WPR19LA233

NTSB accident investigation · Cessna 120 · Livermore, CA · August 21, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 21, 2019, 11:50 local (18:50 UTC)
Place
Livermore, CA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N4237NCessna 120
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
20190821018039A
Case key
100119

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

A partial loss of engine power due to fouled spark plugs in the No. 4 cylinder. Contributing to the accident was the pilot’s exceedance of the airplane’s critical angle of attack and a subsequent loss of control during the initial climb.

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.

Ignition system: spark plugs/ignitersAircraft › Aircraft power plant · Damaged/degradedCessna 120: 2 casesAll aircraft: 38 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 120: 22 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededCessna 120: 2 casesAll aircraft: 990 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 accident flight was the first flight following the airplane’s annual inspection. The pilot reported that, during the takeoff roll, the airplane took longer than expected to accelerate, and after becoming airborne, did not seem to be producing full power. Witnesses stated that the airplane made a sharp left turn about 100 feet above the ground and the left wing impacted the ground; the airplane cartwheeled before coming to rest, resulting in substantial damage. A postaccident examination revealed that the upper and lower spark plugs from the No. 4 cylinder and the lower spark plug from the No. 3 cylinder exhibited oil and soot bridging the gap between the electrodes. All other spark plugs exhibited black soot build-up on the electrodes and insulators. The reason for the fouled spark plugs was not determined based on the examination. The mechanic who completed the annual inspection reported that he cleaned, gapped, and functionally tested all of the spark plugs. After the inspection, he conducted an engine run-up and found that one of the plugs had become fouled. He cleaned the plugs a second time and reinstalled them using new gaskets. He ran the engine up a second time, and it ran smoothly. Based on the condition of the No. 4 cylinder spark plugs, it is likely that the engine was not producing nominal power and that its takeoff and climb performance was degraded. The witness observations of a steep left turn and descent to impact is consistent with an aerodynamic stall due to the pilot exceeding the airplane’s critical angle of attack during the initial climb.

Factual narrative

On August 21, 2019, about 1150 Pacific daylight time, a Cessna 120 airplane, N4237N, was substantially damaged when it was involved in an accident near Livermore, California. The pilot was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, in 2018, the airplane had an issue with the “fuel leads” to the engine. After repairs, she flew the airplane back to her home airport and parked it in a hangar until its annual inspection the month of the accident. The accident flight was the first flight following the annual inspection. The airplane started normally, the runup revealed no anomalies. During the takeoff roll, the airplane took longer than expected to accelerate. The pilot reported that, after the airplane became airborne and began a shallow climb, the engine seemed like it wasn’t operating at full power despite sounding normal. The airplane stopped climbing and the pilot made a left turn for a forced landing. During the emergency descent, the left wing impacted either brush or the ground before the airplane tumbled and came to rest in an area of brush-covered terrain. A witness reported that the airplane’s engine was not sputtering, but it did not sound like it was producing full power. About 100 feet above the ground, the airplane made a sharp left turn and started to descend. The left wing impacted the ground and the airplane cartwheeled before coming to rest. The mechanic who completed the annual inspection also witnessed the accident. He reported that he saw the airplane low over the runway after takeoff and it did not appear to be climbing. Shortly thereafter, the airplane banked “steeply” to the left and impacted the ground. The mechanic reported that, as part of the annual inspection, he cleaned, gapped, and functionally tested all of the spark plugs. After the inspection, he conducted an engine run and “found a rough-running magneto.” He removed all spark plugs and observed that one had become fouled. He cleaned the plugs a second time and reinstalled them using new gaskets. He ran the engine up a second time, and it ran smoothly. During a postaccident engine examination, the spark plugs were removed from the engine. Both the upper and lower spark plugs from the No. 4 cylinder and the lower spark plug from the No. 3 cylinder exhibited oil and soot bridging the gap between the electrodes. All other spark plugs exhibited black soot build-up on the electrodes and insulator. The ignition harness exhibited damage consistent with impact and could not be functionally tested. The magnetos were removed and disassembled; no anomalies were noted with their internal components. The oil filter was removed and opened; no particulates were noted within the filter element. The propeller assembly and valve covers were removed from the engine. The engine was rotated by hand; thumb compression was established on all cylinders, and the valves moved consistentlythroughout. Borescope examination of the cylinders revealed no anomalies. The pilot did not complete and submit the National Transportation Safety Board form 6120.1, nor did she provide copies of the accident airplane’s most recent maintenance logbook entries.

Aircraft

Registration
N4237N
Reported as
Cessna 120
Category
Airplane
Serial number
13708
Built
1947
Engine
Continental O-200-A, 85 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 19, 2019 · 0 hours before
Departed
LVK · Livermore, CA
Airport
LVK · Livermore Municipal Airport, runway 25L, 2,699 × 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
69
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Flight hours
1 total · 1 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 55 °F
Altimeter
29.94 inHg
Observed at
LVK

Docket · 7

The files NTSB released with the investigation on March 16, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.4 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.