ERA10LA187

NTSB accident investigation · Cessna 152 · Moore, SC · March 24, 2010

Accident · No injuriesLimited investigationFinal report
Date
March 24, 2010, 11:15 local (15:15 UTC)
Place
Moore, SC
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N93441Cessna 152
Defining event
Enroute-descent: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report April 12, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20100324030339A
Case key
75576

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

The certificated mechanic's improper installation of a helicoil, which resulted in the separation of a sparkplug and the helicoil and led to a partial loss of engine power.

Findings · 4

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 152: 6 casesAll aircraft: 442 cases
Ignition system: spark plugs/ignitersAircraft › Aircraft power plant · FailureCessna 152: 3 casesAll aircraft: 38 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 152: 4 casesAll aircraft: 371 casesProbable cause
Ignition system: spark plugs/ignitersAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 152: 3 casesAll aircraft: 38 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

The local instructional flight had departed from the airport about 30 minutes prior to the accident. After completing several aerial maneuvers, including slow flight and power-off stalls, the student pilot had begun a recovery from another power-off stall. When he applied throttle, the engine immediately began to run rough. The certificated flight instructor decided to perform a forced landing in a farm field. During the landing roll, the nosewheel came in contact with the soft soil and the airplane nosed over. A postaccident examination of the engine by a Federal Aviation Administration inspector revealed that the bottom sparkplug and associated helicoil on the No. 4 cylinder had separated from the cylinder. After new sparkplug and helicoil was installed in the engine, it ran normally. The airplane's engine maintenance logbook showed that four days prior to the accident, the bottom sparkplug and helicoil had been replaced on the No. 4 cylinder due to a bad helicoil. The mechanic had installed a standard helicoil contrary to the engine manufacturer's recommendation to install oversize helicoil spark plug inserts.

Factual narrative

HISTORY OF FLIGHT On March 24, 2010, about 1115 eastern daylight time, a Cessna 152, N93441, was substantially damaged during a forced landing in a field following partial loss of engine power, near Moore, South Carolina. The certificated flight instructor (CFI) and student pilot were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight which departed from Spartanburg Downtown Memorial Airport (SPA), Spartanburg, South Carolina, about 1045. The flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilots had been performing maneuvers at 3,000 feet above mean sea level (msl) and had began a descent to 2,500 feet msl utilizing carburetor heat for the engine. In a written statement the student pilot reported that after performing several maneuvers including slow flight and three approach to landing stalls the engine began making unusual noises and minor vibrations. The engine began running "rough" and the CFI elected to perform a forced landing in an open farm field. On final approach to the field the CFI had shut off the fuel valve; however, did not shut off the engine in case a little "extra" power was needed at touchdown. During the landing roll the nose wheel encountered soft soil and the airplane nosed over and came to rest inverted. The airplane incurred substantial damage to both wings and the empennage. PERSONNEL INFORMATION According to the pilot and Federal Aviation Administration (FAA) and records, the CFI held a commercial pilot certificate with ratings for airplane single-engine land, multi-engine land, and instrument airplane, and a flight instructor certificate with ratings for single-engine and instrument airplane. Her most recent FAA second-class medical certificate was issued on April 1, 2008, at which time the pilot reported 25,000 total hours of flight experience. According to the student pilot and FAA records, the student pilot was issued her third-class medical certificate on October 12, 2009 which also served as her student pilot certificate. She had accumulated 35 total hours of flight experience all of which were in the accident aircraft make and model. AIRCRAFT INFORMATION The airplane was a Cessna 152, manufactured in 1982. It was equipped with a Lycoming O-235-L2C engine. It was two-place, all-metal, high-wing, single-engine, cantilever monoplane with fixed tricycle landing gear. The airplane's most recent 100-hour inspection was accomplished on January 21, 2010 and at that time had 6,337.4 total hours time in service. An entry in the maintenance logbook dated March 20, 2010 revealed a sparkplug in the No. 4 cylinder bottom position was "fouled out" and the "helicoil in sparkplug hole bad." The helicoil was replaced, a sparkplug was installed and torqued, and the engine was run and flight tested, and were reported as "Ok." METEOROLOGICAL INFORMATION The 1115 recorded weather observation at SPA, locatedapproximately 5 miles northeast of the accident site, included winds from 030 degrees at 6 knots, clear skies, 10 miles visibility, temperature 18 degrees C, dew point 11 degrees C, and an altimeter setting of 30.10 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane was located in an open plowed field, inverted, and approximately 5 miles from the intended destination airport. The wings, fuselage, and tail section were impact damaged. According the FAA investigator that arrived on-scene the airplane was up righted and a considerable amount of fuel was drained from the wing tanks and no contaminants were found. The engine cowling was removed and the No. 4 cylinder bottom sparkplug and helicoil had become unthreaded from the cylinder and was found hanging next to the engine suspended from the sparkplug wire. On March 25, 2010 the FAA inspector reported to the Safety Board that a new sparkplug was inserted into the cylinder and the engine started and "ran normally." ADDITIONAL INFORMATION In a written statement the mechanic reported that he had replaced the helicoil on the No. 4 Cylinder since it "came out with the plug." He stated that "it [helicoil] had been cross threaded and the plug was completely fouled." He further reported that the CFI had stated that the engine began to run rough after the student pilot "jammed the throttle" to the full power setting. In a telephone interview with the NTSB investigator the mechanic stated that they use "a standard size heli-coil." In a follow-up telephone interview with the CFI it was confirmed that the student pilot was told several times to apply power slowly. However, the student pilot "got nervous after practicing power off stalls" and did apply power very quickly. Immediately after that, the engine began to run rough. According to Textron-Lycoming Service Instruction 1043A dated September 19, 1969, "Spark Plug Heli-Coil Insert Replacement" states in part "…standard size inserts have been found in holes with badly damaged threads that had not been repaired by retapping…does not recommend standard size Heli-Coil Inserts for replacement in the spark plug holes…repair facilities are urged to stock only .010 oversize Heli-Coil spark plug inserts…"

Aircraft

Registration
N93441
Reported as
Cessna 152
Category
Airplane
Serial number
15285490
Airframe hours
6,337
Engine
Lycoming O-235-L2C, 118 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Aero II Inc
Registered owner
Shelby Aviation Inc
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · January 31, 2010
Departed
SPA · Spartanburg, SC
Destination
SPA · Spartanburg, SC

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
Flight instructor
Age
76
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 10, 2009
Seat
Right
Flight hours
30,000 total · 15,000 in this make and model
Role
Student pilot
Age
36
Injuries
None
Certificate
Student
Medical
Class 3, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
35 total · 35 in this make and model · 1 as pilot in command · 24 in the last 90 days · 6 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 52 °F
Altimeter
30.10 inHg
Observed at
SPA, 5 nm away

Docket · 9

The files NTSB released with the investigation on November 19, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.