# NTSB WPR22LA287: Cessna 177RG, N2591V, Livermore, CA, July 30, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 30, 2022, 08:00 local (15:00 UTC) - Place: Livermore, CA - Coordinates: 37.693789, -121.80988 - Nearby events: https://openairdocs.org/map.md?lat=37.6938&lon=-121.8099&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 105630 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22LA287 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105630/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105630 - Page: https://openairdocs.org/ntsb/WPR22LA287 ## Probable cause The total loss of engine power due to an inadequately maintained fuel injection servo. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Not serviced/maintained (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=2073709), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=2073709), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 177RG, 16 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073709), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 177RG, 22 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073709), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis About 30 minutes after takeoff on a cross-country flight, the pilot noticed an increase in engine exhaust gas temperatures (EGTs) for all cylinders. The engine then briefly “stuttered,” and he decided to divert to an airport en route for a precautionary landing. The EGTs then returned to normal, and he decided to continue to the original destination. However, during the landing approach, the EGTs again began to rise; the engine lost all power; and the airplane landed short of the runway and struck approach lights, which resulted in substantial damage to the left wing and stabilator. Data recorded by the airplane’s engine monitor showed the EGT increases that were reported by the pilot. Disassembly of the fuel injection servo revealed significant internal corrosion and corrosion deposits along with evidence of water ingestion. The corrosion deposits likely resulted in a partial blockage (restriction) of fuel to the cylinders, which manifested itself as a lean fuel mixture. This lean mixture was consistent with the observed increase in EGTs. During the final approach, the blockage likely became severe enough to result in the total loss of power. The fuel injection servo manufacturer recommends by service bulletin that the unit should be overhauled either every 12 years or at the time of engine overhaul. The unit had last been overhauled 23 years before the accident, and it was not overhauled at the last engine overhaul 10 years before the accident. Additionally, the service bulletin stated that the unit should be overhauled in the event of water contamination. The unit had clearly ingested water at some point during its life, although it could not be determined when this occurred. ## Factual narrative On July 30, 2022, about 0800 Pacific daylight time, a Cessna 177RG, N2591V, sustained substantial damage when it was involved in an accident near Livermore, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 flight. The pilot departed Salinas Airport (SNS), Salinas, California, en route to Livermore Municipal Airport (LVK) after an uneventful prefight check and engine runup. About 30 minutes after takeoff, he noticed that the engine monitor was indicating an increase in EGTs for all cylinders. The engine then briefly “stuttered,” and he decided to divert to an airport en route for a precautionary landing. He then adjusted the fuel mixture control, and the temperatures returned to normal, so he decided to continue to the original destination. About 10 minutes later, he initiated the landing descent to LVK by reducing engine power and moving the fuel mixture to full rich. During the landing approach, the EGTs again began to rise, and the engine lost all power. The airplane sustained substantial damage to the left wing and stabilator after landing short of the runway and striking a set of instrument landing system lights. Postaccident examination did not reveal any anomalies with the engine or airframe, and the engine could be operated at varying speeds during a ground run. Review of the data recorded by the airplane’s engine monitor indicated that the EGT rise was about 200° F, and during the periods of EGT rise, there was no discernible change in fuel flow. (The fuel flow transducer was installed at the inlet of the fuel injection servo, rather than the outlet to the flow divider.) The airplane was equipped with a Bendix RSA-5AD1 fuel injection servo. The servo and flow divider were tested and examined at Precision Airmotive’s facility. The testing revealed that both units met the performance specifications required following a field overhaul. However, disassembly of the fuel injection servo revealed significant