# NTSB ERA11LA103: Cessna 152, N28BA, Wimauma, FL, December 31, 2010 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 31, 2010, 14:00 local (19:00 UTC) - Place: Wimauma, FL - Coordinates: 27.711944, -82.282775 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.7119&lon=-82.2828&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report August 11, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 78082 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA11LA103 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/78082/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=78082 - Page: https://openairdocs.org/ntsb/ERA11LA103 ## Probable cause The mechanic/pilot's failure to detect a visible exhaust gas leak and cracked cylinder head immediately prior to the accident flight, which resulted in a partial loss of engine power during initial climb. Contributing to the accident was an inadequate 100-hour maintenance inspection, which also failed to detect a visible exhaust gas leak. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Failure; cases with it: [Cessna 152, 3 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=2071835), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Inspection](https://openairdocs.org/ntsb-findings/02061500): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-findings/02061500/cases.md?model=2071835), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/02061500/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=2071835), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/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 inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=2071835), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 152, 21 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2071835), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 152, 35 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071835), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 152, 84 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071835), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During initial climb from the airstrip, about 300 feet above ground level, the mechanic/pilot heard a loud noise, followed by a partial loss of engine power. He leveled the nose and verified that the throttle lever was in the full forward position; however, he was unable to maintain altitude. During the subsequent forced landing to a field, the airplane struck a fence. According to the pilot, another pilot who flew the airplane previously reported a rough running engine and had to perform an uneventful precautionary landing to an airstrip. Examination of the wreckage revealed that the No. 2 top spark plug and its associated heli-coil had separated from the cylinder. Further examination revealed that the spark plug and cylinder threads were worn and an approximate 2-inch crack originated near the cylinder head threads. Additionally, the area around the top and bottom spark plug holes exhibited evidence of exhaust gas leakage, which would have most likely been visible during the most recent maintenance inspection. At the time of the accident, the airplane had been operated about 77 hours since its most recent 100-hour inspection, which was completed about 3 months prior to the accident. The No. 2 overhauled cylinder had been operated for 832 hours since it was installed, about 4 years prior to the accident. ## Factual narrative On December 31, 2010, about 1400 eastern standard time, a Cessna 152, N28BA, operated by Cirrus Aviation Inc., was substantially damaged during a forced landing after takeoff from Wimauma Airport (FD77), Wimauma, Florida. The certificated private pilot was not injured. The maintenance flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Sarasota/Bradenton International Airport (SRQ), Sarasota, Florida. During a previous flight in the accident airplane, another pilot reported a rough running engine and performed a precautionary landing to FD77. After the landing, the other pilot thought water in the fuel caused the rough running engine. The accident pilot was also an airframe and powerplant mechanic. He advised the other pilot not to attempt to fly the airplane back to SRQ. Rather, the mechanic would fly to FD77 in another airplane and trade airplanes with the other pilot. Subsequently, the mechanic performed a thorough inspection and troubleshooting of the engine and fuel system, and did not find any problems. He also performed a thorough run-up of the engine, with no anomalies noted. The pilot/mechanic then departed FD77. When the airplane was about 300 feet above ground level, the pilot/mechanic heard a loud "bang," followed by a partial loss of engine power. He leveled the nose and verified that the throttle lever was in; however, he was unable to maintain altitude. The pilot/mechanic felt he was too low to return to FD77 and elected to land in a field ahead of the airplane. During the landing, the airplane struck a fence and a pole, slid across a road, and came to rest upright in a ditch. Examination of the wreckage by a Federal Aviation Administration inspector revealed damage to the nose landing gear, firewall, and forward fuselage. The inspector also noted that the No. 2 top spark plug and its associated heli-coil had separated from the cylinder. Further examination revealed that the spark plug and cylinder threads were worn and an approximate 2-inch crack originated near the cylinder head threads. Additionally, the area around the top and bottom spark plug holes exhibited visual evidence of exhaust gas leakage. Review of maintenance records revealed that at the time of the accident, the airplane had accrued approximately 9,858 total tachometer hours and the engine had accrued about 1,955 tachometer hours since major overhaul. The engine was last overhauled on November 15, 2006. The No. 2 cylinder was subsequently removed and replaced with an overhauled cylinder on May 15, 2009, at 1123.4 tachometer hours since the last major overhaul. The engine had been operated for and additional 832 tachometer hours since the replacement of the No. 2 cylinder, until the accident. The airplane's most recent 100-hour inspection was completed on October 8, 2010, and it had been operated for approximately 77 tachometer hourssince that inspection, until the accident. ## Aircraft - Registration: [N28BA](https://openairdocs.org/deregistered/N28BA-2013-08-22), registration cancelled 2013-08-22, S/N 15285381, built 1981 (OpenAirDocs) - Reported make and model: CESSNA 152 - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15285381 - Airframe hours: 9781 - Engines: LYCOMING O-235 115 horsepower reciprocating - Damage: Substantial damage - Flight: Other work use, Part 91 - Operator: Cirrus Aviation Inc - Registered owner: Cirrus Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 8, 2010, 77 hours before - Departed: FD77, Wimauma, FL - Destination: SRQ, Sarasota, FL - Airport: FD77, Wimauma Air Park, runway 09, 3,000 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: none; private; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review May 29, 2008; seat: left; flight hours: 236 total, 103 in this make and model, 125 as pilot in command, 6 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 59 °F - Altimeter: 30.12 inHg - Observed at: MCF, 12 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 20101231055099A](https://openairdocs.org/incident/20101231055099A), Dec 31, 2010: Cessna 152, Wimauma, FL, Substantial damage. On December 31, 2010, at 1430 EDT, a Cessna 152, N28BA, serial no. 15285381, registered to Cirrus aviation flight school, and operated by [privacy data… ## Docket (9 files) The files NTSB released with the investigation on June 13, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=78082. 4.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349041&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Interview Summary (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349000&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Excerpts From Maintenance Logbooks (item 3, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349098&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Logbooks-Redacted.PDF - Weather Report (item 4, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349002&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Photo: Main Wreckage (Photo Courtesy of FAA) (item 5, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349004&FileExtension=.PDF&FileName=Photo%3A%20%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo: Spark Plug And Heli-coil (Photo Courtesy of FAA) (item 6, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349005&FileExtension=.PDF&FileName=Photo%3A%20%20Spark%20Plug%20And%20Heli-coil%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo: No. 2 Top Spark Plug Hole (Photo Courtesy of FAA) (item 7, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349006&FileExtension=.PDF&FileName=Photo%3A%20%20No.%202%20Top%20Spark%20Plug%20Hole%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo: No. 2 Bottom Spark Plug Hole (Photo Courtesy of FAA) (item 8, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349223&FileExtension=.PDF&FileName=Photo%3A%20%20No.%202%20Bottom%20Spark%20Plug%20Hole%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo: Crack at Top of Cylinder (Photo Courtesy of FAA) (item 9, .PDF, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40349007&FileExtension=.PDF&FileName=Photo%3A%20%20Crack%20at%20Top%20of%20Cylinder%20(Photo%20Courtesy%20of%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.