# NTSB CEN20LA014: Cessna 172, N1443E, Swea City, IA, October 25, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: October 24, 2019, 21:00 local (Oct 25, 2019, 02:00 UTC) - Place: Swea City, IA - Coordinates: 43.384166, -94.320274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.3842&lon=-94.3203&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 100490 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100490/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100490 - Page: https://openairdocs.org/ntsb/CEN20LA014 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172N, 4 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072434), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 172N, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=2072434), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Incorrect service/maintenance (probable cause); cases with it: [Cessna 172N, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=2072434), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna 172N, 3 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=2072434), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172N, 28 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072434), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172N, 31 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072434), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N1443E-2023-04-24), registration cancelled 2023-04-24, S/N 17271003, built 1978 (OpenAirDocs) - Reported make and model: Cessna 172 (N) - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17271003 - Year built: 1978 - Airframe hours: 4063.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 20; injuries: minor; 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 ## 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 20191024016919A](https://openairdocs.org/incident/20191024016919A), Oct 24, 2019: Cessna 172N, Swea City, IA, Substantial damage. The aircraft involved was substantially damaged when it impacted a ditch after an emergency approach to land initiated by the pilot. The pilot sustained minor… ## Other investigations on N1443E (1) 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. - [NTSB CHI83LA432](https://openairdocs.org/ntsb/CHI83LA432), Sep 18, 1983: Cessna 172 (N1443E), Carthage, IL, substantial damage ## Docket (6 files) The files NTSB released with the investigation on December 10, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100490. 7.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478913&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Reports from Federal Agencies (item 2, .PDF, 323 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478914&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-Master.PDF - Memo (item 3, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478915&FileExtension=.PDF&FileName=Memo-Master.PDF - Maintenance Records (Excerpts) (item 4, .PDF, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478916&FileExtension=.PDF&FileName=Maintenance%20Records%20(Excerpts)-Master.PDF - Photos (item 5, .PDF, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478917&FileExtension=.PDF&FileName=Photos-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478918&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.