DEN04LA136

NTSB accident investigation · Cessna 182 · Gillette, WY · September 6, 2004

Accident · No injuriesLimited investigationFinal report
Date
September 6, 2004, 17:45 local (23:45 UTC)
Place
Gillette, WY
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2725GCessna 182
Weather
Visual (VMC) · Day
Status
Completed · report July 7, 2005
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Casper Flight Standards Field Office
FAA report
20040906020939A
Case key
60062

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

improper engine overhaul performed by the mechanic which resulted in the fractured exhaust valve and subsequent partial loss of engine power. Contributing to the accident was the lack of suitable terrain for a forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(partial) - mech failure/malfCruise
Engine assembly,piston - fractured
Engine assembly,valve,exhaust - fracturedCause
Maintenance,installation - not performedOther maintenance personnel
Maintenance,overhaul - improperOther maintenance personnelCause
Forced landingDescent - emergency
Emergency procedure - initiatedPilot in command
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - none suitableFactor
Terrain condition - rough/uneven
Terrain condition - ground

Analysis

The pilot stated he was in cruise flight when the engine began to run rough. He heard sounds of grinding metal and shortly thereafter, the "engine began to shake violently." The pilot shut the engine down and attempted a forced landing to a plowed field. During the forced landing, the nose wheel impacted a small rut, separating the nose landing gear tire from the nose landing gear assembly. The airplane nosed over, causing substantial damage. An internal examination of the engine showed the number 3 piston, piston rings, and tension springs, and the number 3 exhaust valve head had fragmented into numerous pieces. These pieces were located in the oil sump. The inside of the crankcase halves showed impact damage in the areas aft of the number 4 piston and forward of the number 3 piston. The top inside of the number 3 cylinder head showed numerous impact marks including a 7/8 inch long, 1/8 inch wide and 1/8 inch deep indentation at one of the spark plug openings, and a 1/2 inch long, 1/8 inch wide, and 1/8 inch deep indentation at the area of the exhaust valve seat which were consistent with a valve head edge impact. The number 3 exhaust valve seat was not present. The number 3 exhaust valve stem was removed and examined. Fractures observed on the valve stem were consistent with an overload failure. The number 3 exhaust valve guide showed elongating distortion. An examination of the crankshaft, camshaft, other cylinders, pistons, valves, and valve springs showed no pre-existing failures. No evidence of the number 3 exhaust valve seat was found among the fractured pieces in the engine. An examination of the remaining airplane systems revealed no anomalies.

Factual narrative

On September 6, 2004, approximately 1745 mountain daylight time, a Cessna 182, N2725G, piloted by a private pilot, was substantially damaged during a forced landing 8 nautical miles southwest of Gillette, Wyoming. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot reported no injuries. The cross-country flight originated at Casper, Wyoming, at 1700.

According to the accident report submitted by the pilot, he was in cruise flight when the engine began to run rough. In a telephone conversation with the pilot, he stated he heard sounds of grinding metal. Shortly thereafter, the "engine began to shake violently." The pilot shut the engine down and attempted a forced landing to a plowed field. During the forced landing, the nose wheel impacted a small rut, separating the nose landing gear tire from the nose landing gear assembly. The airplane nosed over wrinkling the fuselage, crushing the vertical stabilizer and bending both wings.

The engine was examined at Mobile, Alabama, on February 22, 2005. An external examination showed no apparent damage. The top and rear seams of the crankcase and the accessory drive housing showed evidence of oil leakage. The crankcase seam at the front portion of the engine, just below the propeller flange gasket, also showed evidence of previous oil leakage. The gasket area between the front crankcase and the front of the oil sump showed oil leakage. Oil covered the bottom of the oil sump.

An internal examination of the engine showed the number 3 piston, piston rings, and tension springs, and the number 3 exhaust valve head had fragmented into numerous pieces. These pieces were located in the oil sump. Approximately 2 tablespoons of oil was recovered from the sump. The inside of the crankcase halves showed impact damage in the areas aft of the number 4 piston and forward of the number 3 piston. The inside walls of the crankcase were significantly blackened. The top inside of the number 3 cylinder head showed numerous impact marks including a 7/8 inch long, 1/8 inch wide and 1/8 inch deep indentation at one of the spark plug openings, and a 1/2 inch long, 1/8 inch wide, and 1/8 inch deep indentation at the area of the exhaust valve seat which were consistent with a valve head edge impact. The number 3 exhaust valve seat was not present. The number 3 exhaust valve stem was removed and examined. Fractures observed on the valve stem were consistent with overload failure. The number 3 exhaust valve guide was elongated. An examination of the crankshaft, camshaft, other cylinders, pistons, valves, and valve springs showed no pre-existing failures. The rocker box housings, rockers, and springs, were oil stained. No evidence of the number 3 exhaust valve seat was found among the fractured pieces in the engine.

The left and right magnetos were bench-tested. Both magnetos' leads consistently fired within the range of 300 to 3,000 rpm.

According to maintenance records, the engine had accumulated approximately 200 hours since the annual inspection when the accident occurred. Previous to the annual inspection, the airplane had not been flown within the previous 10 years.

An examination of the remaining airplane systems, conducted by the FAA, revealed no anomalies.

Aircraft

Registration
N2725G
Reported as
Cessna 182
Category
Airplane
Serial number
52025
Airframe hours
3,371.8
Engine
Continental O-479-L, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 22, 2004 · 200 hours before
Departed
CPR · Casper, WY
Destination
GCC · Gillette, WY

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
47
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
August 1, 2004
Seat
Left
Flight hours
1,547 total · 1,547 in this make and model · 122 in the last 90 days · 45 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 36 °F
Altimeter
30.20 inHg
Observed at
GCC, 8 nm away

Docket · 2

The files NTSB released with the investigation on April 26, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 341 KB 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.