Summary
On August 22, 2001, a Cessna 152 (N4755B) was involved in an accident near Weatherford, TX. The accident resulted in 1 fatal injury. The aircraft was destroyed.
The National Transportation Safety Board determined the probable cause of this accident to be: The student pilot's improper decision making in that he landed with a tailwind and failed to execute a go-around, which resulted in a runway overrun. Contributing factors were the inaccurate reading of the left fuel gage as a result of improper maintenance by the operator/maintenance personnel, and the tailwind condition.
HISTORY OF FLIGHT
On August 22, 2001, approximately 0910 central daylight time, a Cessna 152 airplane, N4755B, overran runway 35 during the landing roll at the Parker County Airport (WEA), near Weatherford, Texas, and impacted a tractor/trailer vehicle on Interstate 20. The airplane was owned by a private individual and operated by Aer Mistral, Inc., of Fort Worth, Texas, under 14 Code of Federal Regulations (CFR) Part 91. The student pilot, sole occupant, received fatal injuries, the airplane was destroyed, and the vehicle sustained substantial damage. Visual meteorological conditions prevailed for the planned cross-country flight, and a flight plan was not filed.
This accident is documented in NTSB report FTW01FA188. AviatorDB cross-references NTSB investigation data with FAA registry records to provide comprehensive safety information for aircraft N4755B.
Accident Details
Probable Cause and Findings
The student pilot's improper decision making in that he landed with a tailwind and failed to execute a go-around, which resulted in a runway overrun. Contributing factors were the inaccurate reading of the left fuel gage as a result of improper maintenance by the operator/maintenance personnel, and the tailwind condition.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHT
On August 22, 2001, approximately 0910 central daylight time, a Cessna 152 airplane, N4755B, overran runway 35 during the landing roll at the Parker County Airport (WEA), near Weatherford, Texas, and impacted a tractor/trailer vehicle on Interstate 20. The airplane was owned by a private individual and operated by Aer Mistral, Inc., of Fort Worth, Texas, under 14 Code of Federal Regulations (CFR) Part 91. The student pilot, sole occupant, received fatal injuries, the airplane was destroyed, and the vehicle sustained substantial damage. Visual meteorological conditions prevailed for the planned cross-country flight, and a flight plan was not filed. The solo instructional flight departed the Fort Worth Meacham International Airport (FTW), Fort Worth, approximately 0652, for the planned round robin flight to the Kickapoo Downtown Airpark (T47), Wichita Falls, Texas.
During interviews, conducted by the FAA inspector, the flight instructor stated that the CFR Part 61 student pilot was endorsed for the solo cross-country flight from FTW to T47 with a return to FTW. This was the student's second solo cross-country flight. He had made a solo cross-country flight from FTW to Gainesville Municipal Airport (GLE), Gainesville, Texas, to FTW on August 20, 2001. Further, the student pilot and his instructor had flown the cross-country flight from FTW-T47-FTW the previous day.
The air traffic control data and transcripts were reviewed by the NTSB investigator-in-charge (IIC) and all times were converted to central daylight time unless otherwise noted.
At 06:40:05, the student pilot contacted the local controller at FTW for taxi clearance to Runway 16. At 06:52:00, the pilot requested a northwest departure and was cleared for takeoff. No radar data was obtained for the departure from FTW. At 07:19:13, radar tracked an airplane squawking 1200 on a northwest heading 36 nautical miles north of FTW. The airplane track continued on a northwest heading until 07:39:17, approximately 13 nautical miles southeast of T47. No radar track was observed for an aircraft landing at Kickapoo Airport (T47).
A person at the airport in Wichita Falls (T47), reported to the FAA inspector, that she recalled an airplane making a touch and go landing approximately 0730 on the morning of the accident; however, she could not be certain that the airplane was N4755B. Further, she stated that N4755B had not been refueled that morning at T47.
Approximately 07:39 the radar track of the airplane (4,400 feet msl) turned to a southerly heading and continued in a southeasterly arc flight path. At 0840:58, the pilot contacted the Fort Worth Air Traffic Control Tower (FTW ATC Tower) and reported to the controller that he was flying the airplane from the Kickapoo Airport and that he was lost. At 0841:10, the pilot was assigned a transponder code of 0427. At 0845:02, the controller informed the pilot that the airplane was about 30 nautical miles west of FTW and suggested a heading of 090 degrees. At 0854:40, the airplane (altitude 2,200 feet msl) was approximately 7 nautical miles west of WEA, and the controller asked the pilot what the fuel quantity gages indicated. At 0854:48, the pilot transmitted that the left fuel tank gage indicated full, and the right fuel tank gage indicated empty. At 0855:24, the airplane was approximately 5 nautical miles west of WEA and the controller suggested a heading of 060 degrees to follow Interstate 20 to FTW. At 0901:50, the pilot transmitted that "I was lost and I think that I'm ah low on fuel." At 0901:57, the controller told the pilot that WEA was just to the right of the airplane, and the wind at FTW was from 170 degrees at 18 knots. At 0902:03, the pilot told the controller that he would land the airplane at WEA. No additional communications with the pilot were recorded. According to radar data, the airplane flew to the north and west of WEA, and then entered a final approach for Runway 17.
One witness/pilot at the airport (WEA) observed the airplane land on runway 17 into the wind (20 knots from south) and bounce several times before departing the east side of the runway into the grass. Subsequently, the pilot added power, executed a go-around, made a 270 degree turn to the west, and approached runway 35 for landing. The airplane touched down about the middle (GPS 32 degrees 44.41 minutes North; 097 degrees 40.56 minutes West) of runway 35 (2,889-foot long by 40-foot wide) and remained on the runway. The elevators were up, flaps retracted, propeller turning, and the aircraft speed was "estimated at 40 mph." The airplane was approximately 300 feet from the end of runway [17] threshold, and the witness "never heard the brakes or power applied." The airplane rolled off the end of runway [35] at an "estimated speed of 30 mph."
Another witness/pilot at the airport (WEA) observed the airplane make a "rough" downwind landing (more than 1/2 way down the runway) at an "estimated landing speed of 75 mph." The airplane continued down the runway, slowed to "45-50 mph;" however, the witness "never saw or heard any indication of braking, nor did the pilot add power to takeoff." The airplane continued down the runway until it "ran off the end crushing into a flatbed 18 wheeler truck." The wind was 15-20 knots from the south.
A third witness/student pilot observed the airplane, with all three wheels (GPS 32 degrees 44.46 minutes N; 097 degrees 40.56 minutes West) on the runway, moving from south to north. The wind was "strong from the south." This witness observed the airplane near the north end of the runway, "shake left and right, then disappear from the end" of runway 35.
The driver of the tractor/trailer truck reported that his vehicle was traveling eastbound in the center lane of Interstate 20 when he saw the airplane coming from the south "like is taken off." The driver stated the "[air]plane come straight to my cab, hit back of sleeper," and subsequently, the airplane "hit right side of trailer" and then looked "like roll over like half turn." The driver reported the "speed of his truck was 60 mph."
PERSONNEL INFORMATION
On June 18, 2001, Aer Mistral, Inc., notified the Honorable US Consulate General, US Embassy, India in writing that the pilot's flight and ground training would be followed according to Federal Aviation Regulations Part 61, Part 91, and Part 141, and would also meet the flight requirements as per the Indian DGAC.
According to the pilot's logbook and the FAA records, reviewed by the NTSB IIC, the pilot was issued an FAA student pilot certificate and a first class medical certificate on June 22, 2001. There were no limitations on the medical certificate. The pilot's initial dual flight was performed on July 17, 2001. The student pilot, with an accumulated flight time of 18.8 hours dual instruction in the make and model of the accident aircraft, was endorsed for solo flights on August 6, 2001. During the pilot's initial solo flight of 0.9 hour on August 10, 2001, he logged 3 landings. The student pilot's logbook accumulated flight time was 27.1 hours of which 2.2 were solo. The pilot's logbook indicated 4 solo landings prior to the day of the accident. Approximately 8 additional hours (undeterminable dual or solo) were estimated from the company pilot log for July and a page of flight times found in the accident airplane.
