CEN20LA014

NTSB accident investigation · Cessna 172 · Swea City, IA · October 25, 2019

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
October 24, 2019, 21:00 local (Oct 25, 2019, 02:00 UTC)
Place
Swea City, IA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1443ECessna 172
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20191024016919A
Case key
100490

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

The pilot's failure to replace the oil filler cap during his preflight inspection, which resulted in oil starvation and a subsequent total loss of engine power.

Findings · 3

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.

Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 172N: 4 casesAll aircraft: 551 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna 172N: 1 caseAll aircraft: 174 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Incorrect service/maintenanceCessna 172N: 1 caseAll aircraft: 174 casesProbable cause

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 conducted a preflight inspection of the airplane in preparation for a night cross-country flight, during which he added a half quart of oil to the engine. During the flight, the pilot noticed that the oil pressure gauge was near zero. The pilot diverted back to his departure airport; the engine started to shake, then lost all power, and he subsequently conducted a forced landing to a road. Examination of the airplane noted substantial damage to the fuselage and engine oil on the side of the cowling; the engine oil filler cap/dipstick was located 2 to 3 ft in front of the airplane. Borescope examination of the engine revealed scoring on the Nos. 2 and 4 cylinders, consistent with inadequate lubrication. In a follow-up interview with the pilot, he stated that he typically placed the oil filler cap/dipstick in the wing's tie-down loop when checking the engine oil level or adding oil. It is likely that the pilot forgot to replace the dipstick during his preflight inspection, which resulted in the loss of engine oil in flight and a subsequent total loss of engine power due to oil starvation.

Factual narrative

On October 24, 2019, about 2100 central daylight time, a Cessna 172 airplane, N1443E, conducted a forced landing near Swea City, Iowa. The pilot, the sole occupant, received minor injuries, and the airplane sustained substantial damage. The airplane was registered to Iowaair, Inc, and operated by Iowa Flight Training, under the provisions of Title 14 Code of Federal Regulations Part 91 as a cross-country flight. Night visual meteorological conditions prevailed for the flight and no flight plan had been filed. The multi-leg flight originated from the Estherville Municipal Airport (EST), Estherville, Iowa, The pilot reported that he conducted a preflight inspection of the airplane. He added a half quart of oil to the engine from a bottle that was in the airplane. He also got another bottle of engine oil from the FBO (Fix Based Operator) to keep in the airplane. He disposed of the empty oil bottle and continued with his preflight. After engine start and before takeoff, he noted that both oil pressure and temperature gauges "seemed to read within the green range". While on the night cross-country flight, about half-way between Mason City and Fort Dodge, the pilot noticed that the oil pressure gauge indicated near zero, so he diverted back to EST. Shortly afterwards, the engine started to shake and then stopped producing full power. The airplane was unable to hold altitude, so he elected to conduct a forced landing to a road. An examination of the airplane by the responding Federal Aviation Administration (FAA) inspector found the airplane had impacted a dirt road and came to rest upright, in the ditch. Substantial damage was noted to the airplane's fuselage. The inspector also noted engine oil on the side of the cowling, and the engine's oil dipstick was on the ground, about 2 to 3 ft in front of the airplane. In a follow-up interview with the pilot, the FAA inspector reported the pilot would typically place the oil dipstick in the wing's tie down loop, when he checked or added oil to the engine. After the airplane was recovered to a hangar, an engine examination was conducted by maintenance personnel under the supervision of the FAA. Oil was observed on the firewall and the airplane's right-side fuselage. The oil filter was cut open and the engine borescoped; scoring on the number two and four cylinders was observed.

Aircraft

Registration
N1443E
Reported as
Cessna 172 (N)
Category
Airplane
Serial number
17271003
Built
1978
Airframe hours
4,063.8
Engine
Lycoming O-320 SERIES, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Iowa Flight Training
Registered owner
Iowair Inc Dba
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · September 22, 2019
Departed
KMCW · Mason City, IA
Destination
KFOD · Fort Dodge, IA

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
20
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Flight hours
182 total · 28 in this make and model · 130 as pilot in command · 31 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
10 statute miles
Temperature
28 °F, dew point 25 °F
Altimeter
30.35 inHg

Docket · 6

The files NTSB released with the investigation on December 10, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.5 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.

Other investigations on N1443E · 1

Matched to the same aircraft by N-number and date.