ERA14LA142

NTSB accident investigation · Cessna 172R · Jackson, TN · March 5, 2014

Accident · No injuriesLimited investigationFinal report
Date
March 5, 2014, 10:56 local (16:56 UTC)
Place
Jackson, TN
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9417ZCessna 172R
Defining event
Enroute-climb to cruise: Powerplant sys/comp malf/fail
Weather
Instrument (IMC) · Day
Status
Completed · report November 3, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20140305001819A
Case key
88880

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 total loss of engine power due to maintenance personnel’s improper installation of the lower vacuum pump.

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 rear sectionAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172R: 1 caseAll aircraft: 42 casesProbable cause
Engine (reciprocating): recip eng rear sectionAircraft › Aircraft power plant · Damaged/degradedCessna 172R: 1 caseAll aircraft: 42 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 172R: 1 caseAll aircraft: 371 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 pilot reported that, during the climb after takeoff in instrument meteorological conditions, he noted that the engine was losing oil pressure rapidly. He immediately made a 180-degree turn to return to the departure airport. While inbound on the instrument landing system (ILS) approach, he realized that the airplane was too high, so he executed a 360-degree descending turn. He then again proceeded inbound on the ILS approach. He continued the descent but, because the airplane had not captured the glideslope, he executed a missed approach. He then circled the airplane around and re-established the airplane on the localizer. Subsequently, the engine lost all power, and the airplane began descending. The pilot subsequently landed the airplane on a road just north of the airport. During the landing, the right wing impacted a highway sign, which resulted in substantial damage to the right wing. The airplane then veered right and entered a cornfield. Examination of the wreckage revealed the presence of oil on the back of the engine, firewall, and belly. The engine was started with the engine cowling removed, and oil was observed to appear on the back of the accessory pad near the lower vacuum pump. Further examination of the area revealed that the accessory drive adapter gasket was the source of the leak. Review of the airplane's maintenance records revealed that, on the day before the accident, the lower vacuum pump had been removed and that a new vacuum pump, shaft seal, and accessory drive adapter gasket had been installed. Examination revealed that the proper gasket was installed; however, it was distorted and showed signs of excessive compression and "squeezeout," which indicated that the nuts had been overtorqued during installation.

Factual narrative

According to FAA and maintenance records the airplane was manufactured in 1997. The airplanes most recent annual inspection was completed on November 22, 2013. At the time of the inspection, the airplane had accrued 4036.1 total hours of operation. METEOROLOGICAL INFORMATION The recorded weather at MKL, included: wind 110 at 3 knots, 1/2 mile visibility in fog, variable visibility of 200 feet, temperature 0 degrees C, dew point -1 degrees C, and an altimeter setting of 30.21 inches of mercury. According to the Airport Facility Directory, MKL was a publicly-owned, tower controlled airport. It had two runways oriented in a 02/20 and 11/29 configuration. Runway 2 was asphalt, grooved, in fair condition, and was equipped with high intensity runway lights and precision runway markings in fair condition. A 4-light Precision Approach Slope Indicator located on the left side of the runway provided a 3.00 degree glide path. The total length of the runway was 6,006 feet, and its width was 150 feet and was equipped with a 1,400 foot medium intensity approach lighting system with runway alignment indicator lights. No obstructions were present and it was equipped with an Instrument Landing System. On March 5, 2014, about 1056 central standard time, a Cessna 172R, N9417Z, was substantially damaged during a forced landing after a loss of engine power during an instrument landing system (ILS) approach at McKellar Sipes Regional Airport (MKL), Jackson, Tennessee. The private pilot and his passenger were not injured. Instrument meteorological conditions prevailed, and an IFR flight plan had been filed for the flight destined for Augusta Regional Airport (AGS), Augusta, Georgia, conducted under Title14 Code of Federal Regulations Part 91. According to the pilot, during the climb from MKL as he was at 6,500 feet above mean sea level (msl) he noted that he was losing oil pressure rapidly. He immediately did a 180 degree turn and headed on a direct course back to MKL. A few miles from the airport, he asked for radar vectors for the "ILS RWY 2," and was vectored for the approach by air traffic control. Inbound on the ILS, he realized that he was too high, and executed a 360 degree descending turn to lose altitude. He then proceeded inbound on the ILS once again. At approximately 2,100 feet msl, the glideslope was "hopping from the top peg to the bottom peg rapidly" and he never was able to get a "solid indication from the glideslope." He continued to descend and when he was at approximately 1,500 feet msl, and still had not captured the glideslope, he executed a missed approach. The pilot then climbed to 2,000 feet msl. There was now "zero oil pressure" and the engine would only produce partial power. He then circled around again and re-established himself on the localizer. He still had no glideslope indication and the glideslope needle was still "hopping from top to bottom." At this time the engine had lost all power and the airplane began descending. He was on thelocalizer and he knew he was lined up with the runway. At approximately 400 feet above the runway he still could not see the runway and the airplane was still descending with no engine power. The airplane continued to travel to the north of the airport and when the airplane was about 150 feet above ground level, the pilot saw a field and then a road. He then made a "sharp" left turn, lined up with the road and touched down. During the rollout, the right wing made contact with a highway sign, veered to the right and entered a cornfield. According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument airplane. His most recent application for a FAA second-class medical certificate was dated August 20, 2009. The pilot reported that he had accrued approximately 275 total hours of flight experience, of which 215 hours were in the accident airplane make and model. During the examination of the wreckage, it was revealed that the engine was still operable. The engine was started with the engine cowling removed and oil was observed to appear on the back of the accessory pad in the area of the lower vacuum pump. Further examination of the area revealed that the accessory drive adapter gasket was the source of the leak. Review of maintenance records revealed that on March 4, 2014 (the day before the accident), at 4083.1 total hours of operation, the lower vacuum pump had been removed and a new vacuum pump had been installed along with a new shaft seal and accessory drive adapter gasket. Review of invoice information and FAA Form 8130.3 Airworthiness Approval Tags indicated that the accessory drive adaptor gasket was part number 68315. Examination of the gasket installed revealed that it was the proper gasket, however, it was discovered that it was distorted and showed signs of excessive compression and squeeze out. Examination of the accident site revealed that the road the pilot landed on was US Highway 70 and that after striking the highway sign it came to rest in a cornfield facing approximately 90 degrees from its direction of travel. Examination of the wreckage by a Federal Aviation Administration inspector revealed that during the impact with the highway sign, and then the ground, the right wing incurred substantially damaged. Several large dents were visible, the lift strut was broken, the attach fittings and spar were damaged, and the wing tip was damaged. Further examination revealed the presence of oil on the back of the engine, firewall, and belly.

Aircraft

Registration
N9417Z
Reported as
Cessna 172R
Category
Airplane
Serial number
17280265
Built
1997
Airframe hours
4,083
Engine
Lycoming I0-360-B1E, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 22, 2013 · 47 hours before
Departed
MKL · Jackson, MS
Destination
AGS · Augusta, GA
Flight plan
IFR
Airport
MKL · McKellar Sipes Regional, runway 02, 6,006 × 150 ft, asphalt
Equipment
Stall warning system

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
28
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
October 19, 2013
Seat
Left
Restraint
3-point
Flight hours
275 total · 215 in this make and model · 237 as pilot in command · 19 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
Calm
Visibility
1 statute miles
Lowest ceiling
200 ft overcast
Temperature
34 °F, dew point 30 °F
Altimeter
30.20 inHg
Observed at
MKL, 1 nm away

Docket · 14

The files NTSB released with the investigation on August 26, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.2 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 N9417Z · 1

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