ERA15LA338

NTSB accident investigation · Cessna R172 · Cresskill, NJ · September 3, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
September 3, 2015, 17:10 local (21:10 UTC)
Place
Cresskill, NJ
Injuries
2 serious
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N758DKCessna R172
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2016
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20150903020689A
Case key
91923

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Maintenance personnel’s failure to apply proper torque to the cylinder flange nuts and through bolts during installation of the engine cylinders, which resulted in the loosening of the components, loss of lubrication, failure of the crankshaft, and the subsequent total loss of engine power.

Findings · 4

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 · Incorrect service/maintenanceCessna R172K: 2 casesAll aircraft: 373 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Damaged/degradedCessna R172K: 3 casesAll aircraft: 233 casesProbable cause
Maintenance: repairPersonnel issues › Task performance · Maintenance personnelCessna R172K: 1 caseAll aircraft: 99 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna R172K: 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 private pilot reported that, while the public aircraft flight was in cruise flight about 2,000 ft mean sea level, the airplane's engine stopped producing power. During the subsequent descent, the pilot chose a large open area of several athletic fields for the forced landing. As the airplane approached the fields, the pilot observed that they were in use and that only a small space was available for landing due to people on the ground. The airplane subsequently landed hard and was destroyed during the impact. Examination of the engine maintenance records revealed that the Nos. 3 and 4 cylinders had been removed and reinstalled 231 hours before the accident. The cylinder flange nuts and through bolts were checked for security and breakaway torque, and several were found below factory specification. Disassembly of the engine revealed metal fragments and bearing material in the oil sump. Disassembly of the crankcase revealed that it was fractured and that the Nos. 1 and 2 main bearings and bearing journals had damage consistent with a loss of lubrication, high heat, and fatigue. It is likely that maintenance personnel did not apply sufficient torque to the cylinder flange nuts and through bolts during the installation of the engine cylinders.

Factual narrative

On September 3, 2015, about 1710 eastern daylight time (EDT), a Cessna R172K, N758DK, was destroyed by collision with terrain during a forced landing following a total loss of engine power near Cresskill, New Jersey. The private pilot and pilot-rated observer were seriously injured. The flight departed Republic Airport (FRG), Farmingdale, New York, about 1400. Visual meteorological conditions prevailed, and no flight plan was filed for the public use flight.According to the United Stated Coast Guard (USCG), the flight was conducted as a USCG Auxiliary Maritime Observation Mission. Federal Aviation Administration (FAA) inspectors interviewed the pilot in the hospital the day after the accident. Due to his injuries, the inspectors conducted only a brief interview. According to the pilot, he departed Lincoln Park, New Jersey (N07) about 1300 and flew to Farmingdale, New York (FRG) to pick up the observer for the flight. They then departed FRG, and flew to the Albany, New York area where they reversed course and flew south along the Hudson River. While in cruise flight about 2,000 feet mean sea level (msl), the airplane's engine stopped producing power. During the subsequent descent, the pilot selected a large open area adjacent to a community center that contained several athletic fields for the forced landing. As the airplane approached, the pilot observed that the fields were in use, and that only a small space was available for landing which would allow separation from people on the ground. The resultant hard landing destroyed the airplane and required first responders to affect the egress of the airplane's occupants. According to FAA and USCG records, the pilot held a private pilot certificate with a rating for airplane single engine land. His most recent FAA third-class medical certificate was issued on April 20, 2015. The pilot updated a USCG Pilot/Aircrew Qualification form on April 30, 2015, and reported 510 total hours of flight experience on that date. According to the FAA, the pilot reported he had 648 total hours of flight experience, of which 382 were in the accident airplane make and model. The four-seat, single-engine, high-wing, retractable-gear airplane was manufactured in 1978 and was equipped with a Continental Motors 210-horsepower reciprocating engine. According to the FAA, the airplane's maintenance records showed the most recent annual inspection was completed on July 17, 2015, at 2,194 total aircraft hours. The hobbs meter indicated 2,281 total aircraft hours at the accident site. Review of engine maintenance records revealed the #3 and #4 cylinders had been removed and reinstalled for maintenance on May 11, 2012. The engine accrued approximately 231.5 hours of operation prior to the accident. Examination of photographs revealed the accident site was located in a hedgerow on the perimeter of an athletic field about 41 feet elevation. The wreckage path was approximately 36 feet long, oriented about 130 degrees magnetic. Thetail section and empennage appeared intact, but the roof and wingbox structure appeared collapsed into the cockpit and cabin areas. The airplane came to rest in about a 30-degree, right wing-down attitude. The right wing was visible, and remained intact from the cabin to about mid-span, where it wrinkled and curled upwards towards the tip. The airplane was removed from the accident site, and the engine was shipped to the manufacturer for a detailed examination at a later date. The engine was examined at the manufacturer's facility under the supervision of an FAA aviation safety inspector. Examination revealed impact damage to the fuel pump housing, and the right magneto, which had a broken mount flange and was hanging loose from the engine. The right front engine mount was broken and several ignition harness leads were severed. The cylinder flange nuts were checked for security and breakaway torque, and the #2 and #3 cylinders' through bolts nuts and perimeter nuts were below factory specifications. The #2 cylinder through bolts breakaway torque was 236/365 in. lbs. respectively. The #3 cylinder through bolts breakaway was 286/351 in. lbs. respectively. The manufacturer's specification was 590-610 in lbs. Removal of the engine oil pan revealed metal fragments and bearing material in the sump. Disassembly of the crankcase revealed damage to the #1 and #2 main bearings and bearing journals consistent with a loss of lubrication, high heat, and fatigue. Fretting was noted around the #1, #2, and #3 through bolt bosses as well as the #2 and #3 cylinder deck pads. The crankshaft was fractured through the #4 throw.

Aircraft

Registration
N758DK
Reported as
Cessna R172 (K)
Category
Airplane
Serial number
R1723011
Built
1978
Airframe hours
2,281
Engine
Cont Motor IO-360 SER, 210 horsepower, reciprocating
Damage
Destroyed
Flight
Aerial observation · Public use
Operator
USCG Auxiliary
Registered owner
Black Sheep Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 17, 2015 · 187 hours before
Departed
FRG · Farmingdale, NY
Destination
FRG · Farmindale, NY

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
Pilot
Age
44
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 3, Unknown
Last flight review
April 30, 2015
Seat
Left
Restraint
3-point
Flight hours
648 total · 382 in this make and model · 43 in the last 90 days
Role
Other flight crew
Age
44
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Right
Restraint
3-point
Flight hours
0 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
16 °F
Altimeter
29.79 inHg
Observed at
TEB, 12 nm away

Docket · 7

The files NTSB released with the investigation on February 25, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.7 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.