ERA12LA405

NTSB accident investigation · Cessna 152 · Miami, FL · June 16, 2012

Accident · No injuriesLimited investigationFinal report
Date
June 16, 2012, 00:40 local (04:40 UTC)
Place
Miami, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N67324Cessna 152
Defining event
Approach-VFR pattern final: Loss of engine power (total)
Weather
Visual (VMC) · Night
Status
Completed · report September 30, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20120616014859A
Case key
84030

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 pilots’ operation of the airplane with an insufficient supply of engine oil, resulting in engine seizure and total loss of engine power.

Findings · 3

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.

Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Not serviced/maintainedCessna 152: 1 caseAll aircraft: 130 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · Flight crewCessna 152: 14 casesAll aircraft: 551 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna 152: 3 casesAll aircraft: 174 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 student and flight instructor reported that, during their preflight inspection, 4.5 quarts of oil was in the engine and the fuel tanks were full. Another quart of oil was added to the engine, and the flight departed. About 1 hour 40 minutes into the flight, the engine began to run rough. The engine subsequently stopped running and attempts to restart it were unsuccessful. The flight instructor force landed the airplane in a field, and it nosed over, resulting in substantial damage to the wings. During the recovery of the wreckage, the fuel tanks were drained, and each tank contained about 1 quart of fuel. There was no oil or fuel on the ground under the wreckage. The oil dipstick showed no oil on the stick. About 1 1/3 quarts of oil were drained from the engine. According to the engine manufacturer, the minimum safe quantity of oil in the sump is 2 quarts. Examination of the wreckage revealed no evidence of an oil leak anywhere on the engine or airframe. The engine showed evidence of seizure due to a lack of lubrication. The engine oil and filter were reportedly changed during a 100-hour inspection that occurred 3 days before the accident. Although the crewmembers reported that they departed with sufficient oil and fuel, the physical evidence does not support that assertion; the lack of lubrication led to the loss of engine power.

Factual narrative

On June 16, 2012, about 0040 eastern daylight time, a Cessna 152, N67324, was substantially damaged following a loss of engine power and collision with terrain near Miami, Florida. The flight instructor and student pilot were not injured. The airplane was registered to a private corporation and was operated by Dean International Flight School under the provisions of 14 Code of Federal Regulations (CFR) Part 91, as an instructional flight. Night, visual meteorological conditions prevailed and a visual flight rules flight plan was filed. The flight originated at Fort Myers, Florida (FMY) about 2300 on June 15, 2012 and was destined for Miami, Florida (TMB). The student and flight instructor reported the following. A pre-flight inspection was performed, the fuel tanks were “topped off,” and the engine oil level showed 4.5 quarts. An additional quart of oil was added and the flight departed FMY about 2300. The departure and en route portions of the flight were uneventful. About 0040, 7 miles northwest of TMB, the pilot observed the first indication of engine roughness. The student was at the controls at the time. Carburetor heat was applied; however, no improvement in performance was noted. Shortly thereafter, “…the engine made sputtering sounds and quit…” The flight instructor took the controls and attempted to restart the engine. The engine would not restart, and the flight instructor performed a forced landing in a nearly field. According to an airworthiness inspector with the Federal Aviation Administration (FAA), mechanics, who were employed by the operator, responded to the accident site to recover the wreckage. A NTSB Air Safety Investigator provided direction on documenting the condition of the wreckage and photographing the evidence. During the recovery, the mechanics noted that the wreckage was inverted; however, no fuel or oil spill was noted and the wing fuel tanks were not compromised. The fuel filler caps were secure. Once the aircraft was righted, the fuel was drained from the wing tanks into plastic containers and the quantity was documented. About one quart of fuel was recovered from each tank. The oil dipstick was removed and inspected. It showed no oil level registering on the stick. There was no evidence of an oil leak on the engine or its components, on the interior of the engine cowling, or on the exterior of the fuselage. On June 19, 2012, the FAA inspector visited the operator’s facilities and inspected the wreckage. No oil or oil residue was observed on the engine firewall, engine, or cowling. The engine propeller could not be turned. While in conversation with the operator’s lead mechanic (who was present in the recovery of the aircraft), the FAA inspector was informed that the oil temperature line for the engine was removed after the accident and installed on another engine to test for leaks. The mechanic stated that the oil temperature line leaked when installed on the other aircraft. The FAA inspector had not beenprovided release of the wreckage from the NTSB and was unaware, nor present when the test had been performed. She informed the lead mechanic the NTSB had not given permission to the operator to remove or test any oil lines. An examination of the disassembled engine revealed evidence of seizure. The crankshaft, aft of the number 3 crankpin journal, was twisted counterclockwise and bent. The area of the number 3 crankpin journal was discolored, consistent with elevated temperature and lack of lubrication. Ferrous particles were found in the oil sump. The number 3 connecting rod exhibited heat damage and distortion. For additional information regarding the engine examination, refer to the “Engine Examination Field Notes” located in the public docket for this investigation. According to the aircraft engine maintenance records, a 100-hour inspection was performed on June 13, 2012. The maintenance included an oil and filter change. The tachometer time at the inspection was 3,662.1 hours. The tachometer time reading when the FAA inspector examined the wreckage was 3,677.6 hours. According to the engine manufacturer, the minimum safe quantity of oil in the sump is 2 quarts. 49 CFR Part 830.10 (NTSB) addresses the preservation of aircraft wreckage. It states, “The operator of an aircraft involved in an accident or incident for which notification must be given is responsible for preserving to the extent possible any aircraft wreckage, cargo, and mail aboard the aircraft, and all records, including all recording mediums of flight, maintenance, and voice recorders, pertaining to the operation and maintenance of the aircraft and to the airmen until the Board takes custody thereof or a release is granted pursuant to § 831.12(b) of this chapter. Prior to the time the Board or its authorized representative takes custody of aircraft wreckage, mail, or cargo, such wreckage, mail, or cargo may not be disturbed or moved except to the extent necessary: (1) To remove persons injured or trapped; (2) To protect the wreckage from further damage; or (3) To protect the public from injury.”

