ERA11LA388

NTSB accident investigation · Cessna 172N · Orange Beach, AL · July 4, 2011

Accident · No injuriesLimited investigationFinal report
Date
July 4, 2011, 14:30 local (19:30 UTC)
Place
Orange Beach, AL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N109DPCessna 172N
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report January 31, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20110704011939A
Case key
81042

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

The operation of the airplane using unapproved fuels, which resulted in abnormal combustion and subsequent damage to the No. 3 cylinder. Contributing to the accident was the inadequate 100-hour inspection because the mechanic failed to note the lack of placards by either fuel filler cap specifying the minimum automotive fuel grade and no alcohol allowed as specified by the installed STC’s.

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.

Fluids: fuelAircraft › Fluids/misc hardware · Fluid typeCessna 172N: 8 casesAll aircraft: 1,695 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Inadequate inspectionCessna 172N: 1 caseAll aircraft: 76 casesProbable cause
Placards and markingsAircraft › Aircraft handling/service · Not serviced/maintainedCessna 172N: 1 caseAll aircraft: 11 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 airplane had been modified by several Supplemental Type Certificates (STCs) allowing the use of 91 minimum octane alcohol-free fuel, or a combination of 100LL and 91 minimum octane ethanol-free fuel. After takeoff while operating the engine on a mixture of 100LL and 87 octane automotive fuels with 10 percent ethanol additive, the engine experienced abnormal combustion in the No. 3 cylinder, which burned a hole through the cylinder near the lower spark plug hole. The resulting loss of engine power necessitated a forced landing in water. Postaccident examination of the engine revealed no discrepancies with the power train, ignition, lubrication, or air induction systems that would have led to the event. Metallurgical examination of the No. 3 cylinder revealed no manufacturing defects that would have damaged to the cylinder. No placards were noted by either fuel cap; these were required by the installed STCs specifying minimum octane rating of 91 without alcohol; however, on the day of the accident, the airplane underwent a 100-hour inspection by the pilot-in-command who held a mechanic certificate with airframe and powerplant ratings and inspection authorization; he had also performed the modification allowing the airplane to use automotive fuel. Although no fuel samples were retained for testing, the damage to the cylinder was consistent with the usage of unapproved fuel with too low an octane rating.

Factual narrative

On July 4, 2011, about 1430 central daylight time, a Cessna 172N, N109DP, registered to and operated by Gulf Coast Aerial Advertising, Inc., nosed over during a forced landing in water near Orange Beach, Alabama. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 banner tow flight from Resort Airport (0AL1), Foley, Alabama. The airplane sustained substantial damage, and the airline transport pilot and commercial second pilot were not injured. The flight originated from 0AL1 about 1400. The pilot-in-command (PIC) stated that the flight departed on the banner tow flight with 48 gallons of 100 low lead (100LL) fuel, and at about the return point of their planned route of the banner tow flight, they began to climb to the north to return to the field. The pilot then noticed a loss of engine rpm and a small vibration, which he attempted to resolve the issues but was unable and reported the engine continued losing power. He then elected to release the banner and maneuvered towards Wolf Field, but was unable to land there. He then maneuvered the airplane for a forced landing in water near shore of Walker Island, and after touchdown, the airplane nosed over. The airplane was recovered for further examination. Examination of the airframe and engine was performed by a Federal Aviation Administration (FAA) airworthiness inspector-in-charge (IIC). The examination of the airframe revealed the left fuel tank contained 100LL fuel, while the fuel selector was found positioned to the right tank which contained a mixture of 100LL and automotive fuel; but the mixture was mostly automotive fuel. No placards specifying grade of automotive fuel were noted by either fuel filler cap. Inspection of the fuel strainer and carburetor revealed the presence of automotive fuel. The examination of the engine revealed damage to the No. 3 cylinder around the bottom spark plug. Further examination of the engine revealed no discrepancies with the powertrain, air induction, or lubrication systems of the engine. Inspection of the spark plugs revealed all except the No. 3 cylinder exhibited dark discoloration consistent with a rich fuel to air ratio. The magnetos were properly timed to the engine with no discrepancies of the magnetos reported. No discrepancies with the ignition harness was noted with the exception of the No. 3 bottom ignition lead which was heat damaged in the area of the bottom spark plug. The No. 3 cylinder was removed for further examination. Examination of the operator’s on airport fuel tank was also performed by the FAA-IIC. The FAA-IIC reported that the fuel tank had been serviced by 87 octane automotive fuel with 10 percent ethanol and regionally adjusted additives. No fuel samples were obtained. Examination of the No. 3 cylinder and piston was performed by the NTSB Materials Laboratory located in Washington, DC. The examination revealed the piston crown contained areas withflaky brittle spatter material. The majority of the damage to the cylinder was around the bottom spark plug hole, and approximately 25 percent of material around the threaded spark plug insert ring was obliterated. Energy dispersive X-ray spectroscopy (EDS) of white spatter contamination revealed the compounds were high in carbon and oxygen as well as elements expected to comprise the casting material of the cylinder head. Testing of the composition of the cylinder head near the bottom spark plug hole revealed the material was consistent with the specified material in the engineering drawing for the casting. Further examination of the cylinder head near the bottom spark plug hole revealed the microstructure was consistent with aluminum alloys having undergone incipient melting. No manufacturing defects were reported in the factual report. A copy of the NTSB Materials Laboratory Factual Report is contained in the NTSB public docket for this case. The airplane was equipped with a 180 horsepower Lycoming O-360-A4M engine which had been converted from a 150 horsepower O-320-E2D engine. According to type certificate data sheets for the O-320-E2D and O-360-A4M engines, the minimum fuel grade aviation gasoline are 80/87, and 100LL, respectively. After the engine conversion, supplemental type certificates (STC’s) SA2600CE and SE2563CE were installed on the airframe and engine allowing the use of automotive fuel. Paperwork associated with both STC’s specifies that the approved fuel minimum octane rating is 91 and intermixing with aviation gasoline is approved, but fuel containing alcohol is not approved. The STC’s also stipulate that placards by each fuel filler opening are required; the placards specify in part that fuel containing alcohol is not allowed. Copies of the STC’s are contained in the NTSB public docket for this case. Review of the airframe maintenance records revealed the last 100-Hour inspection was signed off as being completed on the day of the accident. The inspection was performed by the PIC, who also holds a mechanic certificate with airframe and powerplant ratings, and also an inspection authorization (IA). The same person who inspected the airplane on the day of the accident modified the airplane in 2009, allowing the use of automotive fuel. The airplane had been operated for approximately 2.0 hours since the inspection was signed off as being completed.

