Pilot Debrief

CESSNA 172F near Marysville, CA — 2013-01-20

Final reportWPR13LA098
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Date
2013-01-20
Location
Marysville, CA, USA
Airport
MYV
Aircraft
CESSNA 172F
Registration
N5208F
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Initial climb

Probable cause

A total loss of engine power during initial climb due to fuel starvation, which resulted from maintenance personnel’s improper installation of the fuel selector handle. Contributing to the accident was an incorrectly modified fuel selector handle assembly.

Contributing factors

Contributing to the accident was an incorrectly modified fuel selector handle assembly.

NTSB narrative

The airplane had recently undergone an annual inspection, and the accident flight was the first flight since that maintenance was performed. After departure, the pilot made a 6-nautical-mile flight to another airport, at which point, he decided to perform several practice touch-and-go landings. Following a smooth landing, he configured the airplane for takeoff by confirming the fuel selector was positioned to both wing tanks and then applied full power. The airplane climbed to about 150 feet above ground level, and, then the engine suddenly experienced a total loss of power. The pilot could not restart the engine, and the airplane touched down in a muddy field and came to rest inverted. The airplane's fuel selector handle was designed to be affixed to its shaft via a spring pin that slides through a hole on the handle and shaft only when the handle is properly aligned with the shaft; the spring pin prevents the handle from being installed incorrectly. A postaccident examination revealed that the fuel selector handle had been installed 180 degrees out of alignment, which was only possible because the spring pin attaching the handle to the shaft had been modified. Disassembly of the fuel valve also revealed excessive wear to the internal mechanism. The mechanic who conducted the airplane's annual inspection reported that he had taken off the fuel selector handle to remove the panel and check for leaks. He checked the "off" position when receiving the airplane, but he did not check it after finishing the annual inspection. During postaccident examinations, the fuel flowed freely through the valve when the fuel selector handle was near the "off" position, and the fuel stopped flowing when the handle was in the "both" position consistent with the handle indicating an opposite selection. Although one of the magnetos had worn beyond service limits and was not producing an adequate spark, its failure was unlikely related to the total loss of engine power. It is likely that the mechanic improperly installed the fuel selector handle after taking it off during the annual inspection, which was only possible due to the incorrectly modified fuel selector handle assembly.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly aligning the fuel selector handle during maintenance could have prevented the failure.

NTSB coding

Evidence available

  • 3 docket documents
View NTSB final reportView NTSB docket

Docket documents3

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