WPR19LA174

NTSB accident investigation · Cessna 182M · Upland, CA · June 15, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
June 15, 2019, 09:43 local (16:43 UTC)
Place
Upland, CA
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N777RKCessna 182M
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Textron Aviation
FAA report
20190615007069A
Case key
99648

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

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Probable cause

The total loss of engine power due to detonation within the No. 2 cylinder as a result of a lean fuel flow setting.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · FailureCessna 182M: 1 caseAll aircraft: 373 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that during takeoff, as the airplane ascended through about 250 ft above ground level, the engine began to sputter, and he initiated a left turn in an attempt to return to the airport. Shortly after, the engine lost all power, and the pilot initiated a forced landing to an open area near the departure runway on airport property. During landing, the airplane bounced, became airborne, and traveled across a road before it landed in a parking lot, impacted trees, and came to rest upright. Examination of the engine revealed that the No. 2 cylinder would not produce compression. Further examination and removal of the cylinder revealed evidence of detonation on the piston and cylinder head. Due to impact damage sustained to the airplane, throttle, mixture, and propeller control travel limits could not be determined. Downloaded data from the engine monitoring unit revealed evidence of a low fuel flow rate for takeoff about, or about 8 to 10 gallons per hour below the calculated takeoff fuel burn rate. Recorded data from the two previous flights before the accident flight indicated that the No. 2 cylinder produced temperatures higher than the manufacturer’s maximum cylinder head temperature limit. Postaccident testing of the carburetor showed that the carburetor fuel flow rate was slightly higher than the specification and would not have contributed to detonation. It’s likely that the detonation occurred as a result of the reduced fuel flow and lean fuel to air mixture, however, the reason for the reduced fuel flow rate could not be determined.

Factual narrative

On June 15, 2019, about 0932 Pacific daylight time, a Cessna 182M airplane, N777RK, was substantially damaged when it was involved in an accident near Cable Airport (CCB), Upland, California. The private pilot and two passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that during takeoff, as the airplane ascended through about 250 ft above ground level, the engine began to “sputter,” and he initiated a left turn to return to the airport. Shortly after, the engine lost all power, and he initiated a forced landing to an open area south of the departure runway on airport property. The pilot stated that he intended to land “hard to break both landing gear legs off so the airplane would slide to a stop;” however, the airplane bounced upon landing, became airborne, and traveled across a road before it landed in a parking lot, impacted trees, and came to rest upright. Examination of the airplane by local law enforcement revealed that the left wing was separated, and the fuselage was structurally damaged. The airplane was recovered to a secure location for further examination. Examination of the Continental Motors O-470-R engine revealed that compression was obtained on all cylinders except for the No. 2 cylinder. The No. 2 cylinder was examined internally using a lighted borescope. The No 2. cylinder was removed. Scuffing was observed throughout the sides of the piston. The airplane was equipped with an engine monitoring unit. Data from the accident flight was downloaded from the unit and had a sample rate of every 6 seconds. The data spanned 1 minute, 42 seconds, from the time takeoff power was applied to the last recorded data plot. When takeoff power was applied at a unit time of 16:21:56, rpm, manifold pressure, and fuel flow increased. Fuel flow reached a maximum flow rate of 14.5 gallons per hour (GPH) at a unit time of 16:23:02, however decreased briefly for 12 seconds before reducing significantly 24 seconds later. Table 1 shows the manifold pressure, RPM, fuel flow, and altitude for the takeoff sequence. Unit Time Manifold Pressure RPM Fuel Flow Altitude 16:21:56 18.5 969 2.1 1438 16:22:02 21 1791 3.2 1436 16:22:08 24.7 2383 6.4 1433 16:22:14 27.1 2613 11.9 1426 16:22:20 27.1 2613 12.7 1422 16:22:26 27.1 2613 12.9 1446 16:22:32 27.1 2603 12.3 1536 16:22:38 27.8 2389 12 1615 16:22:44 27 2486 12.5 1701 16:22:50 27.2 2524 12.2 1750 16:22:56 27.9 2238 12.5 1729 16:23:02 27.1 2571 14.5 1675 16:23:08 27.6 2564 13.9 1664 16:23:14 27.5 2585 13.8 1637 16:23:20 16 1522 9.6 1658 16:23:26 15.4 1314 1.6 1627 16:23:32 15.9 1255 1.4 1533 16:23:38 16.9 1205 2.8 1426 Table 1: Portion of downloaded engine monitoring data for the takeoff sequence. Review of recorded data for the two flights prior to the accident flight, cylinder No. 2’s temperature had exceeded 460° on both flights. According to the Continental owner’s manual for the O-470-R, the max cylinder headtemperature is 460°. Using the engine performance chart for the O-470-R, it was calculated that the fuel flow at a takeoff power setting should be about 22 gallons per hour. The carburetor was examined under the supervision of a Federal Aviation Administration inspector. The inspector reported that due to damage to the throttle shaft, fuel flow measurements at any settings other than full throttle could not be obtained. When the carburetor was tested at full throttle, the carburetor had a flow rate slightly higher than the optimal specification, consistent with a slightly rich condition. The FAA’s Pilot’s Book of Aeronautical Knowledge states in part “An overly lean mixture causes detonation, which may result in rough engine operation, overheating, and/or a loss of power.” “Detonation is an uncontrolled, explosive ignition of the fuel-air mixture within the cylinder’s combustion chamber. It causes excessive temperatures and pressures which, if not corrected, can quickly lead to failure of the piston, cylinder, or valves. In less severe cases, detonation causes engine overheating, roughness, or loss of power. Detonation is characterized by high cylinder head temperatures and is most likely to occur when operating at high power settings. Common operational causes of detonation are: - Use of a lower fuel grade than that specified by the aircraft manufacturer - Operation of the engine with extremely high manifold pressures in conjunction with low rpm - Operation of the engine at high power settings with an excessively lean mixture”

Aircraft

Registration
N777RK
Reported as
Cessna 182M
Category
Airplane
Serial number
18259623
Built
1969
Airframe hours
4,092.7
Engine
Continental O-470-R, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 29, 2019
Departed
CCB · Upland, CA
Destination
MYF · San Diego, CA
Flight plan
IFR
Airport
CCB · Cable, runway 24, 3,863 × 75 ft, asphalt

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
259 total · 24 in this make and model · 173 as pilot in command · 7 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
5 statute miles
Lowest ceiling
1,200 ft overcast
Temperature
63 °F, dew point 57 °F
Altimeter
29.96 inHg
Observed at
KCCB

Docket · 9

The files NTSB released with the investigation on April 26, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.5 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.