# NTSB WPR16LA094: Cessna 182A, N9909B, Selma, CA, April 19, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: April 18, 2016, 18:05 local (Apr 19, 2016, 01:05 UTC) - Place: Selma, CA - Coordinates: 36.561668, -119.632499 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.5617&lon=-119.6325&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report July 26, 2017 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Cessna Aircraft, Continental Motors Inc. - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 93042 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA094 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93042/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93042 - Page: https://openairdocs.org/ntsb/WPR16LA094 ## Probable cause The total loss of engine power due to carburetor icing, which resulted from the flight instructor's failure to use carburetor heat during the descent. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Cessna 182A, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2072704), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Ice/rain protection system: intake anti-ice, deice](https://openairdocs.org/ntsb-findings/01023020): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Cessna 182A, 3 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md?model=2072704), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/01023020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 182A, 3 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072704), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 182A, 1 case](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=2072704), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 182A, 20 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072704), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Enroute-cruise: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 182A, 15 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072704), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 182A, 15 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072704), [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 182A, 15 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072704), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis Following an uneventful flight, the flight instructor and student pilot began a descent toward an airport where they intended to refuel the airplane. The flight instructor reported that, during the descent, the engine lost power. After notifying air traffic control, they received vectors to the nearest airport. Despite multiple attempts, the flight instructor was unable to restart the engine. He realized that the airplane would not be able to reach the airport, so he initiated a forced landing to an open sand- and dirt-covered field. During the landing roll, the airplane nosed over. The flight instructor reported that he did not use carburetor heat during the descent. During examination of the airplane, the fuel strainer valve was stuck in the open position and the valve and the mixture metering sleeve were contaminated with sandlike debris, which likely entered the system during the accident sequence. The debris was removed. The fuel strainer valve then closed, indicating the impact sequence caused it to open. The carburetor was reassembled and reinstalled on the engine, and the engine started and ran continuously at various power settings until it was shut off using the mixture control. Recovery personnel noted that each wing fuel tank contained less than 2 quarts of fuel; the wings were not breached. Fuel burn calculations revealed that the airplane would have used 43.5 gallons of fuel after the airplane was topped off with fuel about 1 hour before the flight and should have had about 21.5 gallons of fuel remaining (the two tanks had a total capacity of 65 gallons), 18.5 gallons of which would have been usable. It could not be determined why only about 2 quarts of fuel remained in each wing tank. Weather conditions in the area at the time of the accident were conducive to the formation of carburetor icing at glide and cruise power. It is likely that the flight instructor's failure to use carburetor heat during the descent resulted in the accumulation of carburetor icing and subsequent total loss of engine power. ## Factual narrative On April 18, 2016, about 1805 Pacific daylight time, a Cessna 182A, N9909B, was substantially damaged during a forced landing following a loss of engine power near Selma, California. The airplane was registered to HBC Aero LLC, Rancho, Murieta, California, and operated by the student pilot. The student pilot and the Certified Flight Instructor (CFI) sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed for the instructional flight. The cross-country flight originated from Mc Clellan-Palomar Airport, Carlsbad, California, about 1600, with an intended destination of Madera, California.In a written statement to and a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the flight instructor (FI) reported that following an uneventful flight from Rancho Murieta to Hesperia, California, they flew to Apple Valley, California, to refuel. The FI stated that they topped the airplane off with 56.08 gallons of fuel, and flew to Carlsbad, which was about a 1-hour flight, where they dropped two people off prior to departing to return to Rancho Murieta. During the flight, the FI and student pilot decided instead of their original intended fuel stop at Fresno, California, they would refuel in Madera. The FI further stated that during a descent from 6,500 feet to 4,500 feet mean sea level (msl), the engine lost power. The FI and student pilot received vectors from air traffic control to the nearest airport. Despite multiple attempts, the FI was unable to restart the engine, and realized they would not be able to make it to the Selma Airport, Selma, California. Subsequently, the FI initiated a forced landing to an open field, and during the landing roll, the airplane nosed over. The FI reported that during the descent, carburetor heat was not used. