# NTSB CEN17LA311: Cessna 172S, N5274Q, Wellston, OH, August 9, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: August 9, 2017, 12:20 local (16:20 UTC) - Place: Wellston, OH - Coordinates: 39.125, -82.53833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1250&lon=-82.5383&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report January 25, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Textron Aviation, Lycoming Engines, Federal Aviation Administration - ADs cited in the narratives: [AD 2017-16-11](https://openairdocs.org/ad/2017-16-11) (OpenAirDocs) - NTSB case key (mKey): 95791 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA311 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95791/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95791 - Page: https://openairdocs.org/ntsb/CEN17LA311 ## Probable cause The failure of a connecting rod small end bushing, which resulted in a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 172S, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2072439), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Terrain: sloped/uneven terrain](https://openairdocs.org/ntsb-findings/03021017): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 172S, 3 cases](https://openairdocs.org/ntsb-findings/03021017/cases.md?model=2072439), [All aircraft, 270 cases](https://openairdocs.org/ntsb-findings/03021017/cases.md) - [Object/animal/substance: fence/fence post](https://openairdocs.org/ntsb-findings/03022047): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 172S, 7 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md?model=2072439), [All aircraft, 313 cases](https://openairdocs.org/ntsb-findings/03022047/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172S, 19 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072439), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172S, 118 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The commercial pilot and observer were conducting an aerial observation flight of a pipeline. The pilot reported that, while maneuvering at a low altitude toward an airport to refuel, he heard a "significant boom" and noticed a reduction in engine rpm. The pilot unsuccessfully attempted to regain engine power and then initiated a forced landing to a space between trees. During the forced landing, the airplane impacted rolling, uneven grass terrain and a barbed wire fence. Examination and disassembly of the engine revealed a large hole on the top of the engine crankcase inboard of the No. 4 cylinder. The examination revealed that the No. 4 connecting rod had failed due to the installation of a nonconforming small end connecting rod bushing. Five days before the accident, the engine manufacturer had issued a mandatory service bulletin indicating that the accident connecting rod bushing may not have met engine specifications and may require followup action. Six days after the accident, the Federal Aviation Administration issued an airworthiness directive that required inspecting the connecting rods, replacing affected connecting rod small end bushings, and accomplishing the instructions in the engine manufacturer's mandatory service bulletin. ## Factual narrative On August 9, 2017, about 1220 eastern daylight time, a Cessna 172S airplane, N5274Q, experienced a loss of engine power while maneuvering at low altitude near Wellston, Ohio. The pilot and passenger sustained minor injuries, and the airplane sustained substantial damage. The airplane was registered to and operated by KCSI Texas, Inc., under the provisions of 14 Code of Federal Regulations Part 91 as an aerial observation flight. Visual meteorological conditions prevailed and a company visual flight rules flight plan had been filed. The flight departed Newark-Heath Airport (VTA), Newark, Ohio, about 1330, and was destined for James A. Rhodes Airport (I43), Jackson, Ohio. The pilot and observer were conducting an aerial observation flight of a pipeline. While maneuvering toward I43 to refuel, the pilot heard a "significant boom" and noticed a reduction in engine rpm. The pilot unsuccessfully attempted to regain rpm and then initiated a forced landing to a green space between trees. During the forced landing, the airplane impacted rolling, uneven grass terrain, and a barbed wire fence. The airplane sustained substantial damage to the right wing and fuselage. Examination of the engine by a Federal Aviation Administration (FAA) inspector noted a large hole on the top of the engine crankcase. The airplane was recovered for further examination. On August 24, 2017, the engine was examined at a recovery facility by a Lycoming Engine representative under the supervision of a FAA inspector. Examination and disassembly of the engine revealed a large hole at the top of the crankcase inboard of the No. 4 cylinder. According to Lycoming Engines, the No. 4 connecting rod failed at the small end bushing. The other 3 connecting rod small end bushings were found displaced forward from their normal positions, and the No. 3 connecting rod small end bushing was free to move by hand. A review of the aircraft maintenance records revealed the engine