# NTSB ERA09LA372: Cessna 172D, N172TJ, Shepherdsville, KY, June 27, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 27, 2009, 10:10 local (14:10 UTC) - Place: Shepherdsville, KY - Coordinates: 37.900684, -85.460464 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.9007&lon=-85.4605&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 10, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 74159 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA372 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74159/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74159 - Page: https://openairdocs.org/ntsb/ERA09LA372 ## Probable cause The mechanic's improper inspection of the mixture control cable. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2072410), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Engine controls: mixture control](https://openairdocs.org/ntsb-findings/01057602): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-findings/01057602/cases.md?model=2072410), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01057602/cases.md) - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=2072410), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/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: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 172D, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072410), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172D, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072410), [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 172D, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072410), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot was in cruise flight between 1,700 and 2,200 feet mean sea level when the engine rpms decreased. He applied throttle with negative results. The airplane continued to descend and he performed a forced landing to a soybean field. Review of the airplane logbooks revealed that the airplane had flown 2.29 hours since the last annual inspection. Postaccident examination of the airframe and flight controls revealed no anomalies; however, the mixture control cable was found to be separated from the mixture control arm. The mixture cable wire tip was not bent 90 degrees to prevent it from being withdrawn if the attaching nut should become loose, as required by the maintenance manual. The cable did not exhibit any signs of damage or stretching, and it was not broken at the attach point to the attaching bolt in the mixture control arm of the carburetor. The mechanic who performed the last annual inspection stated that he did not remember if he did or did not bend the cable 90 degrees. ## Factual narrative On June 27, 2009, at 1010 eastern daylight time, a Cessna 172D, N172TJ, registered to and operated by a private owner, as a Title 14 Code of Federal Regulations Part 91 personal flight, lost engine power while in cruise flight in the vicinity of Shepherdsville, Kentucky. Visual meteorological conditions prevailed and no flight plan was filed. The airplane received substantial damage and the private pilot reported no injuries. The flight originated at Lick Airport, Louisville, Kentucky, at 0945. The pilot stated the engine was set at 2,400 rpm and the airplane was between 1,700 feet to 2,200 feet mean sea level, when the engine rpm decreased. He applied throttle with negative results. The airplane continued to descend and he performed a forced landing to a soybean field. The nose landing gear separated on landing roll out, the nose pitched down, and both wings received structural damage. Examination of the airplane by a Federal Aviation Administration (FAA) inspector revealed the forward cabin area was not damaged. The throttle was in the full forward position and the carburetor heat was in the off position. The fuel selector valve was in the “Off” position. Continuity of the flight controls was confirmed from the flight controls aft to all flight control surfaces. The right main landing gear remained attached to the airframe and the wheel pant cover was damaged. The left main landing gear remained attached to the airframe and was not damaged. The left and right main fuel tanks were observed and visually found to contain considerable amount of fuel. The fuel caps had a tight seal and the fuel vent line was clear of obstructions. The left wing fuel sump was checked and approximately 3.25 ounces of water was removed. The right wing fuel sump was checked and approximately 2 ounces of water was removed. A fuselage low point drain under the aircraft was not installed. The fuel inlet supply line was removed and fuel was present to the carburetor and no evidence of water was noted. The inlet screen was removed from the carburetor and was observed to have a small amount of a white sludgy substance on the screen, but it did not obstruct the screen. The empennage exhibited minor skin wrinkling behind the main landing gear attachment points. The horizontal stabilizers, vertical fin and rudder were not damaged. Examination of the engine revealed the carburetor had separated from its mounting pad. The fuel inlet supply line was attached and not damaged. The carburetor heat cable was attached and operated. The throttle cable and throttle arm of the carburetor remained attached to the engine case and the throttle operated freely. The mixture control cable was separated from the mixture control arm, the cable did not exhibit any signs of damage or stretching, and it was not broken at the attach point to the attaching bolt in the mixture control arm of the carburetor. The mixture cable wire tip was not bent 90 