tank as a backup reserve. He departed with the fuel selector valve (FSV) in the left tank position. The pilot intended to accomplish the recommended Lycoming break-in procedures for the engine as he flew to Chehalis. The pilot reported a loss of engine power about 2,000 feet agl during the climb to cruise. Attempts to restart the engine were unsuccessful, which lead to a forced landing in a field. In order to clear some tall trees, the pilot pulled the nose of the airplane up, which resulted in a stall, and hard landing in the field. The pilot was airlifted to the hospital with a facial bleeding and back pain. An aviation routine weather report (METAR) for Chehalis-Centralia (KCLS), Washington, elevation 177 feet, 5 nautical miles (nm) southeast of the accident site) was issued at 1156 PDT. It stated: wind from 330 degrees at 8 knots; visibility 10 miles; sky 2,700 feet scattered, 3,600 feet broken; temperature 13/55 degrees C/F; dew point 9/48 degrees C/F; altimeter 30.14 inches of mercury. An examination of the pilot's logbook indicated that as of the last entry dated March 23, 2015, he had a total flight time of 2,688 hours. He logged 10 hours in the previous 90 days, and 0 hours in the previous 30 days. He had an estimated 512 hours in this make and model. He completed a flight review on September 18, 2013. Investigators from the NTSB, FAA, Cessna, and Lycoming examined the wreckage at the owner's hangar on Shady Acres Airport on May 20, 2015. A full report is contained within the public docket for this accident. No evidence of preimpact mechanical malfunction was noted during the examination of the recovered engine. The firewall fuel strainer contained a clear blue fluid; the screen was clean. A water paste test did not indicate any water contamination. The FSV was properly installed. The FSV handle was slightly right of the forward position. According to the airframe manufacturer's investigator, selector handle forward should be the BOTH tanks position, RIGHT position would be right wing, aft would be OFF, and LEFT would be the left wing. The FSV handle was observed to be incorrectly indexed to the drive shaft that coupled the handle to the FSV, allowing the handle to be installed 180 degrees from its correct position. The valve was verified to be open when positioned in all three feed positions, and closed when positioned to off. The handle orientation observed made the valve position closed when the handle was in BOTH, right when in LEFT, left when in RIGHT, and off when in BOTH. The FSV handle had a hole drilled in it at manufacture that was angled to prevent incorrect orientation of the handle. Investigators observed an additional hole drilled through the operating arm and handle that allowed incorrect installation. ## Aircraft - Registration: [N1296D](https://openairdocs.org/deregistered/N1296D-2018-03-09), registration cancelled 2018-03-09, S/N 25424, built 1958 (OpenAirDocs) - Reported make and model: CESSNA 170B - Registry model: [Cessna 170B](https://openairdocs.org/model/cessna-170b) (registry code 2072306) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 25424 - Year built: 1958 - Airframe hours: 3740 - Engines: LYCOMING O-360-A1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 25, 2015 - Departed: 3B8, Spanaway, WA - Destination: CLS, Chehalis, WA - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: serious; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 2,688 total, 512 in this make and model, 10 in the last 90 days, 0 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 8 knots - Visibility: 3 statute miles - Lowest ceiling: 3,500 ft broken - Temperature: 55 °F, dew point 48 °F - Altimeter: 30.13 inHg - Observed at: KCLS, 5 nm away ## Docket (6 files) The files NTSB released with the investigation on August 29, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91095. 4.4 MB in all. - Pilot Statement (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443845&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Record of Conversation - FAA Inspector (item 2, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443846&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - NTSB Airframe & Engine Examination (item 3, .PDF, 15 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443847&FileExtension=.PDF&FileName=NTSB%20Airframe%20%26%20Engine%20Examination-Master.PDF - Maintenance Logbook Excerpts (item 4, .PDF, 545 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443848&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Excerpts-Master.PDF - Pilot Logbook Excerpts (item 5, .PDF, 282 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443849&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Master.PDF - Certification of Party Representatives to NTSB Investigation (item 6, .PDF, 814 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40443850&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF From the NTSB's public API. 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