CEN22LA141

NTSB accident investigation · Cessna 150M · Brodhead, WI · March 13, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
March 13, 2022, 12:40 local (17:40 UTC)
Place
Brodhead, WI
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N63246Cessna 150M
Defining event
Approach-VFR pattern downwind: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20220313003189A
Case key
104769

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 loss of engine power due to the fatigue fracture of the No. 1 cylinder’s rocker shaft bosses, which resulted in a forced landing into uneven terrain.

Findings · 2

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.

Terrain: rough terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna 150M: 2 casesAll aircraft: 442 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 pilots reported the engine began to vibrate and lose power while on the downwind leg in the traffic pattern. The pilot in the right seat took control and attempted to conduct a downwind forced landing to the runway, but the airplane’s flight path continued beyond the end of the runway into uneven terrain and the airplane nosed over. The airplane sustained substantial damage to both wings and the vertical stabilizer. Postaccident examination revealed the No. 1 cylinder rocker shaft bosses were fractured. Further examination of fracture surfaces with a stereomicroscope revealed fatigue crack initiation at and progression from the rocker shaft bore hole. In 1996, based on a history of fatigue cracking of cylinder rocker shaft bosses, the Federal Aviation Administration issued an airworthiness directive (AD) that required inspection of the cylinder shaft rocker bosses at the next overhaul or cylinder removal. Since the engine was last overhauled in 1978 and the No. 1 cylinder was last removed 1991, compliance with the AD was not required for the accident airplane’s No. 1 cylinder.

Factual narrative

On March 13, 2022, about 1240 central daylight time, a Cessna 150M, N63246, was substantially damaged when it was involved in an accident at Brodhead Airport (C37), Brodhead, Wisconsin. The two pilots sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilots reported that they flew two visual approaches without incident to runway 27 at C37. While on downwind for a third approach, the engine began to vibrate violently and lost power. The pilots attempted a forced landing to runway 9. The flight path continued beyond the end of the turf runway and the airplane nosed over, which resulted in damage to both wings and the vertical stabilizer. During the postaccident examination of the engine the No. 1 cylinder valve rocker cover was removed and the two rocker arms, pivot shaft, and pieces of the cylinder shaft rocker bosses came off freely with the rocker cover. Examination of the rocker boss fracture surfaces with the aid of a stereomicroscope revealed fatigue crack initiation at and progression from the rocker shaft bore hole. In 1996, the Federal Aviation Administration issued an AD 94-05-05 R1 that required inspection of the cylinder rocker shaft bosses at the next engine overhaul or cylinder removal, whichever occurred first. The AD was issued based on a history of fatigue cracking and separation of cylinder rocker shaft bosses of the installed cylinders. A review of maintenance records indicated the AD was not required to be complied with for the installed cylinders since the engine was last overhauled in 1978 and the No. 1 cylinder was last removed in 1991. A search of previous National Transportation Safety Board reports revealed one accident after the AD issuance that involved failure of rocker shaft bosses. This accident occurred on June 27, 1998.

Aircraft

Registration
N63246
Reported as
Cessna 150M
Category
Airplane
Serial number
15077200
Built
1975
Airframe hours
3,832
Engine
Continental O-200-A, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 13, 2021 · 50 hours before
Departed
EFT · Monroe, WI
Destination
C37 · Brodhead, WI
Airport
C37 · Brodhead, runway 09, 2,430 × 155 ft, grass/turf

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
July 20, 2021
Seat
Left
Restraint
Lap only
Flight hours
190 total · 190 in this make and model
Role
Pilot
Age
61
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
March 5, 2020
Seat
Right
Restraint
Lap only
Flight hours
934 total · 400 in this make and model · 22 in the last 90 days · 10 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 25 °F
Altimeter
29.91 inHg
Observed at
KEFT, 10 nm away
METAR
KEFT 131735Z AUTO 28013KT 10SM CLR 06/M04 A2991 RMK AO2 T00571036

Docket · 9

The files NTSB released with the investigation on August 15, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.3 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.