ERA13LA187

NTSB accident investigation · Cessna 152 · Miami, FL · April 4, 2013

Accident · No injuriesLimited investigationFinal report
Date
April 4, 2013, 08:40 local (12:40 UTC)
Place
Miami, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N6141QCessna 152
Defining event
Maneuvering: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report August 7, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20130404004609A
Case key
86585

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

A partial loss of engine power due to the failure of the No. 3 exhaust valve. Contributing to the accident was the airplane operator’s failure to follow the engine manufacturer’s recommended engine overhaul intervals.

Findings · 2

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 cyl sectionAircraft › Aircraft power plant · FailureCessna 152: 5 casesAll aircraft: 373 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 152: 2 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

Near the conclusion of a local training flight, the airplane’s engine experienced a partial loss of power, and the flight instructor performed a forced landing to a road. The airplane departed the road during the landing, and the right wing was substantially damaged. Postaccident examination of the engine found that the No. 3 cylinder exhaust valve had fractured and separated from the valve stem. Review of maintenance records showed that the valve may have been installed during a repair to the No. 3 cylinder that occurred about 28 years before the accident flight; however, due to the incomplete nature of the records provided, a definitive determination of the engine’s complete service history could not be made. Recent engine log entries showed that the engine had accumulated nearly 2,500 flight hours since the most recent overhaul. The engine-manufacturer-recommended time between overhaul is every 2,400 flight hours or 12 calendar years.

Factual narrative

On April 4, 2013, at 0840 eastern daylight time, a Cessna 152, N6141Q, was substantially damaged during a forced landing following a partial loss of engine power near Miami, Florida. The certificated flight instructor and the certificated student pilot were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which originated from Kendall-Tamiami Executive Airport (TMB), Miami, Florida, at 0745. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. At the conclusion of an uneventful training flight, the flight instructor asked the student pilot to demonstrate a steep turn prior to returning to TMB. While in the turn, the engine experienced a partial loss of power, and the propeller continued to “windmill.” The flight instructor then took control of the airplane and returned to straight-and-level flight before attempting to restore power to the engine. After determining that engine power could not be restored, and that the airplane would be unable to reach TMB from their current position, the flight instructor elected to perform a forced landing to a road. During the landing, the left main landing gear caught on a grassy area next to the runway, yawing the nose left. The airplane subsequently struck a bush, resulting in substantial damage to the right wing. The engine was examined following the accident under the supervision of a Federal Aviation Administration inspector. Internal examination of the number 3 cylinder showed that the exhaust valve head had fractured and was separated from the valve stem. The valve head was recovered from the engine cylinder, and showed evidence of post-separation damage and contact with the interior of the cylinder and piston dome. No other mechanical deficiencies of the engine were identified during the examination. The accident airplane was manufactured in 1981 and was equipped with a Lycoming O-235-L2C engine. Review of maintenance logs provided by the operator revealed that the engine was installed in the accident airplane following a field overhaul in June 1985. At the time of the overhaul, the engine had accumulated 1,994 total hours of operation. In December 1985, after the engine had accumulated 299 flight hours since the most recent overhaul, inspection of the number 3 cylinder revealed a broken rocker shaft boss. The remedy to the discrepancy included the installation of “serviceable valves.” Between 1985 and the date of the accident, no other replacement of the number 3 cylinder or its valves was noted. No other documents accompanied the log entry, and the prior service history of the installed “serviceable” valves could not be determined. Based on the maintenance records provided, the engine’s maintenance history between 1985 and 2011 could not be determined; however review of an entry dated October 2011 noted that the engine had accumulated 1,876 total hours since its most recent overhaul. Theairplane’s most recent annual inspection was completed on April 14, 2012. At that time the engine had accumulated 5,702 total hours, and 1,929 hours since overhaul. The most recent 100 hour inspection was completed on March 26, 2013, and at that time the engine had accumulated 2,408 hours of operation since the most recent overhaul. At the time of the accident, the engine had accumulated 2,495 hours since the most recent overhaul, and 6,269 hours since its manufacture. According to Lycoming Service Instruction 1009AS, revised May 25, 2006, the recommended overhaul interval for the O-235 engine was 2,400 hours or 12 calendar years.

Aircraft

Registration
N6141Q
Reported as
Cessna 152
Category
Airplane
Serial number
15285164
Airframe hours
6,408
Engine
Lycoming O-235, 110 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
C&G Aircraft Maintenance Inc.
Registered owner
C&G Aircraft Maintenance Inc.
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · March 26, 2013 · 87 hours before
Departed
TMB · Miami, FL
Destination
TMB · Miami, FL

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
25
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 4, 2013
Seat
Right
Flight hours
903 total · 901 in this make and model · 828 as pilot in command · 368 in the last 90 days · 124 in the last 30 days · 2 in the last 24 hours
Role
Student pilot
Age
23
Injuries
None
Certificate
Student
Medical
Class 1, With waivers/limitations
Seat
Left
Flight hours
64 total · 64 in this make and model · 49 in the last 90 days · 16 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 70 °F
Altimeter
30.02 inHg
Observed at
TMB, 7 nm away

Docket · 7

The files NTSB released with the investigation on June 5, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 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.

Other investigations on N6141Q · 2

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