# NTSB ERA16LA027: Cessna 150M, N171RD, Key Biscayne, FL, October 26, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 26, 2015, 14:23 local (18:23 UTC) - Place: Key Biscayne, FL - Coordinates: 25.7175, -80.159164 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.7175&lon=-80.1592&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report August 1, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 92234 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16LA027 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92234/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92234 - Page: https://openairdocs.org/ntsb/ERA16LA027 ## Probable cause The fatigue failure of the No. 1 cylinder intake valve, which resulted in the partial loss of engine power. ## 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 · Fatigue/wear/corrosion (probable cause) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome ## Analysis The commercial pilot was conducting a personal flight. The pilot reported that, several minutes after takeoff and while en route to his destination airport, the engine began to run roughly and lose power. He subsequently attempted to restore power without success. He then maneuvered the airplane for a forced landing on the fairway of a golf course. The airplane touched down on wet grass, and the pilot was unable to stop the airplane before it collided with two palm trees, which separated the outboard sections of both wings. Postaccident examination of the engine revealed that the intake valve of the No. 1 cylinder had failed due to fatigue, which would have resulted in the partial loss of engine power and engine roughness reported by the pilot. The origin and the extent of the fatigue region could not be determined due to postfracture damage. Further examination of the tip of the valve revealed an abnormal contact wear pattern likely caused by either misalignment relative to the valve seat, valve guide wear, or sticking between the valve stem and the valve guide. A review of maintenance records revealed that new cylinders had been installed when the engine was overhauled about 904 total flight hours before the accident. ## Factual narrative On October 26, 2015, at 1423 eastern daylight time, a Cessna150M, N171RD, collided with trees during the landing roll following a forced landing on a golf course near Key Biscayne, Florida. The commercial pilot and one passenger were not injured. The airplane was substantially damaged. The airplane was registered to and operated by Ameri Air Support, Inc., under the provisions of 14 Code of Federal Regulations (CFR) as a Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The flight originated about 22 minutes earlier from the Opa-Locka Executive Airport (OPF), Miami, Florida, and was destined for the Miami Executive Airport, Miami, Florida.The pilot stated that in preparation of the flight he performed an engine run-up and all parameters were satisfactory. After takeoff the flight climbed to 1,300 feet and proceeded in a southeasterly direction, then south along the coast. After passing the Virginia Key VORTAC, he proceeded in a southerly direction on the 200 degree radial and about 3 miles later, the pilot further reported the engine began to run rough and lose power. Attempts to restore engine power were unsuccessful. He turned back towards Key Biscayne and began looking for a suitable landing spot, indicating his best choice was a golf course. He landed on the fairway of the 18th hole at the Crandon Golf at Key Biscayne. According to the FAA inspector-in-charge (FAA-IIC), after touchdown on the wet grass, the airplane collided with 2 coconut palm trees resulting in partial separation of both wings outboard of the fuel tanks; the airplane came to rest beyond the palm trees or about 912 feet from the touchdown point. The airplane was recovered for further examination. Examination of the Continental O-200-A engine, S/N 213516-71A by a FAA airworthiness inspector revealed no suction or compression was noted in the No. 1 cylinder during inspection for crankshaft, camshaft, and valve train continuity. The spark plugs for the No. 1 cylinder were removed and mechanical damage to both was noted. Following removal of the No. 1 cylinder, a hole was noted in the top of the piston with an object embedded into the top of the piston; the head of one valve was not in position. The cylinder and piston were sent for analysis to the NTSB Materials Laboratory located in Washington, D.C. According to the NTSB Materials Laboratory Factual Report, the intake valve for the cylinder was fractured in the stem just above the head. While most of the fracture was obliterated by post-fracture impact damage, the middle of the fracture exhibited curving crack arrest lines features consistent with fatigue. The fatigue features extended across the entire remaining middle portion of the fracture surface, but the origin or the extent of the fatigue region could not be determined due to post-fracture damage. Inspection of the intake and exhaust valve tips showing the rocker arm contact wear patterns revealed the intakevalve had an abnormal wear pattern consisting of a mix of linear wear contact lines rotating about the center mixed with a linear scratch pattern and a diffuse reflective wear patch. Review of the airplane maintenance records revealed new cylinders were installed when the engine was last overhauled on August 8, 1996. Following overhaul, the engine was installed in the airplane on August 21, 1996; the airplane total time at that time was recorded to be 8,411.0 hours. Maintenance record entries were noted from the engine installation date, to December 15, 2004; the next single entry was dated December 11, 2014. The recorded tachometer time between the 2004 and 2014 entries reflect an increase of 7 hours, though no maintenance record entries were noted. There was no record that the No. 1 cylinder was removed, replaced, or repaired since being installed at engine overhaul in 1996. At the time of the accident, the airframe total time was 9,314.9 hours, and the engine time since major overhaul was about 904 hours. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) ## Aircraft - Registration: [N171RD](https://openairdocs.org/deregistered/N171RD-2018-04-20), registration cancelled 2018-04-20, S/N 15078530, built 1976 (OpenAirDocs) - Reported make and model: CESSNA 150M - Registry model: [Cessna 150M](https://openairdocs.org/model/cessna-150m) (registry code 2071830) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15078530 - Year built: 1976 - Airframe hours: 9183.4 - Engines: Continental O-200-A 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Ameri Air Support, Inc. - Registered owner: Ameri Air Support, Inc. - Airworthiness certificate: Standard, Utility - Last inspection: Annual, December 11, 2014, 132 hours before - Departed: OPF, Opa-Locka, FL - Destination: TMB, Miami, FL - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: none; commercial; airplane ratings: single-engine sea, multi-engine land, single-engine land, multi-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 20, 2014; seat: left; flight hours: 5,500 total, 50 in this make and model, 30 in the last 90 days, 10 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 11 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 3,100 ft broken - Temperature: 81 °F, dew point 66 °F - Altimeter: 30.00 inHg - Observed at: MIA, 8 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 20151026023539A](https://openairdocs.org/incident/20151026023539A), Oct 26, 2015: Cessna 150M, Key Biscayne, FL, Substantial damage. On 10/26/2015 received notification form roc of an aircraft N171RD a Cessna 150 departed opf at 18:01 z. flew VFR southeast bound. At approximately 18:20 z.… ## Docket (9 files) The files NTSB released with the investigation on May 11, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92234. 7.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439960&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Initial Statement (item 2, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439961&FileExtension=.PDF&FileName=Pilot%20Initial%20Statement-Master.PDF - Materials Laboratory Factual Report 16-015 (item 3, .PDF, 4 photos, 940 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439962&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2016-015-Master.PDF - Weather Report and Record (item 4, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439963&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF - Witness Statement (item 5, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439964&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Record of NTSB Conversations (item 6, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439965&FileExtension=.PDF&FileName=Record%20of%20NTSB%20Conversations-Master.PDF - Excerpts from Engine Maintenance Records (item 7, .PDF, 727 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439966&FileExtension=.PDF&FileName=Excerpts%20from%20Engine%20Maintenance%20Records-Master.PDF - Investigative Photographs (item 8, .PDF, 11 photos, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439967&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 and NTSB Evidence Control Forms (item 9, .PDF, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439968&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20and%20NTSB%20Evidence%20Control%20Forms-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.