NTSB CAROL · Event
Event LAX99LA314
Registry · N39AE
FAA Aircraft Registry record.
Make / Model
BELL 407
Year of manufacture
1997 · 2 years old at event
TCDS
H2SW · BELL HELICOPTER TEXTRON CANADA LTD
Engine
ROLLS-ROYC 250-C47 SER (650 hp)
Seats / Engines
7 seats · 1 engine
Last airworthiness date
20191212
ADS-B equipped
Yes — Mode-S A48075
Registrant of record
AIR EVAC EMS INC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
A loss of engine power due to fuel system contamination, which resulted from the mechanic's failure to fully inspect and verify the serviceability of the fuel system before returning the aircraft to service for a maintenance ferry flight. The pilot's decision to attempt flight with unresolved discrepancies in the reliability of the engine to produce power was a factor in the accident.
Factual narrative
On September 20, 1999, about 1139 hours Pacific daylight time, a Cessna 177A, N39AE, ditched in Big Bear Lake after losing power near Big Bear City, California. The aircraft sustained substantial damage; however, the certificated airline transport pilot, the sole occupant, was not injured. The aircraft was being operated under the provisions of 14 CFR Part 91 by the pilot as a maintenance test flight when the accident occurred. The flight originated from the Big Bear City Airport about 1130. Visual meteorological conditions prevailed at the time and no flight plan was filed. The pilot reported that the aircraft had been parked outside, on the ramp, for nearly 7 months. The owner had reported that the left main tank had been "seeping." At the time the aircraft was parked, both fuel drains were removed and all fuel was drained from the tanks. At the end of the period of inactivity, an airframe and powerplant mechanic (A&P) replaced the fuel drain in the aircraft's right tank and added fuel to prepare the aircraft for a ferry flight to Corona, California. After sitting for most of a day, no leaks were noted. The mechanic then added enough additional fuel to bring the level up to 20 gallons. The pilot performed a preflight and before takeoff checks; however, the engine stalled once during taxi. On the first flight, the pilot had climbed to 8,000 feet msl when he found that the engine began to miss and run roughly. After returning, the pilot again drained the fuel sumps and obtained a "small amount of water" from the gascolator. He then drained an additional gallon of fuel from the tank, and at that time, did not find any additional water or sediment. The pilot's procedures were observed by the mechanic. Prior to takeoff on the accident flight, the pilot again performed the same preflight and before takeoff checks. This time the checks were performed without incident. The mechanic did not perform or offer to perform any additional troubleshooting procedures between the first and second flight. The pilot reported that he took off with about 18 gallons of fuel in the right main tank. After takeoff, he climbed to 7,500 feet msl heading east of the airport and over the lake. After reaching 7,500 feet, the engine began surging and then quit. He turned on the electric fuel boost pump, pushed the mixture handle into the "full rich" position, and "pumped" the throttle. When his attempts to restart the engine failed, he turned back toward the airport but was unable to reach the runway. He ditched the airplane in about 1.5 feet of water, 50 yards from the south shore of the lake, west of the Stanfield cutoff. After touching down, the aircraft nosed over and came to rest on its back. The pilot turned off the electric fuel pump and master switch, and crawled out of the cockpit and onto the wing. He waited there until rescued by boaters who had witnessed the accident. On November 1, 1999, a Safety Board investigator examined the engine and airframe at Action Towing and Recovery in Fresno, California. A cold compression check of the Nos. 1 through 4 cylinders revealed the following readings: 62, 61, 61, and 63 psi, respectively. All four top spark plugs were removed and examined. The tips of all four plugs were covered with a similar looking brownish substance consistent with the color and texture of rusted metal. The inside of the gascolator was found to be coated with an apparently insoluble greenish-brown film. The left wing fuel quantity transmitter was removed and examined. It was coated with material that was similar in appearance to silicon sealant. The material was decomposing and readily flaked off when touched. The fuel reservoir drain plug was removed and approximately 10cc of liquid was recovered. The liquid precipitated into a lower layer and upper layer in a manner similar to the precipitation that follows the mixture of water and gasoline. The sample also contained some heavier sediment that was similar in color and consistency as to the sealant-like material found on the fuel quantity transmitter. The above noted discrepancies were located in areas that are not accessible or serviceable by a pilot performing a preflight inspection or before takeoff checks. The aircraft was parked outside on the ramp for several months, with the fuel drains removed and the tanks drained. An A&P mechanic replaced the fuel drain in the right tank and added fuel for a maintenance ferry flight. The pilot performed a preflight and before takeoff checks. The engine stalled once during taxi, then began to miss and run roughly after takeoff. After returning, the pilot drained the fuel sumps and found a 'small amount of water' in the gascolator. He then drained an additional gallon of fuel from the tank without finding any additional water or sediment. After takeoff on the second flight, the engine began surging and then quit. When attempts to restart the engine failed, he turned back toward the airport but could not reach the runway and ditched the airplane in the water. The mechanic did not perform or offer to perform any additional troubleshooting procedures between the first and second flight. The inside of the gascolator was coated with an insoluble greenish-brown film. The left wing fuel quantity transmitter was coated with material that was similar in appearance to a non-silicon sealant. The material was decomposing and readily flaked off when touched. About 10cc of liquid was recovered from the fuel reservoir; about half was water, with a heavier sediment that was similar in color and consistency as to the material coating the fuel quantity transmitter. The above noted discrepancies were located in areas that would not be accessible or serviceable by a pilot performing a preflight inspection. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1999_LAX99LA314.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
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Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- Semantic Scholar 2025 · Article (Applied Sciences)
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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