Aircraft Accident/Incident Report

Chanute, Kansas 66720
Friday, May 11, 2012 16:30 CDT

NTSB Narrative Summary Released at Completion of Accident

While en route to the destination airport, the pilot turned on the cabin heater and, afterward, an unusual smell was detected by the occupants and the ambient air temperature increased. When the pilot turned the heater off, dark smoke entered the cabin and obscured the occupants' vision. The smoke likely interfered with the pilot’s ability to identify a safe landing site. During the subsequent emergency landing attempt to a field, the airplane’s wing contacted the ground and the airplane cartwheeled. Examination of the airplane found several leaks around weld points on the combustion chamber of the heater unit. A review of logbook entries revealed that the heater was documented as inoperative during the most recent annual inspection. Although a work order indicated that maintenance work was completed at a later date, there was no logbook entry that returned the heater to service. There were no entries in the maintenance logbooks that documented any testing of the heater or tracking of the heater's hours of operation. A flight instructor who flew with the pilot previously stated that the pilot used the heater on the accident airplane at least once before the accident flight. The heater’s overheat warning light activated during that flight, and the heater shut down without incident. The flight instructor showed the pilot how to reset the overheat circuit breaker but did not follow up on its status during their instruction. There is no evidence that a mechanic examined the airplane before the accident flight. Regarding the overheat warning light, the airplane flight manual states that the heater “should be thoroughly checked to determine the reason for the malfunction” before the overheat switch is reset. The pilot’s use of the heater on the accident flight suggests that he did not understand its status and risk of its continued use without verifying that it had been thoroughly checked as outlined in the airplane flight manual. A review of applicable airworthiness directives found that, in comparison with similar combustion heater units, there is no calendar time limit that would require periodic inspection of the accident unit. In addition, there is no guidance or instruction to disable the heater such that it could no longer be activated in the airplane if the heater was not airworthy.

NTSB Probable Cause Narrative

The malfunction of the cabin heater, which resulted in an inflight fire and smoke in the airplane. Contributing to the accident was the pilot’s lack of understanding concerning the status of the airplane's heater system following and earlier overheat event and risk of its continued use. Also contributing were the inadequate inspection criteria for the cabin heater.

Event Information

Type of Event Accident
Event Date 5/11/2012
Event Day of the Week Friday
Time of Event 1630
Event Time Zone Central Daylight Time
Event City Chanute
Event State KANSAS
Event Country --
Zipcode of the event site 66720
Event Date Year 2012
Event Date Month 5
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 373818N
Event Location Longitude 0963647W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1652 Central Daylight Time
Direction of event from weather observation facility (degrees) 74
Weather Observation Facility ID KCNU
Elevation of weather observation facility 1002
Distance of event from weather observation facility (units?) 6
Time Zone of the weather observation CDT
Lighting Conditions Day
Lowest Ceiling Height 11000
Lowest Non-Ceiling Height 11000
Sky/Lowest/Cloud Conditions Thin Broken
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 21
Dew Point at event time (in degress fahrenheit) 15
Wind Direction (degrees magnetic) 180
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 4
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 30.07
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report METAR KCNU 112152Z AUTO 18004KT 10SM BKN110 21/15
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 4
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 5
Investigating Agency NTSB
NTSB Docket Number (internal use) 31597
NTSB Notification Source ICT FSDO
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Sep 3 2013 11:52AM
User who most recently changed record coln
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N9DM
NTSB Number CEN12FA290
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage Substantial
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 401
Aircraft Series Identifier --
Aircraft Serial Number 401-0123
Certified Max Gross Weight 6300
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats 2
Cabin Crew Seats --
Passenger Seats 5
Total number of seats on the aircraft 7
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Jan 15 2012 12:00AM
Airframe hours since last inspection --
Airframe Hours 2455.5
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name DRDJ Sales Inc.
Aircraft Owner Street Address --
Aircraft Owner City Muskogee
Aircraft Owner State OK
Aircraft Owner Country USA
Aircraft Owner Zipcode --
Operator is an individual? No
Operator Name Private Individual
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code RVS
Departure City Tulsa
Departure State OK
Departure Country USA
Departure Time 1545
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code CBF
Destination City Council Bluffs
Destination State IA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jun 19 2013 11:53AM
User who most recently changed record aguj
Since inspection or accident Last Inspection
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --