Aviation Accident Summaries

Aviation Accident Summary LAX99FA262

TUSAYAN, AZ, USA

Aircraft #1

N19113

Cessna 177B

Analysis

The cross-country flight departed Big Bear, California, with stops in Las Vegas, Nevada, Grand Canyon, Arizona, and returning to Big Bear. The accident departure from Grand Canyon National Park Airport was performed on runway 03; an 8,999-foot runway with a 0.8 percent up gradient (76-foot increase), and a density altitude of 8,800 feet msl. Witnesses reported that the airplane appeared to be slow, and barely cleared trees and buildings while climbing into mildly rising terrain. About 2 miles from the runway, the airplane was seen to roll to the left and descended into trees. The FAA Approved Flight Manual (AFM) for the accident airplane/performance data was not found at the accident site; however, a Cessna 337 Skymaster AFM was found. A California Airport Directory was also recovered. No Grand Canyon Airport information was found at the site other than the Las Vegas Sectional Chart airport information. Examination of the dual magneto revealed internal case corrosion on the left interior of the magneto. The right magneto was timed 22 degrees BTC instead of 25 degrees BTC. Test bench results indicated that the right magneto exhibited a weak spark. The massive electrode spark plugs exhibited a gap in excess of the recommended maximum gap for the plug. Cylinder plugs No. 1 and 2 were fuel sooted, No. 3 appeared lean, and No. 4 was slightly sooted.

