NTSB Factual Report

HISTORY OF FLIGHT

On November 17, 1994, at 1020 eastern standard time, a Cessna 195A, N1527D, owned and piloted by Jan Shaffer, was destroyed when it struck trees during a forced landing near Broadview Heights, Ohio. The pilot received fatal injuries. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed for the flight operating under 14 CFR 91.

The airplane was based at the Cleveland-Hopkins International Airport (CLE), Cleveland, Ohio. The purpose of the flight was to fly N1527D to the Salem Airpark, Salem, Ohio, for routine maintenance. Mr. Shaffer filed his flight plan with the Cleveland Automated Flight Service Station and received his IFR clearance from CLE clearance delivery.

About 1014, N1527D was cleared for takeoff by the CLE tower. After takeoff, N1527D contacted CLE departure control and was directed to maintain 5,000 feet and proceed direct to the Akron VOR navigational fix. About 1021, N1527D asked the CLE departure controller to confirm that the radar showed the airplane level at 5,000 feet, which the controller verified.

At 1022:59, N1527D reported that he had a problem. After a response from the CLE controller, N1527D replied at 1023:09, "We've got some kind of fire on board...I think it's a heater (thing)..." The Cleveland controller suggested to N1527D that he return to CLE and provided a heading to the airport. There was no response to the transmission, and at 1023:54 the controller stated, "Ah, two seven delta, you're cleared to Cleveland-Hopkins, fly heading, ah if you can three zero zero, and it's ten miles, report the airport in sight."

The pilot of N1527D responded, "Ah, we can't make it." No further transmissions were received.

Several witnesses observed the airplane on fire, flying low to the trees in a southwesterly direction. One witness, a police officer, stated:

"...I observed a small single engine plane coming from the south, banking left then going in a southwesterly direction, losing altitude. Fire was visible on the right side of the aircraft and black smoke was trailing from the tail area..."

Another witness traveling east along a highway stated:

"...My wife and I saw a plane...[with] fire coming from the back half of the plane. The plane was 100 feet in the air directly over Route 82, then all of a sudden it took a direct left into the valley...As soon as it hit the woods, the plane blew up..."

The accident occurred during the hours of daylight about 41 degrees, 19 minutes north latitude, and 81 degrees, 39 minutes west longitude.

PILOT INFORMATION

The pilot, Mr. Jan Shaffer, held an Air Transport Pilot Certificate, with ratings for airplane single and multiengine land and sea. He held type ratings in several jet aircraft. He also held a Flight Instructor Certificate for airplane single and multiengine land, and instrument airplane.

His most recent Federal Aviation Administration (FAA) First Class Medical Certificate was issued on July 12, 1994.

Mr. Shaffer's current pilot log book was consumed in the airplane post crash fire; however, the most recent available log book from April 1987, indicated that he had accumulated about 23,600 hours of flight experience. On his last FAA medical application he indicated that he had approximately 26,025 hours.

AIRCRAFT INFORMATION

All of the maintenance records were on board the airplane, and were destroyed during the in-flight, and post crash fires. No annual or maintenance history could be documented.

WRECKAGE INFORMATION

The airplane wreckage was examined at the accident site on November 18 and 19, 1994. The examination revealed that all major components of the airplane were accounted for at the scene.

The airplane came to rest on an approximate magnetic bearing of 060 degrees, in a valley about 90 feet below the top of the ridge line.

Initial tree impact scars started at the top of the ridge line, approximately 175 feet from the main fuselage wreckage. Tree impact scars became progressively lower on the trees in the direction of the wreckage. Several trees displayed burned areas near their respective impact scars. The tree scars indicated a general direction of 225 degrees magnetic.

Several components from the airplane were found along the path to the main wreckage. These included the left and right wings, left and right flaps sections, left and right ailerons, control cables, both main landing wheels, the elevator and the tail cone.

A ground impact hole was observed about 150 feet from the initial tree impact scar. The main fuselage rested upright, about 25 feet beyond the impact hole, facing in the opposite direction of the descent path through the trees. Located next to the fuselage was a fire burned tree, about 2 feet in diameter.

The upper 2/3 of the cabin area and ceiling were burned away forward of the tail section. The interior of the cabin was burned down to the floor. The left forward fuselage side and fuel selector area showed minimum signs of fire and smoke damage. The fuel selector was selected to the right wing tank. The right forward area was destroyed by fire; however, the right cabin entrance door was found several feet from the main wreckage intact with only impact and smoke damage. Examination of the cockpit instruments produced no useful information due to impact and fire damage.

The lower fuselage of the cabin area was intact except for an area in the vicinity of the cabin fuel heater (CFH). In this area, the fuselage floor was burned through, and the CFH was resting on the ground.