On August 18, 2001, the initial dual cross-country flight was performed from FTW to GLE to FTW. The student pilot was endorsed for solo cross-country flights on August 18, 2001, and he performed his first solo cross-country flight on August 20, 2001, from FTW to GLE to FTW. The second dual cross country flight was conducted on August 21, 2001, from FTW to T47 with a return leg to FTW. The accident flight occurred the following morning during the return leg (T47 to FTW) of the student pilot's solo flight from FTW to T47 to FTW. The solo cross-country endorsement in the student pilot logbook stated in part: prepared to make the solo flight safely; Limitations-Part 61.89(a)(8): 8 knots crosswind.
The estimated time en route on the cross-country navigation planning log, found in the airplane, was 2 hours and 1 minute, and the total fuel for the flight was calculated as 14.2 gallons at a fuel burn of 6 gph.
AIRCRAFT INFORMATION
N4755B, a 1980 model Cessna 152, serial number 15283618, was re-issued an FAA standard airworthiness certificate on August 15, 1979. Registration to the current owner was dated December 6, 1996.
In June 1999, the McCauley model 1A103 propeller, serial number 771120, was overhauled and re-installed on the engine at an accumulated airframe time of 9,793.8 hours. In August 1999, the Lycoming model O-235-L2C engine, serial number L-19562-15, was overhauled at an accumulated time of 404.86 hours and re-installed on the airframe (accumulated airframe time 9,994.5 hours).
The transponder was tested, in accordance with FAR 91.113 and Appendix F of Part 43, in May 2000. On June 7, 2001, the #3 cylinder was overhauled and re-installed on the engine. On July 26, 2001, the last 100 hour inspection was performed at the accumulated airframe time of 11,581.4 hours and an engine time of 1,586.9 hours since major overhaul (SMOH). The left and right tires were replaced at the previous 100 hour inspection performed on June 26, 2001.
Maintenance records review for the fuel system revealed the following data. On July 19, 1990, a new left fuel tank, P/N 0426019-23, was installed. On June 3, 1995, the fuel line assembly, P/N 12-156392-11, was removed and replaced with a new unit. On July 17, 1997, the right hand fuel tank was repaired, re-installed, and leak tested good, resealed, and serviced. The aircraft maintenance records on October 22, 1999, stated in part: installed on LH [left hand] main tank, fuel transmitter [Rochester] new from Cessna P/N C66805-1201 S/N 1149 was installed IAW [in accordance with] C-152 m/m [maintenance manual]. Positive wire was tightened to RH [right hand] main tank fuel tran[smitter]. Fuel gauges ops [operation] checked satisfactorily. Aircraft returned to service. On October 18, 2001, the right fuel tank transmitter, a Stewart Warner transmitter (Cessna part number C668002-0301, serial number 10511) was overhauled and re-installed.
The Cessna model 152 Series 1978 thru 1985 Parts Catalog shows the Stewart Warner transmitters and fuel gages are no longer procurable. In 1991, Stewart Warner no longer provided fuel gauges and transmitters for the Cessna 152 aircraft. The new gauges and transmitters were provided by Rochester. If a fuel transmitter replacement was required and a Stewart Warner transmitter was not available, the aircraft operator had to replace both the transmitter and the gauge. A note in the parts catalogue shows that for the first installation of the Rochester hardware, the service kit requires installation of both a Rochester transmitter and a gauge. In addition, when a Rochester gauge is installed, the gauge back plate must be changed from steel to aluminum. The service kit for the accident airplane serial number was SK152-21B. The applicable Service Bulletin was SEB91-7. According to the manufacturer representative, "with the Rochester transmitter installed with the Stewart Warner fuel gage, the gage indication would increase as the fuel level in the tank got lower." Neither the Cessna Service Bulletin (SEB91-7) nor the Cessna Service Kit (SK152-21B) or gauge was referenced in the maintenance record entries.
The fuel capacity for the aircraft was 26 gallons (13.0 per tank) with 24.5 gallons usable. At 1845, on August 21, 2001, the airplane was fueled with 9.1 gallons.
On August 21, 2001, the aircraft dispatch record indicated that the airplane was flown 7.0 hours. The last recorded tachometer reading on the aircraft dispatch record was 1,636.2 hours. The tachometer reading at the accident site was 1,638.5 hours, giving an accident flight time of 2.3 hours.
METEOROLOGICAL INFORMATION
At 0853, the weather observation facility at Mineral Wells (20 nautical miles west of WEA) reported clear skies, visibility 10 statute miles, wind 160 degrees at 13 knots, temperature 27 degrees Centigrade (81 degrees Fahrenheit), dew point 22 degrees centigrade (72 degrees Fahrenheit), and the altimeter 30.06 inches of Mercury.
At 0953, the weather observation facility at Mineral Wells reported in part: clear skies, visibility 10 statute miles, wind 180 degrees at 11 knots gusting 17 knots.
AIDS TO NAVIGATION
WEA was located on the 077 degree radial at 16.0 nautical miles from the Millsap (MQP) VORTAC [VHF navigational facility-omni directional course and distance information]. The MQP VORTAC had a VOR/DME/TACAN Standard Service Volume (SSV) Classification as high (H) with a range from 1,000 to 14,500 feet msl above the facility for a distance 40 nautical miles from the facility. The VORTAC facility frequency of 117.7 did not have voice capability.
Communication frequencies were WEA CTAF/Unicom 122.7 Megahertz (MHz); Regional Approach/Departure Control 135.975 MHz; and Flight Service Station civil communication frequencies 122.0 MHz, 122.2 MHZ, 122.3 MHZ, 122.4 MHz, 122.6 MHz, 123.6 MHz; plus receive only 122.05 MHz, 122.1 KHz, 122.15 MHz, and 123.6 MHz. The emergency 121.5 MHz was available at all Flight Service Stations, Towers, Approach Control and RADAR facilities
AERODROME INFORMATION
Parker County Airport (WEA), located approximately 5 miles east of Weatherford, is owned and operated by Parker County, Texas. Interstate 20 runs east-west at the north end of the airport. The listing in the Airport/ Facility Directory, effective July 12, 2001 through September 6, 2001, for the Parker County Airport was reviewed. WEA, located latitude 32 degrees 44.78 minutes North; longitude 097 degrees 40.95 minutes West, is a non-towered airport with one runway (17/35). The airport elevation is 990 feet. Runway 17/35 is an asphalt surfaced runway, 2,889 feet long, and 40 feet wide. Runway 17 has an 219-foot displaced threshold. A tree is located along the approach path for runway 17, and there are multiple trees located along the approach path for runway 35. The airport is closed to transient student training.
State of Texas Aeronautical airport data was reviewed. Runway 17 threshold elevation was 988 feet, and runway 35 threshold elevation was 983 feet. Obstructions were trees located along the approach path for runway 17/35, and a fence located 125 feet west of runway 17 centerline. There was a 20-foot embankment (drop off) at the north end of the airport.
WRECKAGE AND IMPACT INFORMATION
The FAA inspectors and the NTSB investigators, who responded to the site, found the airplane in the eastbound lane of Interstate 20. Initial ground scars were found 119 feet 6 inches beyond the end of runway 35, on a measured magnetic heading of 360 degrees from runway centerline. These ground scars were consistent with the three main landing wheels of the airplane. Eighty-five feet six inches, on a measured magnetic heading of 010 degrees, beyond these ground scars, were scrapes and gouges in the Interstate 20 pavement consistent with the initial impact point with the vehicle. The wreckage distribution path was along a measured magnetic heading of 121 degrees. The main wreckage came to rest (32 degrees 45.02.6 minutes North; 097 degrees 40.55.8 minutes West) on a measured magnetic heading of 285 degrees at 71 feet 1 inch from the impact point with the vehicle.
