# NTSB ERA13LA187: Cessna 152, N6141Q, Miami, FL, April 4, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 4, 2013, 08:40 local (12:40 UTC) - Place: Miami, FL - Coordinates: 25.608612, -80.538612 - Nearby events: https://openairdocs.org/map.md?lat=25.6086&lon=-80.5386&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report August 7, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 86585 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86585/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86585 - Page: https://openairdocs.org/ntsb/ERA13LA187 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 152, 5 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2071835), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 152, 2 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2071835), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: 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 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](https://openairdocs.org/deregistered/N6141Q-2018-02-28), registration cancelled 2018-02-28, S/N 15285164 (OpenAirDocs) - Reported make and model: CESSNA 152 - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Category: Airplane - Serial number: 15285164 - Airframe hours: 6408 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 25; injuries: none; 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 - Student pilot; age 23; injuries: none; 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 ## 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 20130404004609A](https://openairdocs.org/incident/20130404004609A), Apr 4, 2013: Cessna 152, Miami, FL, Substantial damage. On April 4 2013, at 0840, N6141Q, a Cessna 152, registered to c&g aircraft maintenance inc, operating as a 14 CFR 141, under dean international inc (D4RS),… ## Other investigations on N6141Q (2) 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. - [NTSB ERA15LA342](https://openairdocs.org/ntsb/ERA15LA342), Sep 5, 2015: Cessna 152 (N6141Q), Miami, FL, substantial damage. Probable cause: The pilot's improper preflight fuel planning and in-flight fuel management, which resulted in a total loss of engine power due to fuel exhaustion. - [NTSB CHI90LA060](https://openairdocs.org/ntsb/CHI90LA060), Jan 8, 1990: Cessna 152 (N6141Q), Rochester, IN, substantial damage. Probable cause: FAILURE OF THE STUDENT PILOT TO MAINTAIN DIRECTIONAL CONTROL AND/OR PROPERLY COMPENSATE FOR THE WIND CONDITIONS. FACTORS RELATED TO THE ACCIDENT WERE: THE UNFAVORABLE WIND CONDITIONS AND THE DITCH. ## Docket (7 files) The files NTSB released with the investigation on June 5, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86585. 12.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393169&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Engine Log (Excerpts) (item 2, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393187&FileExtension=.PDF&FileName=Engine%20Log%20(Excerpts)-Redacted.PDF - Engine Examination Notes (Summary of Correspondence with FAA Inspector) (item 3, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393260&FileExtension=.PDF&FileName=Engine%20Examination%20Notes%20(Summary%20of%20Correspondence%20with%20FAA%20Inspector)-Master.PDF - Photo 1 - Wreckage from Aft Left (item 4, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393189&FileExtension=.PDF&FileName=Photo%201%20-%20Wreckage%20from%20Aft%20Left-Master.PDF - Photo 2 - Damage to Right Wing (item 5, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393190&FileExtension=.PDF&FileName=Photo%202%20-%20Damage%20to%20Right%20Wing-Master.PDF - Photo 3 - Number 3 Exhaust Valve, Back (Photo Courtesy of FAA) (item 6, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393191&FileExtension=.PDF&FileName=Photo%203%20-%20Number%203%20Exhaust%20Valve,%20Back%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40393188&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.