ERA11LA429

NTSB accident investigation · Cessna 172M · Pahokee, FL · July 28, 2011

Accident · Minor injuriesLimited investigationFinal report
Date
July 28, 2011, 12:00 local (16:00 UTC)
Place
Pahokee, FL
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1443UCessna 172M
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report August 7, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Airline Transport Professionals
FAA report
20110728016379A
Case key
81290

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 flight instructor's misjudgment of the airplane's position and airspeed relative to the runway while returning to the airport after a partial loss of engine power. Contributing to the accident was the separation of the engine's No. 3 cylinder exhaust valve head from the stem, and the operator’s exceedence of the engine manufacturer's recommended time between overhauls.

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.

Action: incorrect action performancePersonnel issues › Action/decision · Instructor/check pilotCessna 172M: 19 casesAll aircraft: 1,386 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Not serviced/maintainedCessna 172M: 4 casesAll aircraft: 497 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 172M: 3 casesAll aircraft: 320 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 flight instructor stated that, as the airplane climbed through about 500 feet above the ground after takeoff on the intended dual instructional cross-country flight, the engine started shaking, sputtering, and making “alarming” noises. The flight instructor took control of the airplane, noted nothing abnormal with the mixture, fuel selectors, engine instruments, or fuel quantity, and decided to return to the departure airport to land. The flight instructor noted that there was not a total loss of engine power, but it was not possible to maintain the airplane’s altitude. When the flight instructor realized that the airplane was too high and too fast to land on the intended runway, she moved the throttle to idle; however, she did not use flaps or slip the airplane to reach the runway. The airplane overflew the entire length of the runway, and the flight instructor elected to land the airplane in a lake on the left to avoid obstacles straight ahead and on the right. Postaccident examination of the engine revealed that the No. 3 cylinder exhaust valve head had sheared off at the stem. The stem, spring, and rocker arm were still intact, and the No. 3 piston exhibited signs of mechanical damage from the sheared head inside the combustion chamber. At the time of the accident, the engine had 2,229.5 hours of operation since major overhaul. The engine manufacturer's recommended time between overhauls was 2,000 hours.

Factual narrative

On July 28, 2011, about 1200 eastern daylight time, a Cessna 172M, N1443U, was substantially damaged during a forced landing in Lake Okeechobee, near Pahokee, Florida. The certificated flight instructor was not injured and the certificated student pilot incurred minor injuries. Visual meteorological conditions prevailed. No flight plan had been filed for the flight, between Palm Beach County Glades Airport (PHK), Pahokee, Florida, and Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the flight instructor, the accident flight was part of a series of cross country and student solo flights that day. Upon arrival at PHK, three practice landings were completed before a full stop landing. During a subsequent takeoff for FXE from runway 17, with winds from 100 degrees magnetic at 10 knots, the student pilot was at the controls. All of the gauges were "in the green," and the fuel tanks were half full. After the takeoff and a straight-out departure, as the airplane reached 500 feet, the engine started shaking, sputtering, and making "alarming" noises. The flight instructor immediately took control of the airplane, and quickly glanced at the mixture, fuel selectors, engine instruments, and fuel, without noting anything abnormal. The flight instructor then turned the airplane back toward runway 35, and transmitted via radio an engine failure, but saw that the engine did not completely quit. Instead, it was not producing any thrust, and the airplane could not maintain altitude. The flight instructor also stated that after turning the airplane back toward runway 35, she realized that it was too high and too fast. She pulled out the throttle; however, she did not use flaps or attempt to slip the airplane. The airplane then overflew the entire length of the runway, and the flight instructor had to consider other options. In front of her was a house, to the right was a road lined with power lines, and to the left was the lake. The flight instructor then turned the airplane over the lake, and "floated" it as long as possible before it touched down and nosed over. The flight instructor and student pilot exited the airplane and waited on its belly until rescue. After its removal from the lake, Federal Aviation Administration (FAA) inspectors and flight school maintenance personnel examined the airplane and the Lycoming 0-320-E2D engine, and found that the No. 3 cylinder exhaust valve head had sheared off the stem. The stem, spring and rocker arm were still intact, and the No. 3 piston exhibited signs of mechanical damage from the sheared head inside the combustion chamber. The airplane's engine was last inspected during a 100-hour inspection on July 21, 2011. According to the logbook entry, at that time, the engine had accrued 2,211.8 hours of operation since major overhaul. At the time of the accident, hours of engine operationsince major overhaul were 2,229.5. According to Lycoming Service Instruction 1009AU, dated November 18, 2009, recommended time between overhauls of the O-320-E engine is 2,000 hours.

Aircraft

Registration
N1443U
Reported as
Cessna 172M
Category
Airplane
Serial number
17267110
Airframe hours
6,585
Engine
Lycoming 0-320 SERIES, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Atp Aircraft 2 LLC
Registered owner
Atp Aircraft 2 LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 21, 2011 · 18 hours before
Departed
PHK · Pahokee, FL
Destination
FXE · Ft. Lauderdale, FL
Airport
PHK · Palm Beach County Glades

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
21
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 7, 2011
Seat
Right
Flight hours
404 total · 221 in this make and model · 339 as pilot in command · 182 in the last 90 days · 86 in the last 30 days · 4 in the last 24 hours
Role
Student pilot
Age
23
Injuries
Minor
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
60 total · 55 in this make and model · 3 as pilot in command · 43 in the last 90 days · 43 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 10 knots, gusting 19
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 75 °F
Altimeter
29.97 inHg
Observed at
PHK

Docket · 5

The files NTSB released with the investigation on June 14, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 MB 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.