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest in a field, which contained a mix of sand and dirt. The right wing and fuselage were structurally damaged. The airplane was recovered to a secure location for further examination. Examination of the recovered airframe and engine was conducted on June 15, 2016, at the facilities of Plain Parts, Pleasant Grove, California, by representatives of Cessna Aircraft and Continental Motors Inc. under the supervision of the NTSB IIC. Both wings and the empennage were separated from the airplane to facilitate recovery of the wreckage. Personnel from the recovery company reported that there was less than 2 quarts of fuel in either fuel tank. Both the left and right fuel caps remained attached and secure. The airframe was intact and undamaged. The nose wheel landing gear was separated. Impact damage to the airframe air filter and air box was observed. When an alternate fuel sources was plumed to the right wing fuel inlet port, fuel was observed leaking out of the airframe fuel strainer. The fuel strainer valve wasfound stuck in the open position along with an abundance of sand like debris. The debris was cleaned away, and the fuel strainer valve closed normally. All accessories remained attached, the ignition harness was intact, and the right side engine mounts were fractured. The left side exhaust was damaged. The crankshaft was rotated by hand, and thumb compression was obtained on all cylinders. In addition, when the crankshaft was rotated, spark was observed on all ignition leads. Due to propeller damage, a test club propeller was installed on the engine in order to facilitate an engine run. An external power supply was connected to the airplane's electrical system, and the engine was started. Initially, the engine ran for about 80 seconds before losing power. Multiple attempts were made to start the engine again, however, the engine would only start when primed, and would not continue running once the initial primer fuel was exhausted. The carburetor was then removed from the engine and disassembled. A small amount of sand like debris was cleared from the Mixture Metering Sleeve using light air pressure. No other anomalies were noted with the carburetor. The carburetor was reassembled and reinstalled on the engine. The engine started, and ran continuously at various power settings until the mixture control was moved to the idle cutoff position. The sources of the debris located within the carburetor mixture metering sleeve was undetermined. Review of the Cessna 182 Pilots Operating Handbook (POH), 182 Cruise and Range Performance Chart, depending on rpm, manifold pressure, and mixture settings, fuel burn rates vary between 9.7 and 14.5 gallons per hour. The airplane was equipped with two wing fuel tanks, which have a capacity of 32.5 gallons of fuel per tank. The POH states that the left and right fuel tank have a usable fuel of 27.5 gallons per tank in all flight conditions along with an additional 3.5 gallons of fuel useable in level flight only. Each fuel tank has an unusable fuel level of 1.5 gallons. The NTSB IIC calculated an estimated fuel burn using a fuel consumption rate of 14.5 gallons per hour, and the result was 3 hours of flight time. It was determined that the flight would have used about 43.5 gallons of fuel since the airplane was topped off with fuel. At 1953, weather conditions recorded at the Fresno-Yosemite International Airport, located about 14 miles north of the accident site, were temperature 81 degrees Fahrenheit, dew point 43 degrees Fahrenheit. According to the Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35, entitled Carburetor Icing Prevention, the temperature and dew point were conducive to the formation of icing at glide or cruise power. ## Aircraft - Registration: [N9909B](https://openairdocs.org/deregistered/N9909B-2018-06-04), registration cancelled 2018-06-04, S/N 34309, built 1957 (OpenAirDocs) - Reported make and model: CESSNA 182A (A) - Registry model: [Cessna 182A](https://openairdocs.org/model/cessna-182a) (registry code 2072704) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34309 - Year built: 1957 - Airframe hours: 3536.2 - Engines: CONT MOTOR O-470 SERIES 230 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 2, 2015, 58 hours before - Departed: Carlsbad, CA - Destination: Madera, CA - Equipment: Stall warning system, Handheld GPS, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 53; injuries: minor; commercial, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: right; restraint: 3-point; flight hours: 3,500 total, 35 in this make and model, 70 in the last 90 days, 25 in the last 30 days, 6 in the last 24 hours - Student pilot; age 39; injuries: minor; student; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 2 total, 2 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 350° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 43 °F - Altimeter: 29.96 inHg - Observed at: KFAT, 14 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 20160418008319A](https://openairdocs.org/incident/20160418008319A), Apr 18, 2016: Cessna 182A, Selma, CA, Substantial damage. On Monday, April 18, 2016,^ Mr. James wirfel^, holder of airline transport pilot and flight instructor certificate number ^2751399^, operated as the pilot in… ## Docket (12 files) The files NTSB released with the investigation on June 7, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93042. 14.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - CFI (item 1, .PDF, 920 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452946&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20CFI-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Student (item 2, .PDF, 6.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452947&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Student-Master.PDF - Record of Conversation - CFI (item 3, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452948&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20CFI-Master.PDF - NTSB Airframe and Engine Examination Summary (item 4, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452949&FileExtension=.PDF&FileName=NTSB%20Airframe%20and%20Engine%20Examination%20Summary-Master.PDF - FAA Special Airworthiness Information Bulletin CE-09-35 - Carburetor Icing Prevention (item 5, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452950&FileExtension=.PDF&FileName=FAA%20Special%20Airworthiness%20Information%20Bulletin%20CE-09-35%20-%20Carburetor%20Icing%20Prevention-Master.PDF - Cessna 182A Pilot Operating Handbook Excerpts (item 6, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452951&FileExtension=.PDF&FileName=Cessna%20182A%20Pilot%20Operating%20Handbook%20Excerpts-Master.PDF - Reports from Parties to the Investigation - Cessna Aircraft (item 7, .PDF, 486 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452952&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Cessna%20Aircraft-Master.PDF - Reports from Parties to the Investigation - Continental Motors Inc. (item 8, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452953&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Continental%20Motors%20Inc.-Master.PDF - Fuel Receipt (item 9, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452954&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Statement of Party Representatives to NTSB Investigation - Continental Motors Inc. (item 10, .PDF, 371 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452955&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Continental%20Motors%20Inc.-Master.PDF - Statement of Party Representatives to NTSB Investigation - Cessna (item 11, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452956&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Cessna-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452957&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.