WPR19LA021

NTSB accident investigation · Cessna 182 · Ontario, CA · November 8, 2018

Accident · No injuriesClass 3 · LimitedFinal report
Date
November 8, 2018, 15:53 local (23:53 UTC)
Place
Ontario, CA
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9914MCessna 182
Defining event
Enroute-descent: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Adminstration FSDO
FAA report
20181108020709A
Case key
98616

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

A partial loss of engine power during descent due to an incorrectly installed carburetor.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The airplane encountered severe turbulence and downdrafts after flying through a mountain pass, and the pilot applied full engine power in an effort to arrest the descent. The engine did not respond, and the pilot performed a forced landing onto a highway. While the pilot attempted to avoid automobiles, the airplane landed hard and sustained substantial damage. Examination revealed that about 20 years and 300 flight hours before the accident, threaded studs had been used to mount the carburetor airbox to the carburetor inlet, rather than the appropriate bolts. The studs had been overdriven and penetrated the carburetor bowl, fracturing the bowl housing. Fragments of the damaged housing lay at the bottom of the bowl until the accident flight, when the turbulence likely caused them to migrate and interfere with either the float or the fuel mixture metering system.

Factual narrative

The factual narrative777 words

On November 8, 2018, at 1553 Pacific standard time, a Cessna 182P, N9914M, was substantially damaged when it was involved in an accident near Upland, California. The airline transport pilot, commercial pilot, and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was flying south through the Cajon Pass, and once clear of the pass at an altitude of 6,500 ft mean sea level (msl) the commercial pilot initiated a turn to the west. The airplane then encountered what the pilot presumed to be leeside turbulence from the mountain range, so she turned the airplane to the south to find smoother air; however, the turbulence became more severe, and the airplane began to rapidly descend. The airline transport pilot attempted to change the radio frequency to the Ontario Airport Control Tower, so he could advise controllers that the flight would need to transition through their airspace in order to escape the downdrafts. He was struggling to switch the radio’s frequency control due to the turbulence, but eventually was able to establish contact. By this time the airplane had descended to 2,000 ft msl (about 500 ft above ground level), and the airline transport pilot requested that the commercial pilot arrest the descent. The commercial pilot applied full engine power, but the engine did not respond. The airline transport pilot then took the flight controls, applied full rich fuel mixture and carburetor heat, and the engine momentarily regained power. Having reached about 2,300 ft msl, the engine again lost power, and the pilot decided to look for an area to land. With limited options, he decided to land on the westbound lanes of a freeway. He maneuvered over a set of trees, and just before touchdown, a vehicle appeared under the right wing. He attempted to avoid a collision, and while doing so, the airplane landed hard. The airplane sustained substantial damage to the forward fuselage. Postaccident examination revealed that both fuel tanks and the gascolator contained fuel; the fuel tank vent was unobstructed, and fuel flowed to the carburetor when the "BOTH" position of the fuel tank valve was selected. The engine mounts were bent, and the engine sustained damage limited to a crack in the inlet "Y" manifold, which appeared to have struck the firewall on impact. All fuel lines along with the throttle, mixture, carburetor heat, and propeller controls were intact. The bottom spark plug electrodes were coated in light grey deposits and exhibited normal wear signatures when compared to the Champion AV-27 Check-A-Plug chart. No anomalies were noted with the engine or airframe that would have precluded normal operation. The engine was removed from the airframe and configured in a test cell with a replacement "Y" manifold. After engine start, the engine reached its operating temperature, but would not accelerate beyond a speed of 1,200 rpm. The carburetor was replaced, and the enginethen operated normally throughout its speed range. The accident carburetor was a Marvel-Schebler model MA-4-5. Maintenance logbooks indicated that it was rebuilt and installed when the engine was last overhauled in September 1998, 288.4 flight hours before the accident. No other maintenance was performed on the carburetor assembly beyond the replacement of the carburetor heat airbox hardware, 27.8 flight hours after the engine overhaul. The carburetor was disassembled and examined. Brass floats had been utilized and bore a date stamp of May 1997. The floats were intact and showed no evidence of leak. Examination revealed that four 1-inch-long studs had been used to mount the airbox assembly to the carburetor bowl, and the forward studs appeared to have penetrated about 1/8 inch into the carburetor bowl. (see Figure 1.) Three fragments of aluminum material ranging in size from 1/8 to 5/8 of an inch were found at the bottom of the bowl. (see Figure 2.) The material had a polished appearance and a shape that matched that of the bowl housing where the studs had broken through. Examination of the Cessna illustrated parts catalog applicable to the accident airplane revealed that the appropriate hardware for mounting the airbox to the carburetor was four MS20074-04-3, 0.4690-inch-long bolts, rather than the 1-inch studs used. (see Figure 3.) The carburetor was sent to the facilities of Marvel-Schebler for further examination under the oversight of an FAA inspector. During the examination, additional metallic particles were found within the fuel mixture metering sleeve, along with scratches and abrasions on the sides of the float. Figure 1 – Yellow Arrows Indicate Forward Studs Penetrating into the Bowl Housing, along with Housing Fragments Figure 2 – Bowl Housing Fragments Figure 3 – Studs in Bowl Housing

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N9914M
Reported as
Cessna 182 (P)
Category
Airplane
Serial number
18264810
Built
1976
Airframe hours
3,230.4
Engine
Continental Motors O-470-S2, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 21, 2018 · 18.2 hours before
Departed
O43 · Yerington, NV
Destination
CCB · Upland, CA
Airport
CCB · Cable
Equipment
Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
52
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane, Helicopter
Medical
Class 1, With waivers/limitations
Last flight review
July 13, 2018
Seat
Right
Restraint
3-point
Flight hours
9,800 total · 75 in this make and model · 7,600 as pilot in command · 62 in the last 90 days · 18 in the last 30 days · 2.7 in the last 24 hours
Role
Pilot
Age
34
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
800 total · 100 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 25 knots, gusting 33
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 10 °F
Altimeter
29.94 inHg
Observed at
KONT, 6 nm away

Docket · 5

The files NTSB released with the investigation on May 11, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.