Factual Information

HISTORY OF FLIGHT On August 3, 1999, at 1407 hours Pacific daylight time, a Cessna 177B, N19113, operated by Aero Haven, Inc., of Big Bear, California, was destroyed when it collided with trees and terrain at Tusayan, Arizona. The private pilot and one passenger received fatal injuries; another passenger received serious injuries. The airplane was rented by the pilot for the personal flight that was being conducted under the provisions of 14 CFR Part 91 when the accident occurred. The flight originated at Big Bear on August 1, 1999, and was to include stops at Las Vegas, Nevada, and Grand Canyon, Arizona, with a return to Big Bear on August 3, 1999. The airplane arrived at the Las Vegas McCarran International Airport parking ramp about 1740 on August 1, 1999, where it remained for the night. On August 2, the airplane was topped off with fuel (15.4 gallons), and the fuel invoice showed an estimated departure time of 1400 for the Grand Canyon. On August 3, 1999, about 1356, the pilot called the Federal Aviation Administration (FAA) Air Traffic Control Tower local controller and asked for the ground control frequency. He contacted ground control and requested to taxi to runway 03. The call-to-ground was partially stepped on by a helicopter transmission. The ground controller was also working a helicopter frequency. The ground controller did not confirm that the pilot had received the Airport Terminal Information Service (ATIS) "Foxtrot," which included the density altitude warning. The pilot was cleared for takeoff at 1405 from runway 03 at the Grand Canyon National Park Airport (GCN). Several pilot witnesses stated that the airplane appeared slow and did not climb much above the trees. About 1 mile north of the airport it was seen to barely clear the buildings at Tusayan. At 1407:39, the local controller advised the pilot "if you need to turn up the highway for altitude you can do that" and the pilot acknowledged. After crossing highway 64, it was observed to roll to the left and descend into trees. At the time of the accident the airport density altitude was reported as 8,800 feet msl, and the wind was light and variable. PERSONNEL INFORMATION The pilot's logbook was recovered at the accident site. The logbook was initiated on October 29, 1990. The last documented log entry is dated June 26, 1998. The last six log entries were for a Cessna Skymaster 337. The log totaled about 422 total flight hours with about 76 hours in the accident airplane. AIRCRAFT INFORMATION According to maintenance logbooks, the last annual inspection occurred on June 21, 1999. According to the time recording tachometer, there were 91.8 hours accumulated on the airplane since the annual/last inspection. The FAA Approved Flight Manual (AFM) for the accident airplane/performance data was not found at the accident site. A Cessna 337 Skymaster AFM was recovered at the accident site. The gross weight for the airplane is 2,500 pounds. The estimated takeoff weight at the Grand Canyon is 2,432.6 pounds. According to the airplane manufacturer's operating data, under the accident conditions the optimum performance climb rate should be about 365 feet per minute. According to the engine manufacturer, under the accident conditions the optimum engine performance would be 70 to 75 percent power, or 125 to 135 horsepower. A discrepancy form for the accident airplane dated July 99 was recovered. The form listed three open discrepancies; 1) Dated 7/19/99, is unclear; 2) Dated 7/28/99, exhaust gas temperature (EGT) inconsistent; and 3) Dated 7/28/99, gyro suction non-op. METEOROLOGICAL INFORMATION At 1354, GCN was reporting: winds variable at 5 knots; visibility 10 miles; scattered clouds at 7,000 feet; temperature 73 degrees Fahrenheit; dew point 52 degrees Fahrenheit; and the altimeter was 30.34 inHg. The airport terminal information service (ATIS) was reporting a density altitude of 8,800 feet msl. AIRPORT INFORMATION According to Department of Commerce Airport/Facility Directory, runway 03 has a positive runway gradient of 0.8 percent (76-foot increase) over the 8,999-foot length. A California Airports Directory was recovered from the accident site, no Arizona; airport information was found other than the Las Vegas Sectional Chart. WRECKAGE AND IMPACT INFORMATION The Safety Board examined the wreckage on scene located at 35 degrees 59.07 minutes north latitude by 112 degrees 07.35 minutes west longitude. The site was about 2 miles north of the airport and 300 feet east of highway 64 in an area of pine trees. A pine tree displayed damage about 40 above ground level with 16 feet of a narrowing tree top section lying at the tree base. About 25 feet from the damaged tree the airplane empennage was found severed from the fuselage. About 37 feet from the damaged tree the fuselage and wings were located standing vertical with the wing leading edges against the ground. At 63 feet the engine cowl was located, and the engine assembly was found at 117 feet. The wreckage path was oriented about 330 degrees magnetic. The right horizontal stabilator exhibited leading edge damage at the root and tip. The root damage revealed bark and tree pitch transfer. The cabin structure from the firewall was collapsed aft to about the mid cabin door area. Both cabin doors were broken from the cabin structure. Both door-latching shafts were in the extended/latched positions. Both wing flaps were found in the full up position. A tree limb measured to be 5.25 inches across the narrowest section was sliced in half with red paint transfer similar to the red paint found on the propeller blade tips. The propeller blades exhibited leading edge damage and chordwise striations and aft bending. The fuel selector was found in the both position. The flap handle was in the up position. The mixture was full forward. The clock was stopped at 2:07. The altimeter barometric pressure was set at 30:31 inHg. The Hobbs recording hour meter was 4,314.8 and the recording tachometer was 9,431.8 hours. MEDICAL AND PATHOLOGICAL INFORMATION On August 4, 1999, the Coconino County Medical Examiner performed an autopsy on the pilot. During the procedure the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma, obtained samples for toxicological analysis. The results of the analysis were negative for carbon monoxide, cyanide, ethanol, and drugs. TESTS AND RESEARCH INFORMATION Postaccident examination of the Lycoming 0-360-A1F6D engine revealed the Bendix D4LN-2021 magneto timing to be 25 degrees left and 22 degrees right. Lycoming recommended timing is 25 degrees before top dead center for both left and right magnetos. Some internal corrosion was evident. Test bench results for the left magneto revealed a strong blue spark. Right magneto test produced a weak reddish spark. Some points burning was noted. Examination of the spark plugs revealed fuel sooting of the plugs located in cylinders No. 1 and 2. Cylinder No. 3 appeared lean looking, and cylinder plug No. 4 was slightly sooted. According to the Champion Spark Plug gap information, the massive electrode plug gaps were beyond the recommended maximum gap. The engine primer line was installed on cylinder No. 4. The primer was locked and seals were good. ADDITIONAL INFORMATION The wreckage was released to the insurance company representative on August 18, 1999.

Probable Cause and Findings

was the pilot's failure to have available and consult the FAA approved flight manual for performance data and, the high density altitude. Contributing to the accident were the dual magneto and spark plug system issues affecting optimum engine performance.

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports