CEN15LA414

NTSB accident investigation · Cessna 172P · Nutwood, IL · September 16, 2015

Accident · Minor injuriesLimited investigationFinal report
Date
September 16, 2015, 10:30 local (15:30 UTC)
Place
Nutwood, IL
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N65191Cessna 172P
Defining event
Landing: Nose over/nose down
Weather
Visual (VMC) · Day
Status
Completed · report January 21, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20150916014639A
Case key
91984

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

On this page

Probable cause

A partial loss of engine power due to the undetected loosening of the four carburetor bolts that connect the throttle body to the bowl assembly.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Inadequate inspectionCessna 172P: 2 casesAll aircraft: 195 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 172P: 3 casesAll aircraft: 320 casesProbable cause
Engine fuel and control: fuel control/carburetorAircraft › Aircraft power plant · MalfunctionCessna 172P: 2 casesAll aircraft: 195 casesProbable cause
TerrainEnvironmental issues › Physical environment · Contributed to outcomeCessna 172P: 3 casesAll aircraft: 267 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that, while maneuvering the airplane at 3,000 ft mean sea level, the engine lost partial power and began running roughly. After unsuccessfully attempting to regain normal engine power, the pilot executed a forced landing into a field, during which the airplane nosed over. Postaccident examination of the carburetor revealed a gap between the throttle body and bowl assembly, and all four bolts connecting the throttle body to the bowl assembly were found loose. Both the engine and carburetor manufacturers had previously issued service bulletins (SB) regarding possible leakage between the bowl assembly and throttle body, likely due to loose bowl to throttle body screws. The SBs recommended inspecting the carburetor screws every 100 hours of engine operation. The last 100-hour inspection of the engine occurred 89 hours before the accident.

Factual narrative

On September 16, 2015, about 1030 central daylight time, a Cessna 172P airplane, N65191, was substantially damaged during a forced landing near Nutwood, Illinois. The pilot sustained minor injuries. The airplane was registered to and operated by Sixninethreeone LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the local flight, which departed from the St. Charles County Smartt Airport (SET), St. Charles, Missouri, about 1000. While maneuvering at 3,000 feet msl, the pilot stated the engine lost partial power and ran rough. After unsuccessfully attempting to regain normal engine power, the pilot executed a forced landing into a field. The airplane nosed over during rollout and damaged the right wing. During post-accident examination of the carburetor, Federal Aviation Administration personnel noted a gap was present between the throttle body and bowl assembly. It was also noted that the four bolts which connect the throttle body to the bowl assembly were loose. Marvel Schebler Service Bulletin (SB)-17, dated August 12, 2010, with a subject of, "Body to Bowl Fuel Leaks", directs an inspection of the carburetor every 100 hours of engine operation. The SB indicates reports of loose body to bowl joints, with resulting leakage past the gasket between the bowl and throttle body. The SB further indicates that the leakage may be accompanied by loose bowl to throttle body screws. The compliance section of the SB indicates to visually inspect the carburetor for evidence of looseness of the bowl relative to the throttle body. The SB goes on to say that if looseness is detected, the carburetor must be removed from the engine and to inspect the threaded holes in the bowl and screws to assure the threads are serviceable. A new gasket and lock tab washers are to be installed, and the carburetor is to be tested in accordance with the appropriate service manual. Lycoming mandatory SB-366B, dated April 18, 2008, also directs an inspection of the carburetor every 100 hours of engine operation. The compliance section of the Lycoming SB is parallel to the Marvel Schebler SB. The last 100 hour inspection of the engine occurred 89 hours prior to the accident. The director of maintenance stated that maintenance personnel were aware of the Lycoming SB and were checking carburetor screws for looseness, but were not documenting accomplishment of the SB in engine logbooks.

Aircraft

Registration
N65191
Reported as
Cessna 172P
Category
Airplane
Serial number
17275705
Built
1982
Airframe hours
8,071
Engine
Lycoming O-320 SERIES, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Sixninethreeonea LLC
Registered owner
Sixninethreeonea LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 30, 2015 · 89 hours before
Departed
KSET · St Charles, MO
Destination
KSET · St Charles, MO
Equipment
Stall warning system

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
66
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
September 12, 2014
Seat
Left
Restraint
3-point
Flight hours
300 total · 300 in this make and model · 167 as pilot in command · 5 in the last 90 days · 2 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 59 °F
Altimeter
30.20 inHg
Observed at
KSET, 11 nm away

Docket · 4

The files NTSB released with the investigation on December 7, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.1 MB in all.

FAA reports on this event · 1

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