WPR21FA048

NTSB accident investigation · Cessna 182 · Los Angeles, CA · November 12, 2020

Accident · FatalClass 3 · FieldFinal report
Date
November 12, 2020, 11:43 local (19:43 UTC)
Place
Los Angeles, CA
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N939CPCessna 182
Defining event
Approach: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Civil Air Patrol, Lycoming Engines, FAA, Textron Aviation
Case key
102277

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

Maintenance personnel’s failure to properly secure the throttle control hardware during recent maintenance, which resulted in its disconnection and a subsequent loss of engine power on approach for landing.

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.

Engine controls: power leverAircraft › Aircraft power plant · FailureTextron 182T: 1 caseAll aircraft: 95 casesProbable cause
Object/animal/substance: wireEnvironmental issues › Physical environment · Effect on equipmentTextron 182T: 1 caseAll aircraft: 588 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelTextron 182T: 1 caseAll aircraft: 167 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

While on final approach to the runway, the pilot reported to the tower controller a loss of engine power, and that he was attempting to make the runway. Shortly thereafter, the airplane collided with power lines in a residential area about 175 ft short of the runway threshold. A postaccident fire consumed the wreckage. Postaccident examination of the wreckage revealed that the engine’s throttle control rod was separated from the throttle body control arm. None of the attachment hardware, which comprised of a bolt, washer, castellated nut, and cotter pin, was found. Additionally, no evidence of impact damage was noted in the throttle lever linkage control rod end or the control arm where it attached. The airplane’s most recent annual inspection was 78 flight hours and about 2 months before the accident. During the inspection, a new engine was installed. Based on the available information, it is likely that the throttle control connecting hardware was improperly installed or secured during the most recent maintenance, which resulted in its disconnection and a loss of engine power and throttle control while on final approach.

