ATL05TA055

NTSB accident investigation · Cessna T-41B · Sparta, TN · March 3, 2005

Accident · Serious injuriesFinal report
Date
March 3, 2005, 16:15 local (22:15 UTC)
Place
Sparta, TN
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N14449Cessna T-41B
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2006
Report
Approved by Office Director
Parties
FAA - Nashville FSDO - 03
FAA report
20050303003299A
Case key
61086

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Improper installation of the timing reference plug by other maintenance personnel, which resulted in oil starvation, and the loss of engine power.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise
Fluid,oil - starvationCause
Maintenance,installation - improperOther maintenance personnelCause
Miscellaneous,bolt/nut/fastener/clamp/spring - missingCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency landing
Terrain condition - grassFactor

Analysis

The pilot stated the flight was cruising at 3,500 feet mean sea level when the engine began to run rough. Moments later, engine oil sprayed on the windscreen and the cockpit filled with smoke. Several hundred yards short of runway 4, the engine lost power completely, and the propeller stopped. The pilot maneuvered the airplane to avoid trees and landed in a field. The pilot stated when the nose wheel touched down, it sank into the soft ground, and the airplane nosed over. Examination of the airplane revealed the empennage was nearly separated aft of the baggage compartment, the fuselage was buckled aft of the firewall, and damage was observed on the engine crankcase. The post-accident examination of the engine revealed the timing reference plug was missing from the crankcase. The timing reference plug threads in the crankcase were not stripped. The crankshaft did not reveal any signs of movement or rotation, and the pistons, rings, and pins in all six cylinders revealed discoloration and mechanical damage.

Factual narrative

On March 3, 2005, about 1615 central standard time, a Cessna T-41B, N14449, registered to and operated by the State of Tennessee Division of Forestry, nosed over during emergency landing in Sparta, Tennessee. The public use flight was operated under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual meteorological conditions prevailed. The private pilot received serious injuries, and the airplane sustained substantial damage. The flight departed Nashville International Airport, Nashville, Tennessee, at 1544.

The pilot stated the flight was cruising at 3,500 feet when the engine began to run rough. Moments later, engine oil sprayed on the windscreen and the cockpit filled with smoke. The pilot estimated he was five or six miles from the Upper Cumberland Regional Airport, Sparta, Tennessee, and he reported the emergency on the airport common traffic advisory frequency. The pilot continued flight towards the airport. The pilot ventilated the cabin by opening the passenger-side window, and attempted to maintain engine power but could see engine oil spurting out the oil service door in the cowling. Several hundred yards short of runway 4, the engine quit completely, and the propeller stopped. The pilot maneuvered the airplane to avoid trees and landed in a field. The pilot stated the field was soft with recent rains, and when the nose wheel touched down, it sank into the soft ground, and the airplane nosed over.

Examination of the airplane revealed the empennage was nearly separated aft of the baggage compartment, the fuselage was buckled aft of the firewall, and damage was observed on the engine crankcase.

Post-accident examination of the engine revealed the timing reference plug was missing from the crankcase. The timing reference plug threads in the crankcase were not stripped. The aircraft oil pressure gauge reference (45-degree fitting) located below and between the numbers two and four cylinder was loose at the union fitting in the crankcase. The crankshaft did not reveal any signs of movement or rotation, and the pistons, rings, and pins in all six cylinders revealed discoloration and mechanical damage. The crankshaft bearings revealed scoring, discoloration, and mechanical damage concentrated at the number two connecting rod journal. The crankcase was breached above the centerline of the number two-cylinder bay. The plug gasket seating area position on the crankcase revealed staining adjacent the crankcase breach. There was no safety wire in the area of the timing reference plug.

Review of maintenance records revealed that the last 100 hour inspection was completed on December 16, 2004. During the 100-hour inspection both magnetos were installed and timed to the engine.

Aircraft

Registration
N14449
Reported as
Cessna T-41B
Category
Airplane
Serial number
R172-0208
Airframe hours
4,144
Engine
Continental IO 360-D, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Public aircraft · Part 91
Registered owner
State of Tennessee, Division of Forestry
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2004 · 0 hours before
Departed
KBNA · Nashville, TN
Destination
KSRB · Sparta, TN

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
October 1, 2003
Seat
Left
Flight hours
407 total · 298 in this make and model · 1 in the last 90 days · 1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 21 °F
Altimeter
30.06 inHg
Observed at
KBNA

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.