# NTSB WPR19LA174: Cessna 182M, N777RK, Upland, CA, June 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: June 15, 2019, 09:43 local (16:43 UTC) - Place: Upland, CA - Coordinates: 34.113334, -117.680557 - Nearby events: https://openairdocs.org/map.md?lat=34.1133&lon=-117.6806&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 3 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Textron Aviation - NTSB case key (mKey): 99648 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA174 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99648/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99648 - Page: https://openairdocs.org/ntsb/WPR19LA174 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 182M, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2072728), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 182M, 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072728), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 182M, 5 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2072728), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 182M, 10 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072728), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N777RK-2021-03-06), registration cancelled 2021-03-06, S/N 18259623, built 1969 (OpenAirDocs) - Reported make and model: Cessna 182M - Registry model: [Cessna 182M](https://openairdocs.org/model/cessna-182m) (registry code 2072728) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18259623 - Year built: 1969 - Airframe hours: 4092.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: serious; 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 ## 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 20190615007069A](https://openairdocs.org/incident/20190615007069A), Jun 15, 2019: Cessna 182M, Upland, CA, Substantial damage. Aircraft departed the Cable Airport (ccb) in Upland, CA and immediately experienced engine loss of power. Pilot turned to return to the airport and hit hard… ## Docket (9 files) The files NTSB released with the investigation on April 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99648. 5.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12225581&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Record of conversation - pilot (item 2, PDF, 1 page, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12225373&FileExtension=pdf&FileName=Record%20of%20Conversation%20pilot-Rel.pdf - Airframe and engine examination summary (item 3, PDF, 4 pages, 3 photos, 998 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12226000&FileExtension=pdf&FileName=Airframe%20and%20Engine%20Examination-Rel.pdf - Continental motors operators manual fuel flow chart (item 4, PDF, 1 page, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678987&FileExtension=pdf&FileName=operators%20manual%20fuel%20flow%20limits-Rel.pdf - Carburetor examination record of conversation - FAA inspector (item 5, PDF, 1 page, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678481&FileExtension=pdf&FileName=Record%20of%20Conversation%20faa%20inspector-Rel.pdf - Jpi data - accident flight (item 6, CSV, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12230264&FileExtension=csv&FileName=Flt81-Rel.csv - Jpi data file (item 7, JPI, 655 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12226020&FileExtension=JPI&FileName=U190723-Rel.JPI - Statement of party representatives to NTSB investigation - Textron (item 8, PDF, 1 page, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12226093&FileExtension=pdf&FileName=party%20form%20textron_Redacted-Rel.pdf - Photo array (item 9, PDF, 1 page, 1 photo, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12230554&FileExtension=pdf&FileName=photo%20array-Rel.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.