Factual narrative

FAA Advisory Circular No. 20-143, Installation, Inspection, and Maintenance of Controls, for General Aviation Reciprocating Aircraft Engines, states that, “In the absence of specific inspection intervals, repetitive inspection of the engine controls in the nacelle and cockpit should be conducted as part of the annual and 100-hour inspection described in Part 43, Appendix D. It further states, “inspect all engine control cables for proper tension, routing, security, and signs of damage caused by chafing and heat distress.” Title 14 CFR Part 43 Appendix D, states that the following should be included in annual and 100-hour inspections: “Flight and engine controls – for improper installation and improper operation.” Additionally, “each person performing an annual or 100- inspection shall inspect … as follows: engine controls – for defects, improper travel, and improper safetying.” The airplane’s most recent annual inspection was completed on September 14, 2020, at which time a Lycoming IO-540-AB1A5 engine was installed. The airplane total time was 1,262.2 hours, and the engine total time was 2046.1 hours. The engine had accrued about 78 hours of flight time since installation. The airplane’s forced landing checklist for emergency landing without engine power called for an airspeed of 75 knots indicated airspeed (KIAS) with flaps retracted and 70 KIAS with flaps 10° to full. Further it called for the Mixture control to IDLE CUTOFF, and the fuel selector and magneto switches OFF. Wing flaps were AS REQUIRED (full recommended). The airplane’s power-off stall speed with flaps retracted was 54 knots calibrated airspeed (KCAS) and 49 KCAS with flaps fully extended. The airport was located in a densely populated area. There were several obstructions noted at the end of runway 12, including a 6-ft fence 60 ft from the end of the runway, a road 70 ft from the end of the runway, and a 12-ft-tall building 135-200 ft from the end of the runway. On November 12, 2020, about 1143 Pacific standard time, a Cessna 182T airplane, N939CP, was destroyed when it was involved in an accident near Los Angeles, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. A review of Automatic Dependent Surveillance – Broadcast (ADS-B) data revealed that the airplane departed Meadows Field Airport, (BFL), Bakersfield, California, about 1102 with a destination of Whiteman Airport (WHP), Los Angeles, California. The pilot contacted the WHP tower controller about six miles from the runway and was subsequently cleared to land. About three minutes later, the pilot reported engine trouble. The pilot was again cleared to land and further reported that he lost the engine and would try to stretch it to the runway. About 20 seconds later, the pilot reported that he was not going to make the runway. Shortly thereafter, the airplane impacted power lines and several vehicles before it impacted the ground. Thelast two data points indicated a descent rate of about 500 ft per minute, and the last data point indicated a speed of 51 knots. The County of Los Angeles, Department of Medical Examiner-Coroner, Los Angeles, California, conducted an autopsy on the pilot. The medical examiner determined that the cause of death was “smoke inhalation and thermal injuries.” The FAA's Forensic Sciences Research Laboratory performed toxicological testing on the pilot. The pilot’s results for the testing were negative except for positive results for glucose, carboxyhemoglobin, chlorpheniramine, and oxymetazoline. The pilot had glucose in the vitreous and urine, but the amounts detected were not significant. Carboxyhemoglobin was within the range seen in a smoker was well as in smoke inhalation. The autopsy revealed soot in the airways, which was consistent with smoke inhalation at the time of the accident. Chlorpheniramine is an antihistamine used to treat allergies and can cause drowsiness. Chlorpheniramine is acceptable for flying if it is used no more than 1-2 times per week and 5 days have elapsed before flying. Oxymetazoline is a topical nasal decongestant that is acceptable for pilots. The airplane was part of the Civil Air Patrol (CAP), Los Angeles Group 1. The pilot had completed CAP flight training and was checked out as an Orientation Pilot. CAP flight training evaluations showed excellent comments about the pilot’s flying ability. CAP contracts with aircraft repair facilities for maintenance of its aircraft. Additionally, the wing’s aircraft maintenance officer coordinates aircraft maintenance, inspections, and repairs. The pilot held a private pilot certificate with ratings for airplane single-engine land and sea. The pilot was issued a Federal Aviation Administration (FAA) third-class airman medical certificate on October 23, 2020, without limitations. At the time of the medical examination, the pilot reported about 460 total hours of flight experience. The accident site was located on a road in a residential area about 175 ft from the runway 12 threshold. The west side of the street was lined with a series of 40 ft-tall-power transmission poles, spaced about 150 ft apart. The first identified point of impact was to a top power line bridging these poles, which had been severed midspan about 250 ft northwest of the main wreckage. All major components of the airplane were located at the site and there was evidence of a postimpact fire. Examination of the airplane’s engine revealed that it sustained impact and thermal damage but there was no evidence of internal catastrophic engine damage. Rotational continuity was established through hand rotation of the propeller, and appropriate valve train and compression were noted. The throttle lever linkage control rod end was found separated from the fuel metering section, which was contained within the throttle body assembly, where it attached to the throttle control arm. None of the attachment hardware, whichcomprised a bolt, washer, castellated nut, and cotter pin, was found. Additionally, no evidence of impact damage was noted in the throttle lever linkage control rod end or the control arm where it attached. Soot was present on the entire assembly (including the opening where the bolt would attach), consistent with the connecting hardware not being present at the time of impact and the ensuing fire. Examination of the flap actuator revealed that the airplane’s wing flaps were extended to 30°.

Aircraft

Registration
N939CP
Reported as
Cessna 182 (T)
Category
Airplane
Serial number
18282404
Built
2015
Airframe hours
1,262.2
Engine
Lycoming IO-540-AB1A5, 230 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Positioning · Part 91
Operator
Civil Air Patrol
Registered owner
Civil Air Patrol
Airworthiness certificate
Standard, Other
Last inspection
100 hour · September 14, 2020
Departed
BFL · Bakersfield, CA
Destination
Same as departure
Airport
WHP · Whiteman, runway 12, 4,120 × 75 ft, asphalt
Equipment
Auto-pilot, ADS-B, Electronic primary flight display, Stall warning system, Onboard weather

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
59
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine sea, Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
November 15, 2019
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
460 as pilot in command · 7 in the last 90 days · 5 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 32 °F
Altimeter
30.08 inHg
Observed at
KWHP, 0.5 nm away

Docket · 14

The files NTSB released with the investigation on December 15, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.3 MB in all.