Aircraft

Registration
N67324
Reported as
Cessna 152
Category
Airplane
Serial number
15281755
Airframe hours
11,144
Engine
Lycoming 0-235 SERIES, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Dean International Flight School
Registered owner
Altitude Airways Corp
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · June 13, 2012 · 15 hours before
Departed
FMY · Fort Myers, FL
Destination
TMB · Miami, FL
Flight plan
VFR
Airport
TMB · Kendall-Tamiami Executive, runway 09L, 5,003 × 150 ft, asphalt

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
30
Injuries
None
Certificates
Flight instructor, Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 14, 2012
Seat
Right
Flight hours
1,685 total · 950 in this make and model · 1,506 as pilot in command · 300 in the last 90 days · 96 in the last 30 days · 3 in the last 24 hours
Role
Student pilot
Age
21
Injuries
None
Certificate
Private
Medical
Class 1, Without waivers/limitations
Last flight review
May 15, 2012
Seat
Left
Flight hours
203 total · 196 in this make and model · 138 as pilot in command · 158 in the last 90 days · 110 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
10° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 72 °F
Altimeter
30.01 inHg
Observed at
TMB, 5 nm away

Docket · 21

The files NTSB released with the investigation on September 5, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.1 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 1.8 MBWritten Statement - TalukderItem 2 · .PDF · 182 KBWritten Statement - SrivastavaItem 3 · .PDF · 306 KBWritten Statement - SuarezItem 4 · .PDF · 249 KBWritten Statement - ValdezItem 5 · .PDF · 193 KBFAA Inspector StatementItem 6 · .PDF · 300 KBCorrespondence with FAA InspectorItem 7 · .PDF · 81 KBAircraft Maintenance Information Provided by FAAItem 8 · .PDF · 1.8 MBEngine Examination Field NotesItem 9 · .PDF · 1.1 MBExcerpts - Lycoming Operator's ManualItem 10 · .PDF · 482 KBPhoto 1: Underside of Engine Cowling (Photo Provided by Dean International Flight School)Item 11 · .PDF · 2.6 MBPhoto 2: Underside of Fuselage (Photo Provided by Dean International Flight School)Item 12 · .PDF · 2.3 MBPhoto 3: Right Wing Damage (Photo Provided by Dean International Flight School)Item 13 · .PDF · 2.1 MBPhoto 4: Right Wing Damage (Photo Provided by Dean International Flight School)Item 14 · .PDF · 1.6 MBPhoto 5: Fuel Removed from Left Wing Tank (Photo Provided by Dean International Flight School)Item 15 · .PDF · 3.2 MBPhoto 6: Fuel Removed from Right Wing Tank (Photo Provided by Dean International Flight School)Item 16 · .PDF · 3.5 MBPhoto 7: Oil Dipstick (Photo Provided by Dean International Flight School)Item 17 · .PDF · 1.7 MBPhoto 8: Oil Recovered from Engine (Photo Provided by FAA)Item 18 · .PDF · 146 KBPhoto 9: Engine Oil Line and Fittings (Photo Provided by FAA)Item 19 · .PDF · 147 KBPhoto 10: Engine Oil Line and Fittings (Photo Provided by FAA)Item 20 · .PDF · 141 KBPhoto 11: Engine Oil Line and Fittings (Photo Provided by FAA)Item 21 · .PDF · 149 KB

FAA reports on this event · 1

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

Other investigations on N67324 · 1

Matched to the same aircraft by N-number and date.