CEN24LA350

NTSB accident investigation · Cessna 172 · Englewood, CO · September 11, 2024

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
September 11, 2024, 09:40 local (15:40 UTC)
Place
Englewood, CO
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N20747Cessna 172
Defining event
Initial climb: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
All ATP, FAA FSDO, Lycoming Engines
FAA report
20240911012829A
Case key
195102

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 fuel-oil contamination of the fuel injection servo.

Findings · 1

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 · Damaged/degradedTextron 172S: 1 caseAll aircraft: 195 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

While performing touch-and-go landings, the flight instructor and student pilot noticed a partial loss of engine power on climbout, about 200 ft above ground level (agl). The flight instructor reported the tachometer read 2,100 and then 1,600 rpm. During a forced landing to a golf course, the airplane’s nose landing gear collapsed and the airplane came to rest inverted. A postimpact test of the engine’s fuel injection servo found fuel flow below the minimum service limit at most test points. When the servo was disassembled, a thick blue liquid consistent with a fuel-oil mixture was found in the venturi chambers. Oil residue was noted in the hex plug and air diaphragm, the spring and stem assembly, and the air passage to the air diaphragm. No other anomalies were detected with the engine. A service bulletin from the fuel injection servo manufacturer states that this type of contamination could cause an engine to exhibit “gradually deteriorating idle, difficulty starting and/or cold engine acceleration performance.” The flight school was aware of the service bulletin and was inspecting airplanes that had the engine symptoms listed in the service bulletin. It is likely that contamination of the fuel injection servo resulted in a partial loss of engine power and subsequent forced landing.

Factual narrative

On September 11, 2024, about 0940 mountain daylight time, a Cessna 172S airplane, N20747, was substantially damaged when it was involved in an accident near Englewood, Colorado. The flight instructor was not injured and the student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilots were performing touch-and-go landings on runway 17R at Centennial Airport (APA), Englewood, Colorado. On climbout for the traffic pattern, when the airplane was about 200 ft agl, the pilots noticed a partial loss of engine power. The instructor reported the tachometer read 2,100 and then 1,600 rpm. He performed a forced landing to a golf course. During the landing roll, the airplane’s nose landing gear collapsed and the airplane came to rest inverted. A review of maintenance logbook entries found that on September 5, 2024, about one week before the accident flight, another pilot reported that the airplane “was only getting 2,000 rpm at max power and was backfiring constantly in the run-up.” However, maintenance personnel found that the engine operated satisfactorily during a subsequent ground run-up. The airplane was then flown daily without any reported engine problems until the accident takeoff. A postimpact examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. However, during a bench test of the engine’s fuel injection servo (AVStar part number LFR-NNSS5), fuel flow was below the minimum service limit at most test points. When the servo was disassembled, a thick blue liquid consistent with a fuel-oil mixture was found in the venturi chambers. Oil residue was noted in the hex plug and air diaphragm, the spring and stem assembly, and the air passage to the air diaphragm. The AVStar LFR-NNSS5 is a variant of the RSA-5AD1 fuel injection servo and was mounted in an updraft configuration on the accident airplane. AVStar service bulletin AFS-SB10, Fuel Servos Installed in an Updraft Configuration, is applicable to RSA-5AD1 servos and states: There have been occasional reports of servo equipped engines that exhibit one or more of the following characteristics - gradually deteriorating idle, difficulty starting and/or cold engine acceleration performance. These engines may have the servo mounted in an updraft, or nearly updraft configuration. Close inspection of the servo may reveal oily contaminant in the bore of the servo that is green/blue in color. It is also possible for this contaminant to migrate into the air section of the regulator. The Precision Airmotive service information letter SIL RS-40, Service Information For RSA-5 Series Fuel Injection Servos Installed in Updraft Configuration, similarly notes reports of reduced engine performance and recommends inspection of fuel injection servos for contamination if these problems are experienced. The flight school’s maintenance personnelstated they were aware of AVStar AFS-SB10 and Precision Airmotive SIL ARS-40 and routinely inspected their airplanes that had any symptoms listed in AFS-SB10. In addition, they reported that they caution their pilots against over-priming the engine during engine starts.

Aircraft

Registration
N20747
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S12578
Built
2020
Airframe hours
3,448
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
ATP Flight School
Registered owner
Atpce LLC
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · August 28, 2024 · 65 hours before
Equipment
Electronic multifunction display, Electronic flight bag or handheld device, ADS-B, Stall warning system, Onboard weather, Electronic primary flight display

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
25
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 6, 2024
Seat
Right
Restraint
3-point
Flight hours
720 total · 607 in this make and model · 675 as pilot in command · 283 in the last 90 days · 64 in the last 30 days · 5 in the last 24 hours
Role
Student pilot
Age
33
Injuries
Minor
Seat
Left
Restraint
3-point
Flight hours
18 total · 18 in this make and model · 18 in the last 90 days · 18 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 7 knots
Visibility
10 statute miles
Lowest ceiling
22,000 ft broken
Temperature
72 °F, dew point 39 °F
Altimeter
30.02 inHg
Observed at
KAPA, 1 nm away
METAR
KAPA 111553Z 30007KT 10SM FEW130 BKN220 22/04 A3002 RMK AO2 SLP095 T02220039

Docket · 8

The files NTSB released with the investigation on May 8, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.5 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.