Aircraft

Registration
N109DP
Reported as
Cessna 172N
Category
Airplane
Serial number
17270607
Airframe hours
2,927
Engine
Lycoming O-360-A4M, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Banner tow · Part 91
Operator
Gulf Coast Aerial Advertising Inc
Registered owner
Gulf Coast Aerial Advertising Inc
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · July 4, 2011 · 2 hours before
Departed
0AL1 · Foley, AL
Destination
0AL1 · Foley, AL

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
53
Injuries
None
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
July 18, 2009
Seat
Right
Flight hours
7,164 total · 500 in this make and model · 6,714 as pilot in command · 75 in the last 90 days · 25 in the last 30 days · 5 in the last 24 hours
Role
Other flight crew
Age
64
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
2,453 total · 32 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 8 knots, gusting 16
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 66 °F
Altimeter
29.96 inHg
Observed at
JKA, 7 nm away

Docket · 17

The files NTSB released with the investigation on November 30, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.8 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 852 KBMaterials Laboratory 15 - Factual Report of Group ChairmanItem 2 · .PDF · 3.9 MBWeather Reports and RecordsItem 3 · .PDF · 26 KBFAA Inspector StatementsItem 4 · .PDF · 225 KBExcerpts from Engine Maintenance RecordsItem 5 · .PDF · 681 KBSupplemental Type Certificate (STC) SA2600CEItem 6 · .PDF · 372 KBSupplemental Type Certificate (STC) SE2563CEItem 7 · .PDF · 370 KBExcerpts from Airframe Maintenance RecordsItem 8 · .PDF · 1.2 MBEngine Type Certificate Data Sheet for Lycoming O-320-E2DItem 9 · .PDF · 40 KBEngine Type Certificate Data Sheet for Lycoming O-360-A4MItem 10 · .PDF · 86 KBNTSB Record of ConversationItem 11 · .PDF · 51 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 12 · .PDF · 257 KBPhoto 1: Digital Photograph Provided by FAA. View depicting the Nos. 1 and 3 Cylinder Pistons After Cylinder Removal.Item 13 · .PDF · 153 KBPhoto 2: Digital Photograph Provided by FAA. View Depicting the Fuel Quantity Gauges and Placard BeneathItem 14 · .PDF · 98 KBPhoto 3: Digital Photograph Provided by FAA. View Depicting a Portion of the Engine Data Plate Associated with the Lycoming O-320-E2DItem 15 · .PDF · 160 KBPhoto 4: Digital Photograph Provided by FAA. View Depicting a Portion of the Engine Data Plate Associated with the Lycoming O-360-A4MItem 16 · .PDF · 187 KBPhoto 5: Digital Photograph Provided by FAA. View Depicting Both Engine Data PlatesItem 17 · .PDF · 126 KB

FAA reports on this event · 1

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