WPR19LA207

NTSB accident investigation · Stinson 108 · Klamath Falls, OR · July 9, 2019

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 9, 2019, 13:20 local (20:20 UTC)
Place
Klamath Falls, OR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N6642MStinson 108
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 Administration
FAA report
20190709004379A
Case key
99984

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 mechanic’s failure to identify an engine performance issue, which led to a partial loss of engine power. Contributing to the accident was the pilot’s decision to operate the airplane with a known mechanical deficiency.

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.

Action: incorrect action selectionPersonnel issues › Action/decision · PilotStinson 108-3: 1 caseAll aircraft: 397 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · MalfunctionStinson 108-3: 1 caseAll aircraft: 497 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelStinson 108-3: 1 caseAll 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

The pilot had departed on a cross-country flight. About 1,000 ft above ground level, the engine lost partial power. The pilot made a forced landing in an open field, during which the left wing sustained substantial damage as it contacted the ground. The airplane had a recurring engine performance deficiency that the pilot was aware of, and he used a temporary fix to work around the issue. The mechanic who performed maintenance on the engine before the accident thought that the issue involved the carburetor. Postaccident examination of the carburetor revealed no malfunctions that would have precluded normal operation. Postaccident examination of the engine revealed multiple incorrectly set valve clearances and multiple cylinders with lower-than-acceptable compression. Thus, the mechanic who performed maintenance on the engine failed to identify the engine’s out-of-adjustment valves or the low-cylinder compression.

Factual narrative

On July 9, 2019, about 1320 Pacific daylight time, a Stinson 108-3 airplane, N6642M. was substantially damaged when it was involved in an accident near Klamath Falls, Oregon. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he and a passenger were relocating the airplane to Alaska. The airplane departed from Red Bluff Municipal Airport (RBL), Red Bluff, California, and landed at Crater Lake-Klamath Falls Airport (LMT), Klamath Falls, Oregon, for a refueling stop. The accident occurred after the takeoff from LMT. The pilot stated that the takeoff was normal but that the engine lost partial power when the airplane was at an altitude of above 1,000 ft above ground level. The pilot initiated a forced landing to a nearby field, where the left wing contacted the ground. The pilot stated that he had experienced previous problems with the carburetor. He stated that, after the carburetor underwent an overhaul, the engine ran better but that it would occasionally not get up to full engine speed, so the airplane would not have top end power. To work around the issue, the pilot used a procedure of slowly advancing the throttle to the first three-quarters of travel and then applying the remaining throttle rapidly to attain full power. The pilot stated that this issue did not occur during the first leg of the trip. The mechanic who worked on the airplane before the accident flight stated that the owner, who was not the accident pilot, reported the maintenance problem. The mechanic also stated that he checked the timing, valve lash, induction system, and fuel line to the airframe fuel filter and found no problems, so he determined that the carburetor was the issue. The mechanic temporarily replaced the carburetor with another one and detected a noticeable increase in engine power, which confirmed that the maintenance problem was due to the original carburetor. The carburetor was then provided to the facility that had previously performed an overhaul, and repairs were made. Afterward, the carburetor was reinstalled on the airplane. Postaccident examination of the carburetor revealed no malfunctions that would have precluded normal operation. The engine rocker box covers were removed, and valve clearance on the right-side intake and exhaust valves (Nos, 2, 4, and 6) was found to be within acceptable limits. Valve clearance on the left-side cylinders (Nos. 1, 3, and 5) were found to be greater than 0.20 inch. According to the manufacturer’s engine service manual, the valve clearance is 0.04 inch. A compression test was conducted on each cylinder. Each cylinder held 80 pounds per square inch (psi). Cylinder No. 1 held 62 psi and leaked air past the exhaust valve. Cylinder No. 2 held 48 psi and leaked air past the piston rings and from the exhaust valve. Cylinder No. 3 held 73 psi and leaked air past the piston rings. Cylinder No. 4 held 56 psi and leaked airpast the piston rings. Cylinder No. 5 held 58 psi and leaked air out of the intake valve. Cylinder No. 6 held 33 psi and leaked air out of the intake valve and past the piston rings. No other anomalies were noted that would have precluded normal operation.

Aircraft

Registration
N6642M
Reported as
Stinson 108 (3)
Category
Airplane
Serial number
108-4642
Built
1948
Engine
Franklin 6A4165 SERIES, 165 horsepower, reciprocating
Damage
Substantial damage
Fire
Unknown
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
LMT · Klamath Falls, OR
Airport
LMT · Klamath Falls
Equipment
Unknown

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
52
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 3 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
75 °F, dew point 32 °F
Altimeter
30.07 inHg
Observed at
KLMT
METAR
SPECI KLMT 092021Z 11003KT 10SM BKN120 24/05 A3007 RMK AO2 T02390050

Docket · 5

The files NTSB released with the investigation on May 4, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.