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Inadequate maintenance proves fatal for pilot

By NTSB · August 10, 2020 ·

The commercial pilot was taking family members for rides in his Cessna 172.

A family member said the pilot retrieved the airplane from under the open-air shelter for “family fun night” and was giving rides to several family members. The family members stated that the pilot had flown the airplane about one week before the accident, then again two times immediately preceding the accident flight. The two preceding flights lasted about 20 minutes and 10 minutes respectively and the family members reported no anomalies with the airplane.

After the second flight, the pilot landed and taxied the airplane back to his property, where three family members boarded the airplane while the engine continued to run. He taxied back to the runway and departed.

A pilot-rated witness stated that the takeoff roll was longer than expected, and, once airborne, the airplane pitched “very high” nose-up to about 50 feet above ground level (agl), then the nose came back down. The airplane appeared to accelerate down the runway until it climbed to about 300 foot agl, then made a left turn and descended out of view.

The airplane hit several trees and continued into a field in Rhome, Texas, where it came to rest inverted. The pilot died in the crash, while the three family members sustained serious injuries.

Damage to the propeller was consistent with a lack of engine power at the time of impact.

Examination of the airplane revealed evidence of a longstanding pattern of inadequate maintenance, including a rodent’s nest in the leading edge of the left wing, a large mud dauber nest on the oil cooler, and cobwebs in the engine compartment.

An automotive hydraulic hose was used in place of the main fuel line from the gascolator to the carburetor. The gascolator fuel strainer contained 3 large pieces of organic debris similar to insect cocoons, which were the same size as the hydraulic hose and associated fuel fitting.

It is likely that the fuel line was removed for an extended period of time and eventually replaced with the automotive hydraulic hose, during which time the fuel system was exposed, which allowed insects to nest inside. Because there were no maintenance records associated with the airplane, it could not be determined when the hose was replaced.

During the accident flight, it is likely that the organic material became dislodged and restricted fuel to the carburetor, which subsequently starved the engine of available fuel and resulted in a total loss of engine power.

The autopsy of the pilot revealed evidence of hypertension and coronary artery disease however it is unlikely that these conditions contributed to the accident. Toxicological testing indicated that the pilot had been using alcohol before the accident and had levels considered impairing. It is likely that alcohol impaired the pilot’s decision making and his ability to operate the airplane. Toxicological testing also revealed evidence that the pilot had used marijuana before the accident, however, it could not be determined if the concentrations would have been impairing or would have affected his performance.

Probable cause: The pilot’s inadequate maintenance of the airplane, which resulted in a total loss of engine power due to fuel starvation when organic debris restricted available fuel to the carburetor, and the pilot’s impairment due to the ingestion of alcohol, which affected his ability to safely operate the airplane following the loss of engine power.

NTSB Identification: CEN18FA336

This August 2018 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. scott says

    November 20, 2020 at 5:18 am

    Interesting comments and perspectives. Accordingly the obvious solution is pay greatly increased aircraft fees to accommodate pilot interviews and ramp inspections on all aircraft before each flight, and all aircraft need be of course on controlled airports.
    And all maintenance work under FAA oversight.
    There, now everyone is safe.

  2. scott says

    August 26, 2020 at 3:39 am

    Sad story. And a number of things were not to code or as they should have been. But the apparent bottom line was the insects blocking fuel flow and a landing in trees. I have to wonder how many thousands of exposed fuel lines there are at this moment in shops nationwide while maintenance work is in process. This was a freak problem and somewhat related to the rural area where the plane was setting. Actually the hydraulic hose, though not code, would have been higher rated part than the approved fuel line.
    Landing in trees never fairs well and usually results in fatalities regardless of toxicology.
    Not defending the actions of the pilot, just saying don’t condemn the system over it and start rioting.

  3. Rich says

    August 11, 2020 at 12:25 pm

    I am more concerned with the innocent people on the ground that have no control over some idiot blatantly operating an aircraft illegally!

    I have seen pilots like him in the past and eventually they crash and kill themselves.

    The sad part is the FAA can not do anything and respond after the accident.

    We do not see pilots like this at safety meeting or do they care about anyone.

    The FAA us to have a hot line to report safety issues but I believe they stoped doing this.

    Local flight instructors can tell you who these people are because they never fly with them and observe them on occasion.

    This fellow was literally a jerk and he paid the price and hurt his own family

    All I can say is at least he didn’t kill anyone else

    Sad!

    • Wylbur says

      August 11, 2020 at 2:48 pm

      I think the answer to the question you raise is called a “Ramp Check”.

      But that raises the following questions: Any one here ever been subjected to a ramp check?

      Was it at an airport that did not have a control tower and was miles away from an FSDO?

      • Rich says

        August 11, 2020 at 3:04 pm

        Yes the ramp check. Ironically the FAA has cut back on this and for the last 4 months the FAA has been on a lockdown working from their homes.

        No inspectors in the field!

        FAA use to do ramp checks at all airports. If a complaint was made an inspector use to be dispatched to check it out!

        Now FAA ramp checks are on the back burner.

        • JimH in CA says

          August 11, 2020 at 3:50 pm

          This is a private , grass, airstrip, in the middle of ‘nowhere’ Texas. [ no slight to any Texans.]
          In my 30 years of flying, I’ve not ever heard of anyone being ramp checked.

          A complaint to the local FSDO may get some action…maybe.

  4. Rich says

    August 11, 2020 at 9:38 am

    Poor or non existent maintenance, automotive parts, an impaired pilot and 4 adults in a 172! What could go wrong! I even wonder if the aircraft was operating within an annual inspection!

    • JimH in CA says

      August 11, 2020 at 11:48 am

      The docket said that were no log books for the aircraft or the pilot.
      This was an unmaintained aircraft, no annual, no logs, and as you mentioned, non-aircraft parts used in critical areas.

      No stupid pilot here. He was an idiot….and now no longer a pilot.

  5. Michael Lessard says

    August 11, 2020 at 5:01 am

    Wow! I can’t even believe this! How many causal factors can you count in this story? What was this guy thinking??? Believe it or not, drug use in flight operations is seriously on the rise. It is concerning enough that we have included a training segment on this topic supported by some staggering data in a recent update to our online Flight Review Ground School at WINGsReality EDU. This one sounds like a no-brainer but positive toxicology in fatal accidents occupies a space high on the food chain of accident causal factors, and every pilot should participate in awareness training on this subject. I am always amazed at how some of the most common fatal accident causal factors are amongst the easiest ones to preclude.

    • John says

      August 13, 2020 at 1:02 pm

      According to several studies by CAMI, Drug use (legal OTC/Rx AND illicit MJ/booze/cocaine/etc) is steadily rising among the US pilot population – or at least the dead pilots who provide tissue samples for Toxicology study following fatal accidents. Maybe “see something, SAY something” should be more in vogue. Too bad it isn’t.

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