The 1/8 inch fuel line for the CFH was found attached to the "T" fitting of the left wing 5/8 inch main fuel supply line to the engine. The "B" nut at the opposite end of the line was burned off at the end and unattached. A fuel filter assembly, minus the glass bowl, was located in the fire debris between the pilot's seat and the CFH. The CFH fuel control regulator was partially melted and not attached to any fuel lines or the CFH. The fuel inlet elbow on the CFH assembly was intact without any "B" nut attached. The heat exchanger and the heatercase were fire damaged; however, there was no evidence of cracks, or of a burn through in the case. Components of the CFH fuel delivery system were removed from the wreckage and sent to the NTSB Materials Laboratory in Washington, D.C., for further analysis.

The engine was separated from the fuselage and found 20 feet beyond the main fuselage. The propeller and hub remained attached to the engine. The engine case was intact and not fractured. The propeller hub displayed rotational twisting and scratches. Both propeller blades displayed chord wise twisting. The propeller hub, blades, and engine received similar post accident fire damage.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on Mr. Jan Shaffer, on November 18, 1994, by Dr. Elizabeth K. Balraj,M.D., Office of the Coroner, Cuyahoga County, Ohio.

The toxicological testing report, from the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for drugs and alcohol for Mr. Jan Shaffer.

TESTS AND RESEARCH

The NTSB Metallurgist's Factual Report was able to confirm the components identification and their respective connection locations. The specific location of the initial source of the fire on the CFH could not be determined.

ADDITIONAL INFORMATION

The CFH used in this airplane was the Model 979-B1, manufactured by the South Wind Division of the Stewart-Warner Corporation. According to a receipt supplied by Mr. Shaffer's family, the CFH in N1527D was replaced in February 1992, by Lorain County Aviation Inc., Elyria, Ohio.

The CFH is a 18,000 BTU/hour heater. All flames and products of combustion occur within a sealed, all welded, stainless steel combustion chamber. In the Cessna 195, the CFH is located below the aft passenger seat, recessed half of its height down into the floor of the airplane. Three feet aft of the CFH, is the lower anti-collision light, mounted on the bottom of the fuselage. The CFH uses fuel from the left wing fuel tank. The CFH 1/8 inch fuel line taps directly into the left wing 5/8 inch fuel line which feeds directly into the engine fuel selector valve. The connection is accomplished at a "T" fitting, without the use of a shut off valve.

According to the Cessna 195 Owner's Manual and Parts Catalog, the 1/8 inch line attaches to a safety valve and fuel filter, then proceeds to a fuel control unit (FCU) located on the CFH. The Cessna publications, depict and describe the location of the safety valve and fuel filter, to be in the left fuselage wall. This area of the fuselage section of N1527D was intact. There was no evidence of a safety valve or fuel filter installation in this area. The 2 foot long, 1/8 inch fuel line, was extended and curved approximately 90 degrees at the center of the line. This line was compared to the fuel line tap and CFH installation of another Cessna 195. The shape and length of the 1/8 inch line was sufficient to connect the fuel line tap and the CFH.

The safety valve stores a quantity of fuel to start the CFH. This prevents the unrestricted head pressure of the main fuel tank from being applied directly to the FCU during the start sequence. Fuel to sustain combustion is permitted to flow only after the shut-off solenoid of the safety valve is energized by a heat sensor on the CFH, indicating the heater is operating.

A portion of a fuel filter was located in the fire debris forward of the CFH and aft of the pilot's seat. The safety valve was not located.

The fuel control unit (FCU) serves two purposes. An electrical connection in the FCU opens and closes a valve in the FCU which starts and stops the flow of fuel to the CFH. This circuit is operated by the pilot when the heater switch is activated. The FCU also regulates the pressure and quantity of fuel to the CFH when the unit is turned on.

The Stewart-Warner Service Manuals for the Model 979-B1, and 977B, depict identical designs with two exceptions. The 979 has a 12 volt electric system, and a fuel safety valve and filter in the fuel supply line. The 977 has a 6 volt electric system, and operates without a fuel safety valve and filter.

According to the South Wind Service Manual for the 979-B1, "All fuel lines should incorporate vibration loops to prevent breakage as a result of vibration in the aircraft during flight. The use of a flexible fuel line between the safety valve and the fuel control valve of the heater is highly recommended.

During examination of the wreckage, none of the CFH fuel lines were observed to contain loops, nor were any flexible lines identified.

The airplane wreckage was released on November 19, 1994, to Mrs. Emily Rose Shaffer, the wife of the pilot and owner of the airplane.

NTSB Probable Cause

the improper installation of a cabin heater system, resulting in an in-flight fire and subsequent loss of control and collision with trees.