# NTSB WPR23LA017: Cessna 177RG, N747ML, Mesa, AZ, October 18, 2022

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Class 3 · Limited · Final report
- Date: October 18, 2022, 07:40 local (14:40 UTC)
- Place: Mesa, AZ · water canal
- Coordinates: 33.451338, -111.73967 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=33.4513&lon=-111.7397&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Defining event: [Approach-VFR pattern final: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330)
- Highest injury: Serious injuries
- Injuries: 1 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Western Pacific Region
- Parties: Lycoming Engines, FAA
- NTSB case key (mKey): 106158
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA017
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106158/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106158
- Page: https://openairdocs.org/ntsb/WPR23LA017

## Probable cause

The failure of maintenance personnel to properly secure the fuel supply line to the fuel flow divider, which resulted in a fuel leak, fuel exhaustion, and a total loss of engine power.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Not serviced/maintained (probable cause); cases with it: [Cessna 177RG, 3 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=2073709), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 177RG, 3 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2073709), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)
- [Oversight: oversight of maintenance](https://openairdocs.org/ntsb-findings/04032020): Organizational issues › Support/oversight/monitoring · Maintenance provider; cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/04032020/cases.md?model=2073709), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/04032020/cases.md)
- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 177RG, 10 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=2073709), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2073709), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Approach-VFR pattern final: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cessna 177RG, 3 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2073709), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)
- [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); 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)
- [Emergency descent: 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

The pilot conducted an hour-long local flight to break in the newly-installed engine, and was returning to the airport for landing when the engine lost all power. After a failed attempt to restart the engine, the pilot initiated a forced landing into a water canal. The airplane impacted a berm and came to rest in the canal, resulting in substantial damage to the left wing and engine mount. About one cup of fuel was recovered from each fuel tank during recovery from the accident site. Examination of the engine revealed that the fuel line from the fuel injection servo to the flow divider, which connected at the baffle union fitting on the aft side of the firewall, leaked when the engine-driven fuel pump actuated during the manual rotation of the propeller. The B-nut fitting could be tightened a half revolution until it seated onto the fitting by hand. There was no physical damage to the fitting, nor any accident-related impact damage within the surrounding area of the fitting. Review of the task cards for the engine installation provided by the repair station indicated that the installation was completed and signed off by both a technician and inspector. Based on the available information, it is likely that the B-nut was not properly torqued onto the baffle union fitting and that, during the accident flight, the B-nut loosened, resulting in a fuel leak, fuel exhaustion, and a total loss of engine power.

## Factual narrative

On October 18, 2022, about 0740 Pacific daylight time, a Cessna 177RG, N747ML, was substantially damaged when it was involved in an accident near Mesa, Arizona. The pilot sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that Falcon Aviation Services, based out of Falcon Field Airport (FFZ), Mesa, Arizona, reinstalled the overhauled engine and signed off the engine logbook entry on October 12, 2022. After multiple ground runs, the pilot completed an uneventful post-overhaul flight. The pilot reported that he departed on the accident flight about 0624 with 28 gallons of fuel onboard and maneuvered north of FFZ, where he flew about one hour orbiting about 4,000 ft above the ground at 65% to 75% engine power. The pilot returned to FFZ and was turning the airplane from base to final for runway 04R when the engine lost total power. The pilot attempted to restart the engine but was unsuccessful, and he conducted a forced landing into a water canal. The airplane impacted a berm and came to rest in the canal, resulting in substantial damage to the left wing, fuselage, and engine mount. (See figure 1.) During the recovery of the airplane, about one cup of fuel was recovered from each fuel tank. Figure 1. Google map view of wreckage location in relation to FFZ Runway 04R, with embedded picture of accident airplane in water canal. Postaccident examination of the airframe and engine revealed that the fuel supply line from the fuel injection servo to the fuel flow divider, which attached to the baffle union fitting, exhibited a surging fuel leak when the propeller was manually rotated. Fuel continued to surge from the fuel line fitting as the engine-driven fuel pump actuated with the continuous manual rotation of the propeller. It was determined that the fuel line B-nut (figure 2) was not secured and was able to be turned ½ revolution to “finger tight.” The fuel pump, fuel flow divider, and each corresponding fuel line was secured to its respective mounting pad or fuel system component. Figure 2. View of fuel supply line from fuel servo with overlayed close-up view of baffle union fitting connection (photo courtesy of engine manufacturer) According to the repair station, there were two primary installers of the accident engine, a technician and an inspector. The recovered task card for the engine installation revealed that the fuel system tasks, including a fuel leak check, were completed and signed off by both the technician and the inspector; however, it could not be determined which individual secured the fuel line to the baffle union fitting.

## Aircraft

- Registration: [N747ML](https://openairdocs.org/aircraft/N747ML), registered now, S/N 177RG0719, built 1975 (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: 177RG0719
- Year built: 1975
- Airframe hours: 3849.3
- Engines: LYCOMING IO-360-A1B6D 200 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Special, Restricted (Special); Standard, Normal
- Last inspection: Annual, October 11, 2022, 9 hours before
- Destination: Same as departure
- Airport: FFZ, Falcon Fld, runway 04, 5,100 × 100 ft, asphalt
- Equipment: Data recorder, Auto-pilot, ADS-B, Onboard weather, Electronic primary flight display, Electronic flight bag or handheld device

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 75; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; last flight review August 26, 2022; seat: left; restraint: 4-point; flight hours: 1,402.6 total, 1,187 in this make and model, 1,321.4 as pilot in command, 13.5 in the last 90 days, 10.3 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 40° at 9 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 73 °F, dew point 48 °F
- Altimeter: 30.08 inHg
- Observed at: KFFZ, 1 nm away
- METAR: KFFZ 181454Z 04009KT 10SM CLR 23/09 A3008 RMK AO2 SLP165 T02280094 53020 $

## 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 20221018020669A](https://openairdocs.org/incident/20221018020669A), Oct 18, 2022: Cessna 177RG, Mesa, AZ, Substantial damage. On October 18, 2022, at 0740 MST, [privacy data omitted], a Cessna model 177RG, single engine airplane, [privacy data omitted], was on a local flight near kffz…

## Docket (12 files)

The files NTSB released with the investigation on October 23, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106158. 33.4 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15590190&FileExtension=pdf&FileName=6120%20017_Redacted-Rel.pdf
- Accident photos (item 2, PDF, 2 pages, 720 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15590118&FileExtension=pdf&FileName=Accident%20Photo%20017-Rel.pdf
- Engine exam summary (item 3, PDF, 8 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17728701&FileExtension=pdf&FileName=Engine%20Exam%20Summary-Rel.pdf
- Video of leaking fuel line (item 4, MOV, 25.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17728478&FileExtension=MOV&FileName=Fuel%20surge%20out%20of%20Fuel%20injection%20servo%20line%20to%20flow%20divider%20at%20baffle%20union%20fitting-Rel.MOV
- Mor- repair station (item 5, PDF, 2 pages, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17729211&FileExtension=pdf&FileName=MOR%20-%20Repair%20Station-Rel.pdf
- Repair station task card excerpt (item 6, PDF, 1 page, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17727316&FileExtension=pdf&FileName=Operator%20Work%20Order%20Excerpt%20for%20Fuel%20Injection%20System%20017_Redacted-Rel.pdf
- Engine logbook entry excerpt (item 7, PDF, 1 page, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17726589&FileExtension=pdf&FileName=Engine%20Logbook%20entry%20017_Redacted-Rel.pdf
- Engine data download report summary (item 8, PDF, 7 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17726571&FileExtension=pdf&FileName=Engine%20Data%20Download%20WPR23LA017-Rel.pdf
- Engine data download data (item 9, CSV, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15590595&FileExtension=csv&FileName=Flt1261-Rel.csv
- Statement of party representatives to NTSB investigation (item 10, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17726706&FileExtension=pdf&FileName=NTSB%20Party%20Form_Lycoming-WPR23LA017_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 2 pages, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17727306&FileExtension=pdf&FileName=Signed%20NTSB%20Wreckage%20Release_Redacted-Rel.pdf
- Evidence control form (item 12, PDF, 2 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17726599&FileExtension=pdf&FileName=Evidence%20Control%20Form%20017_Redacted-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.

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