# NTSB ERA14LA142: Cessna 172R, N9417Z, Jackson, TN, March 5, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 5, 2014, 10:56 local (16:56 UTC) - Place: Jackson, TN - Coordinates: 35.599998, -88.915557 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.6000&lon=-88.9156&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 3, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 88880 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA142 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88880/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88880 - Page: https://openairdocs.org/ntsb/ERA14LA142 ## Probable cause A total loss of engine power due to maintenance personnel’s improper installation of the lower vacuum pump. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng rear section](https://openairdocs.org/ntsb-findings/01058540): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/01058540/cases.md?model=2072401), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01058540/cases.md) - [Engine (reciprocating): recip eng rear section](https://openairdocs.org/ntsb-findings/01058540): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/01058540/cases.md?model=2072401), [All aircraft, 42 cases](https://openairdocs.org/ntsb-findings/01058540/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172R, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072401), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Cessna 172R, 3 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072401), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Cessna 172R, 5 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2072401), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Cessna 172R, 3 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2072401), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 172R, 7 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072401), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172R, 8 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072401), [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 172R, 46 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072401), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N9417Z), registered now, S/N 17280265, built 1997 (OpenAirDocs) - Reported make and model: CESSNA 172R - Registry model: [Cessna 172R](https://openairdocs.org/model/cessna-172r) (registry code 2072401) (OpenAirDocs) - Registry engine: [Lycoming I0-360-B1E](https://openairdocs.org/engine/lycoming-i0-360-b1e) (registry code 41559, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17280265 - Year built: 1997 - Airframe hours: 4083 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; 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 ## 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 20140305001819A](https://openairdocs.org/incident/20140305001819A), Mar 5, 2014: Cessna 172R, Jackson, TN, Substantial damage. On March 5, 2014, aircraft N9417Z, a Cessna 172, departed on an IFR flight from mkl to ags. At 10:33 am, the mkl tower received an emergency call from the… ## Other investigations on N9417Z (1) 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 ERA26LA248](https://openairdocs.org/ntsb/ERA26LA248), Jun 23, 2026: Cessna 172 (N9417Z), Brooksville, FL, minor damage. Probable cause: The student pilot’s failure to ensure clearance while taxiing, which resulted in contact with another airplane that was performing an engine run-up. ## Docket (14 files) The files NTSB released with the investigation on August 26, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88880. 13.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 671 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415679&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 212 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415680&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Redacted.PDF - Weather Reports and Records - KMKL METARs and TAFs (item 3, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415681&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%20-%20KMKL%20METARs%20and%20TAFs-Master.PDF - Satellite Image of Accident Area (Courtesy of FAA) (item 4, .PDF, 661 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415682&FileExtension=.PDF&FileName=Satellite%20Image%20of%20Accident%20Area%20(Courtesy%20of%20FAA)-Master.PDF - Maintenance Records - Vacuum Pump Replacement (item 5, .PDF, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415683&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Vacuum%20Pump%20Replacement-Redacted.PDF - Excerpts from Cessna Model 172 Maintenance Manual - Vacuum Pump Installation (item 6, .PDF, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415684&FileExtension=.PDF&FileName=Excerpts%20from%20Cessna%20Model%20172%20Maintenance%20Manual%20-%20Vacuum%20Pump%20Installation-Master.PDF - Lycoming IO-360-L2A Series IPC - Accessory Drives Information (item 7, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415685&FileExtension=.PDF&FileName=Lycoming%20IO-360-L2A%20Series%20IPC%20-%20Accessory%20Drives%20Information-Master.PDF - Lycoming Aircraft Engines - Service Table of Limits (item 8, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415686&FileExtension=.PDF&FileName=Lycoming%20Aircraft%20Engines%20-%20Service%20Table%20of%20Limits-Master.PDF - Record of Conversation - FAA Inspector's Statement to NTSB (item 9, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415694&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector%27s%20Statement%20to%20NTSB-Master.PDF - Photo 1 - Accident Site (Photo Courtesy of FAA) (item 10, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415689&FileExtension=.PDF&FileName=Photo%201%20-%20Accident%20Site%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Main Wreckage (Photo Courtesy of FAA) (item 11, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415690&FileExtension=.PDF&FileName=Photo%202%20-%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Lower Adaptor Assembly (item 12, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415691&FileExtension=.PDF&FileName=Photo%203%20-%20Lower%20Adaptor%20Assembly-Master.PDF - Photo 4 - Damaged and Distorted Gasket (Photo Courtesy of FAA) (item 13, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415692&FileExtension=.PDF&FileName=Photo%204%20-%20Damaged%20and%20Distorted%20Gasket%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 5 - Comparison of Damaged and Distorted Gasket to New Gasket (Photo Courtesy of FAA) (item 14, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415693&FileExtension=.PDF&FileName=Photo%205%20-%20Comparison%20of%20Damaged%20and%20Distorted%20Gasket%20to%20New%20Gasket%20(Photo%20Courtesy%20of%20FAA)-Master.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.