WPR19LA176

NTSB accident investigation · Cessna 172 · Fullerton, CA · June 21, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 20, 2019, 17:16 local (Jun 21, 2019, 00:16 UTC)
Place
Fullerton, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N64460Cessna 172
Defining event
Takeoff: 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
20190620007599A
Case key
99682

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

Partial loss of engine power during takeoff due to an age-degraded carburetor heat valve seal, which detached and partially blocked the carburetor air inlet. Contributing to the accident was an inadequate maintenance inspection.

Findings · 3

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.

Power plant: air intakeAircraft › Aircraft power plant · Damaged/degradedCessna 172M: 1 caseAll aircraft: 50 casesProbable cause
Power plant: air intakeAircraft › Aircraft power plant · Fatigue/wear/corrosionCessna 172M: 1 caseAll aircraft: 50 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 172M: 3 casesAll aircraft: 320 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

Shortly after takeoff during a practice go-around, the engine lost partial power. With limited time to troubleshoot, the flight instructor maneuvered the airplane for an off-airport landing, and the airplane sustained substantial damage after impacting a street. Postaccident examination revealed that the aft section of the carburetor heat butterfly valve seal had detached and partially blocked the air inlet of the carburetor venturi. The obstruction reduced the amount of air available for combustion, resulting in a rich fuel-to-air mixture, and partial loss of power. The valve seal was composed of a fiber-reinforced rubberized material that degraded and became brittle over the 45-year life of the airplane. The mechanic who performed the last inspection stated that he confirmed the operation and condition of the butterfly valve by observing it through both the airbox assembly forward inlet and the heated air inlet on the rear right side of the unit. He stated that the aft section of the seal is hard to view due to the way it folds behind the butterfly valve and that the only way to clearly see it is through the heated air inlet, which was small.

Factual narrative

On June 20, 2019, at 1716 Pacific daylight time a Cessna 172M, N64460, was substantially damaged when it was involved in an accident near Fullerton Municipal Airport (FUL), Fullerton, California. The flight instructor and pilot receiving instruction were not injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a local instructional flight. The flight instructor reported that he planned to perform a flight review of the pilot receiving instruction and remain within the traffic pattern. He confirmed that both fuel tanks were full prior to departure and that the engine contained over 5 quarts of oil. The preflight checks and the engine runup did not reveal any anomalies. After completing one circuit in the traffic pattern, they performed a practice go-around. During the initial takeoff climb of the maneuver, the engine began to lose partial power. The flight instructor took the airplane's controls and applied carburetor heat. The engine responded for a few seconds, and then power was lost again. With minimal climb performance available, and limited time to perform trouble shooting steps, the instructor decided to land the airplane on a road adjacent to the airport. The airplane sustained damage to the right wing and forward fuselage during the off-airport landing. The airplane was equipped with an airbox assembly mounted to the carburetor venturi inlet on the underside of the engine. Inlet air passed through a filter on the front of the airbox and was directed up into the carburetor venturi by a butterfly valve. The system was designed such that when the pilot pulled the carburetor heat control (ON), the butterfly valve rotated about 90°, and redirected heated air from an exhaust shroud into the carburetor venturi through the back of the airbox. The butterfly valve was composed of two metal plates that sandwiched a flexible fiber-reinforced rubberized seal. Examination of the airbox assembly revealed that the aft section of the carburetor heat butterfly valve seal had broken away from the valve, and partially obstructed the air inlet of the carburetor venturi (See figures 1 and 2). The section was about 4 1/2 inches long and 3/8-inch-wide. It was brittle and exhibited four holes that matched the location of rivets on the lower side of the airbox (See figure 3). Black sooting was also observed on the inner surfaces of the exhaust pipe and the electrodes of all spark plugs (See figure 4). Figure 1 – Carburetor Heat Valve Seal Fragment Obstructing Carburetor Inlet Venturi Figure 2 – Carburetor Heat Valve in the ON Position (Area of Missing Seal Highlighted) Figure 3 – Carburetor Heat Valve Seal Fragment Figure 4 – Top Spark Plugs According to maintenance logbooks, the last inspection was an annual inspection completed 73.5 flight hours before the accident on May 16, 2019, at a total airframe time of 3,052.5 hours. The Cessna 172 service manual recommended that the induction airbox, air valves,doors and controls be inspected at 100-hour intervals. The mechanic who performed the last inspection stated that he confirmed the operation and condition of the butterfly valve by observing it through both the airbox assembly forward inlet and the heated air inlet on the rear right side of the unit. He stated that the aft section of the seal is hard to view due to the way it folds behind the butterfly valve and that the only way to clearly see it is through the heated air inlet, which was small. The only documented maintenance performed on the airbox assembly since the airplane’s manufacture in 1974 was the replacement of the airbox induction filter shroud on June 13, 2017. Review of the Federal Aviation Administration's Service Difficulty Report (SDR) database revealed three similar occurrences involving carburetor-equipped Cessna airplanes. Two occurred in 1977/78 N model 172's and one in a 1974 M model. The total time in service of the affected components was 3,706, 4,925, and 7,993 hours respectively.

Aircraft

Registration
N64460
Reported as
Cessna 172 (M)
Category
Airplane
Serial number
17265247
Built
1974
Airframe hours
2,952.2
Engine
Lycoming O-320 SERIES, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · May 16, 2019 · 74 hours before
Departed
FUL · Fullerton, CA
Destination
FUL · Fullerton, CA
Airport
FUL · Fullerton Muni, runway 24, 3,121 × 75 ft, asphalt
Equipment
Stall warning system, Electronic flight bag or handheld device

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
Flight instructor
Age
35
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2019
Seat
Right
Restraint
3-point
Flight hours
1,408 total · 1,355 in this make and model · 1,350 as pilot in command · 122 in the last 90 days · 44 in the last 30 days
Role
Pilot
Age
33
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
March 6, 2017
Seat
Left
Restraint
3-point
Flight hours
92 total · 89 in this make and model · 47 as pilot in command · 0 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 8 knots
Visibility
10 statute miles
Lowest ceiling
3,000 ft overcast
Temperature
70 °F, dew point 55 °F
Altimeter
29.90 inHg
Observed at
KFUL, 1 nm away

Docket · 7

The files NTSB released with the investigation on May 10, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.8 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.