degrees to prevent it from being withdrawn if theattaching nut should become loose. The FAA inspector noted, "The mixture control cable attaching bolt to the mixture control arm was not damaged. The mixture control cable attaching bolt was observed to have what appears to be a newly installed self locking steel nut instead of a castellated nut. The steel locking nut appears to have been relatively recently installed. The mixture control cable was able to be pushed into the hole in the mixture control cable attaching bolt with very little restriction." The crankshaft was rotated by hand. Valve and drive train continuity were confirmed, and continuity was established with all accessory gears. Suction and compression were obtained. Test for spark was conducted and spark was observed. Both impulse couplings of the magnetos were heard to be functional. Examination of the aircraft logbooks revealed the last annual inspection was conducted on October 3, 2008. The tachometer reading at the time of the annual inspection was 1636.9 hours. The tachometer reading at the accident site was 1638.68 hours. The airplane had flown 2.29 hours since the annual inspection. The Cessna Aircraft Company Service Manual 100 Series, Section 12, Powerplant, page 12-23, paragraph 12-62, MIXTURE CONTROL RIGGING, f. states, "Bend the wire tip 90 degrees to prevent it from being withdrawn if the attaching nut should become loose." The mechanic who performed the annual inspection stated, "he did not remember if he did that or not." ## Aircraft - Registration: [N172TJ](https://openairdocs.org/deregistered/N172TJ-2018-01-11), registration cancelled 2018-01-11, S/N 17249552, built 1962 (OpenAirDocs) - Reported make and model: CESSNA 172D - Registry model: [Cessna 172D](https://openairdocs.org/model/cessna-172d) (registry code 2072410) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17249552 - Airframe hours: 1636 - Engines: Continental O-300-D 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Joseph L. Tapay - Registered owner: Joseph L. Tapay - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 3, 2008, 2 hours before - Departed: 07KY, Louiosville, KY - Destination: BRY, Bardstown, KY ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 23, 2008; seat: left; flight hours: 318 total, 290 in this make and model, 305 as pilot in command, 2 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 70 °F - Altimeter: 29.87 inHg - Observed at: LOU, 17 nm away ## 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 20090627011559A](https://openairdocs.org/incident/20090627011559A), Jun 27, 2009: Cessna 172D, Louisville, KY, Substantial damage. (-23) Aircraft departed Blue Lick (07KY) on a heading of 140 degrees and cruise altitude between 1700 to 1800 MSL. At which the aircraft loss power and the… ## Docket (13 files) The files NTSB released with the investigation on July 23, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74159. 13.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 942 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315473&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector Statement Rechenmacher (item 2, .PDF, 261 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315781&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20Rechenmacher-Redacted.PDF - FAA Inspector Statement Cox (item 3, .PDF, 477 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315959&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20Cox-Redacted.PDF - FAA Mechanic Interview (item 4, .PDF, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315782&FileExtension=.PDF&FileName=FAA%20Mechanic%20Interview-Redacted.PDF - Statement Mechanic (item 5, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315783&FileExtension=.PDF&FileName=Statement%20Mechanic-Redacted.PDF - Extract Logbooks (item 6, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315474&FileExtension=.PDF&FileName=Extract%20Logbooks-Redacted.PDF - Extract Service Manual 100 Series (item 7, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315510&FileExtension=.PDF&FileName=Extract%20Service%20Manual%20100%20Series-Master.PDF - Cessna Owner Advisory Letter and Service Information Letter (item 8, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315784&FileExtension=.PDF&FileName=Cessna%20Owner%20Advisory%20Letter%20and%20Service%20Information%20Letter-Master.PDF - AD Compliance List (item 9, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315785&FileExtension=.PDF&FileName=AD%20Compliance%20List-Redacted.PDF - Photo 1 - View of airplane at accident site. Photo FAA (item 10, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315484&FileExtension=.PDF&FileName=Photo%201%20-%20View%20of%20airplane%20at%20accident%20site.%20Photo%20FAA-Master.PDF - Photo 2 - View of mixture control cable attaching steel locknut. Photo FAA (item 11, .PDF, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315485&FileExtension=.PDF&FileName=Photo%202%20-%20View%20of%20mixture%20control%20cable%20attaching%20steel%20locknut.%20Photo%20FAA-Master.PDF - Photo 3 - View of separated mixture control cable. Photo FAA (item 12, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315486&FileExtension=.PDF&FileName=Photo%203%20-%20View%20of%20separated%20mixture%20control%20cable.%20Photo%20FAA-Master.PDF - Photo 4 - View of mixture control cable attaching bolt. Photo FAA (item 13, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315487&FileExtension=.PDF&FileName=Photo%204%20-%20View%20of%20mixture%20control%20cable%20attaching%20bolt.%20Photo%20FAA-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.