internal corrosion and corrosion deposits throughout. The diaphragm cavities displayed “water lines” and corrosion on the metered and unmetered fuel sides, consistent with water contamination (figures 1 and 2). Corrosion deposits were present in the servo valve seat cavity and in the mixture control assembly (figures 3 and 4). Figure 1 - Water line and corrosion on metered side Figure 2 - Water line and corrosion on unmetered side Figure 3 - Corrosion deposits on the lower side of the mixture control spring Figure 4 - Corrosion on the surfaces of the idle and mixture valve housing bore Precision Airmotive Service Bulletin PRS-97, revision 2, issued in August 2013, stated that the time between overhaul (TBO) for all fuel injection system components is either the same as the TBO specified by the engine manufacturer for the engine or 12 years since placed in service or last overhauled, whichever occurs first. The bulletin also stated that an overhaul is mandatory if the fuelsystem is contaminated with water. Maintenance records indicated that the last rebuild of the fuel injection servo was performed in August 1999, 23 years before the accident while the engine was undergoing an overhaul. Another engine overhaul was performed in August 2012, and the corresponding logbook entry stated that no accessories were overhauled at that time. The maintenance logbooks did not indicate the fuel system had been exposed to water; however, examination of the airplane indicated that the gascolator had recently been replaced. There was no maintenance entry to reflect this work, and the mechanic who performed the most recent annual inspection stated that he did not replace the gascolator at that time. There were no significant periods of inactivity noted in the logbook, although the owner stated that the airplane sat idle for 6 months before he purchased it in June 2020. He stated that the airplane was kept in a hangar for much of its recent life. ## Aircraft - Registration: [N2591V](https://openairdocs.org/aircraft/N2591V), registered now, S/N 177RG0627, built 1974 (OpenAirDocs) - Reported make and model: CESSNA 177RG - Registry model: [Cessna 177RG](https://openairdocs.org/model/cessna-177rg) (registry code 2073709) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177RG0627 - Year built: 1974 - Airframe hours: 6033 - Engines: LYCOMING IO-360-A1B6D 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2022, 27.1 hours before - Departed: SNS, Salinas, CA - Destination: Same as departure - Airport: LVK, Livermore Muni, runway 25R, 5,253 × 100 ft, asphalt - Equipment: ADS-B, Auto-pilot, Data recorder ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 11, 2021; seat: left; restraint: 3-point; flight hours: 308 total, 168 in this make and model, 212 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 1,500 ft broken - Temperature: 63 °F, dew point 55 °F - Altimeter: 29.93 inHg - Observed at: KLVK - METAR: SPECI KLVK 301504Z VRB03KT 10SM BKN015 17/13 A2993 RMK AO2 T01670133= ## 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 20220730013719A](https://openairdocs.org/incident/20220730013719A), Jul 30, 2022: Cessna 177RG, Livermore, CA, Substantial damage. Aircraft crashed short of runway 25R and also impacted approach lights sustaining damage to the left wingand tail due to engine failure. ## Docket (8 files) The files NTSB released with the investigation on August 23, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105630. 6.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15720956&FileExtension=pdf&FileName=r_6120_Redacted-Rel.pdf - Examination report (item 2, PDF, 3 pages, 1 photo, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14886788&FileExtension=pdf&FileName=Examination%20Report%20-%20WPR22LA287-Rel.pdf - Fuel injection servo examination report (item 3, PDF, 9 pages, 8 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14887123&FileExtension=pdf&FileName=FINAL-Servo%20Exam-WPR22LA287-Rel.pdf - Maintenance logbook excerpts (item 4, PDF, 5 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14887281&FileExtension=pdf&FileName=r_Logbook%20Excerpts_Redacted-Rel.pdf - Jpi engine monitor accident flight data (item 5, CSV, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14887019&FileExtension=csv&FileName=Flight-Rel.csv - Jpi engine monitor accident flight data graphs (item 6, PDF, 1 page, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14887133&FileExtension=pdf&FileName=jpi-Rel.pdf - Memorandum for record a�� pilot, mechanic, FAA (item 7, PDF, 3 pages, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14887370&FileExtension=pdf&FileName=MORs-Rel.pdf - Service bulletin PRS-97 REV2 (item 8, PDF, 2 pages, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14886798&FileExtension=pdf&FileName=PRS-97%20Rev2-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.