was field overhauled on September 2, 2016, at a total time of 2,664.5 hours. During the overhaul, Lycoming LW-13923 connecting rod upper bushings were installed (according to an invoice from Lycoming Engines, the bushings were shipped from the factory on June 30, 2016). The most recent 100-hour inspection was completed on June 15, 2017, at 503.5 hours since major overhaul (SMOH). On July 20, 2017, at 556.4 hours SMOH, the engine oil was changed with no anomalies noted in the oil filter or oil suction screen. The July 2017 oil change record was the last record in the engine logbook. On August 4, 2017, Lycoming Engines issued mandatory service bulletin (MSB) No. 632B, Identification of Connecting Rods with Non-Conforming Small End Bushings. According to the MSB, LW-13923 connecting rod bushings, shipped between November 18, 2015, and November 15, 2016, may be suspected as not meeting Lycoming Engine specifications and require follow-up corrective action. The MSB stated the following warning, "You must complete the 'requiredaction' in this service bulletin to ensure that your connecting rod bushings are properly seated. If a connecting rod bushing becomes unseated, the connecting rod can fail, causing an uncommanded and complete loss of power." The MSB time of compliance was within the next 10 hours of engine operation. The FAA issued an airworthiness directive (AD) 2017-16-11, effective August 15, 2017, which required the inspection of connecting rods and replacement of affected connecting rod small end bushings. The AD required accomplishing the instructions in Lycoming Engines MSB No. 623B. ## Aircraft - Registration: [N5274Q](https://openairdocs.org/deregistered/N5274Q-2021-12-04), registration cancelled 2021-12-04, S/N 172S9199, built 2002 (OpenAirDocs) - Reported make and model: CESSNA 172S (S) - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S9199 - Year built: 2002 - Airframe hours: 6300.4 - Engines: LYCOMING IO-360-L2A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial observation, Part 91 - Operator: Kcsi Texas Inc - Registered owner: Kcsi Texas Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 15, 2017 - Departed: VTA, Newark, OH - Destination: I43, Jackson, OH - Flight plan: Company VFR - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 26; injuries: minor; commercial; airplane ratings: multi-engine land, single-engine sea, multi-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 9, 2017; seat: left; restraint: 3-point; flight hours: 5,650.7 total, 1,500 in this make and model, 5,500 as pilot in command, 127 in the last 90 days, 35 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 54 °F - Altimeter: 30.23 inHg - Observed at: UNI, 20 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20170809012839A](https://openairdocs.org/incident/20170809012839A), Aug 9, 2017: Cessna 172S, Wellston, OH, Substantial damage. On August 9, 2017, at approximately 1220 EDT, a Cessna 172-S experienced a loss of engine power while maneuvering near Wellston, Ohio. The pilot and passenger… ## Docket (12 files) The files NTSB released with the investigation on November 3, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95791. 6.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457697&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (item 2, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457698&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF - Excerpt of Lycoming Report (item 3, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457699&FileExtension=.PDF&FileName=Excerpt%20of%20Lycoming%20Report-Master.PDF - Excerpts of Engine Records (item 4, .PDF, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457700&FileExtension=.PDF&FileName=Excerpts%20of%20Engine%20Records-Master.PDF - Invoice - Bushings (item 5, .PDF, 225 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457701&FileExtension=.PDF&FileName=Invoice%20-%20Bushings-Master.PDF - Engine Repair Order (item 6, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457702&FileExtension=.PDF&FileName=Engine%20Repair%20Order-Master.PDF - Lycoming Service Bulletin (item 7, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457703&FileExtension=.PDF&FileName=Lycoming%20Service%20Bulletin-Master.PDF - FAA AD 2017-16-11 (item 8, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457704&FileExtension=.PDF&FileName=FAA%20AD%202017-16-11-Master.PDF - Statement of Party Representatives to NTSB Investigation - Lycoming (item 9, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457705&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Lycoming-Master.PDF - Statement of Party Representatives to NTSB Investigation - Textron (item 10, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457706&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Textron-Master.PDF - Statement of Party Representatives to NTSB Investigation - KCSI (item 11, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457707&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20KCSI-Master.PDF - Photo Array (item 12, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40457708&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.