The airplane was examined at the accident site and the following day at the facility of Air Salvage of Dallas, Lancaster, Texas, under the supervision of the NTSB IIC. The cabin fuselage was displaced to the right and separated from the airframe. The right and left wings were bent downward at the inboard attachment points. The right main landing gear strut was found separated approximately 1-foot outboard from the wing attachment point. The right wing leading edge from the inboard attachment point to approximately 4 feet from the outboard wing tip was crushed aft to the main spar, and the outboard 2 feet of the right wing crushed aft to the main spar. The inboard leading edge of the right aileron was compressed aft. The outboard portion of the right flap was bent upward. The inboard 2 feet of the left wing leading edge had black smear areas consistent with vehicle tire material. The left wing strut was found separated at the airframe and exhibited black smear areas consistent with vehicle tire material. The nose landing gear strut was found separated from the firewall. The engine was found displaced aft and to the right, and was separated from the engine mounts.
The integrity of the cockpit was destroyed with crushing, twisting, and component separation. The cockpit roof was pushed upward and aft, and the left door frame sustained deformation. The left cockpit door was found separated from the airframe. The physical scrapes on the door latch were consistent with the door secured prior to the impact. The left seat base remained attached to both seat tracks. The seat bottom was deformed, separated from the seat base, and pushed to the right. The seat back remained attached to the seat base.
The left front seat lap belt was found buckled. Examination of the left front seat lap belt assembly revealed that the connector half end fitting stitching separated and caused the webbing to separate from the outboard floor attachment end fitting. The part number on the data tag, identified the restraint as VDA 1007. The shoulder harness was found not fastened, and there was no physical evidence found of webbing deformation. The left front seat lap belt assembly and shoulder harness were photographed and retained for further examination.
The electrical system was destroyed; however, evidence of a digital navigation/communication unit, and a single VOR navigation instrument were found in the debris. The transponder was destroyed. The vertical speed indicated an approximate 1,900 fpm rate of descent. The turn coordinator had the ball full left and the airplane full right. The fuel primer was in and locked. The mixture was full rich, and the throttle was full forward, and there was throttle cable continuity to the carburetor. The cockpit ignition switch was found in the "both" position.
The integrity of the brake system was compromised. The left wheel assembly was found separated from the landing gear spring assembly. No grooves were observed on the brake disc. The left brake line was separated (physical evidence of overload) at the fitting and at the brake assembly. The right wheel rotated on the brake disc. The left and right brake linings measured approximately 4/16 inch thick, and the brake discs approximately 3/16 inch thick, respectively. Neither tire exhibited worn or flat spots. There were no anomalies found that would have rendered the brake system incapable of operating per design prior to the impact.
Flight control continuity was confirmed by tracing the flight control cables. The aileron balance cable between the right and left bell cranks was found separated; however, the separation point exhibited physical evidence consistent with overload. According to the airframe manufacturer representative, the flap actuator position was consistent with the flaps in the retracted position. When the flap motor was tested, the flaps moved to the extended and retracted position, respectively.
The fuel selector valve was found in the "ON" position. Both fuel caps were found secured, and the left fuel cap was vented. The integrity of the fuel system was compromised. Discoloration at the inboard aft area of the left lower wing skin was consistent with fuel leakage. Approximately 1/2 gallon of fuel was found in the right fuel tank, and zero fuel was found in the left fuel tank. Fuel was found in the gascolator, and when the carburetor accelerator pump was operated by hand, fuel was expelled. No debris was found in either the gascolator or carburetor fuel screen. Wet liquid consistent with "blue" color of fuel was found on the outer surface of the left fuel tank, the tank fitting, and in the inboard wing area when the tank was removed from the wing.
The fuel tank transmitters were removed from the fuel tanks. The right fuel tank transmitter, a Stewart Warner transmitter, had serial number 10511 and a tag dated October 18, 2001. The tab stop for the fuel float at the EMPTY position on the right tank fuel transmitter was found bent, and the float arm was bent. The left fuel tank transmitter, a Rochester transmitter, had Cessna part number C668050-1201, S/N 1149.
On July 16, 2002, under the supervision of an NTSB investigator, the left fuel tank was opened and the fuel vent examined. According to the manufacturer representative, the fuel vent was properly installed.
On September 3, 2002, under the supervision of an NTSB investigator, the fuel gages were removed from the airplane and examined. Both gages were Stewart Warner gages (Cessna part number 878016), and the gage assembly back plate (C669537-0104) was steel. According to the manufacturer representative, the Stewart Warner gages have a steel back plate as part of the gage assembly.
Engine continuity was confirmed for the valves, pistons, and the accessory case. When the crankshaft was rotated, there was thumb compression at each cylinder. The #1 and #3 cylinders exhibited physical evidence of leaks at the intake pipe to the cylinder attach point, and the spark plugs were indicative of a lean mixture. Both magnetos were found separated from the accessory case housing; however, the magnetos sparked at all terminals during hand rotation of the magneto drive couplings. The vacuum pump rotated and disassembly of the pump found all the internal components intact. The starter flywheel gear was separated with physical evidence consistent with overload.
The propeller flange was bent approximately 10 degrees aft. The spinner was crushed, the 6 propeller attachment bolts were sheared, and the propeller was separated from the crankshaft flange. One propeller blade exhibited torsional twisting, leading edge gouges, and blue paint transfer on the blade face. One propeller blade had the outboard 1-foot bent aft approximately 100 degrees, with leading edge scrapes, and black smear areas consistent with vehicle tire material on the blade face.
No evidence of an in-flight mechanical and/or flight control malfunction was found that would have rendered the airplane uncontrollable prior to the impact.
MEDICAL AND PATHOLOGICAL INFORMATION
The autopsy was performed by the Office of the Chief Medical Examiner of Tarrant County, Texas.
The FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research Center examined the specimens taken by the medical examiner. According to CAMI, the specimens showed no indication of alcohol or drugs of abuse.
SURVIVAL ASPECTS
The accident was not survivable.
TEST AND RESEARCH
The vehicle was a 1987 Peterbilt truck tractor towing a silver 1995 Fontaine flatbed semi-trailer, owned by 3 Way Transportation, Inc., of Dallas, Texas. The vehicle was traveling eastbound in the center lane of Interstate 20, at a reported speed of 60 mph. Following the accident, the Texas Department of Public Safety (DPS) found the vehicle's brakes out of adjustment. Post accident drug screening for the driver was performed by the Right Truck Drug Screening facility at Weatherford. According to the Texas DPS, the screening results were negative.
According to Am-Safe, Inc., at Phoenix, Arizona, the left front seat lap belt assembly data tag, part number VDA 1007, would be associated with lap belt assembly part number 445008. However, the buckle assembly was identified as assembly 441174 (model 5000B3), and the connector assembly as part number 500950. The connector as specified on drawing 445008, is intended for use in a 2-point restraint system. A 3-point installation requires the use of a different lap belt connector and an associated shoulder harness attachment fitting. The shoulder harness was not an Am-Safe part. The end fitting of the shoulder harness was stamped with part number S-2072-5, which corresponds to a Cessna part. The Am-Safe part number 443030-401 was found stamped on the shoulder harness adjustor assembly. Variations were noted for the web color, thread type, and stitch patterns on each of the subassemblies (buckle, shoulder harness, and connector). The buckle half webbing was identified as WN1655 (nylon) per manufacturer specifications. The webbing type for the connector and the shoulder harness could not be confirmed; however, the stitch length patterns and web folds were not typical of the Am-Safe stitch pattern geometry used for production.
ADDITIONAL INFORMATION
Parties to the investigation were the FAA, Cessna Aircraft Company, and Textron Lycoming.
The airplane was released to the owner's representative.
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# FTW01FA188