ERA17LA044

NTSB accident investigation · Cessna 152 · Miami, FL · November 13, 2016

Accident · No injuriesLimited investigationFinal report
Date
November 13, 2016, 14:00 local (18:00 UTC)
Place
Miami, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N94292Cessna 152
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 4, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20161113018619A
Case key
94370

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

The loss of torque on the No. 3 connecting rod’s nuts, which resulted in the failure of the No. 3 connecting rod’s bolts and a subsequent total loss of engine power due to the operator's maintenance personnel’s improper installation of the connecting rod nuts.

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 152: 4 casesAll aircraft: 371 casesProbable cause
Runway/land/takeoff/taxi surface: soft surfaceEnvironmental issues › Physical environment · Contributed to outcomeCessna 152: 5 casesAll aircraft: 264 cases

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, during the instructional flight to accumulate flight time, the airplane experienced a rough-running engine in cruise flight and that the engine subsequently experienced a total loss of power. The pilot tried to restart the engine to no avail. He then chose to conduct a forced landing to a road, during which the airplane touched down on soft, wet ground before reaching the road. It then nosed over and came to rest inverted. During recovery of the airplane, large cracks were noted in the engine crankcase near the No. 2 cylinder. Disassembly of the engine revealed that the crankshaft was fractured at the No. 3 connecting rod journal and exhibited signatures consistent with extreme heat. The No. 3 connecting rod bolts fractured at the point where the nuts contacted the connecting rod. Each connecting rod nut had a flat-face side and a raised-lip side. As found, the nuts were oriented with the raised-lip side touching the connecting rod despite the engine manufacturer's service instruction, which stated that "Nuts [were] to be assembled with flat face side touching the connecting rod." The caution associated with the orientation of the connecting rod nuts at installation stated that "the connecting rod bolt cannot be tightened correctly if the nut on the connecting rod is installed incorrectly." The operator's maintenance personnel likely installed the nuts incorrectly during an engine overhaul about 246 flight hours before the accident flight, which resulted in a loss of torque on the connecting rod's nuts and the subsequent fracture of the connecting rod's bolts and total loss of engine power.

Factual narrative

On November 13, 2016, about 1400 eastern daylight time, a Cessna 152, N94292, was substantially damaged during a forced landing following a total loss of engine power near Miami, Florida. The private pilots were not injured. Visual meteorological conditions prevailed, and a visual flight rules flight plan was filed for the instructional flight operated by Dean International, Inc which was destined for Miami Executive Airport (TMB), Miami, Florida. The flight originated at Lakeland Linder Airport (LAL), Lakeland, Florida about 1220, and was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.Each pilot provided a written statement, and both statements were consistent throughout. The pilots described the flight as a "buddy" flight, the purpose of which was to build flight time for each. The airplane was in cruise flight over the Everglades about 2,000 feet when the crew noted some engine "roughness." They noted that the engine oil temperature was "normal" but the engine oil pressure indication was "low." The pilot on the controls turned the airplane towards the nearest airport, which was 18 miles from its position at that time. Approximately 1 minute later, the engine stopped producing power, and the crew selected a road for the forced landing. During the descent, an engine restart was attempted and was unsuccessful. The airplane touched down prior to the road on soft, wet ground, nosed over, and came to rest inverted. The pilots egressed the airplane uninjured. During recovery of the airplane, large cracks were noted in the engine crankcase near the number 2 cylinder. The pilot held a private pilot certificate with ratings for airplane single engine land and instrument airplane. His most recent first-class medical certificate was issued on September 8, 2015. The pilot reported 212.5 total hours of flight experience, all of which were in the accident airplane make and model. The copilot held a private pilot certificate with a rating for airplane single engine land. His most recent first-class medical certificate was issued on July 11, 2016. The copilot reported 128.3 total hours of flight experience, all of which were in the accident airplane make and model. The two-seat, single-engine, high-wing airplane was manufactured in 1982 and was equipped with a Lycoming O-235 series engine. Its most recent 100-hour inspection was completed November 3, 2016 at 10,955 total aircraft hours and the airplane had accrued 52 hours since that date. C&G Aircraft Maintenance, a Dean International company, completed engine overhaul 246 aircraft hours prior to the accident. On November 18, 2016, a detailed examination of the engine supervised by an FAA aviation safety inspector revealed the crankshaft was broken at the No. 3 rod journal and displayed signatures consistent with "extreme heat." The No. 3 connecting rod bolts fractured at the point where the nut contacts the connecting rod. Each connecting rod nut had a flat faced side, and araised lip side. As found, the nuts were installed with the raised-lip side touching the connecting rod. According to Lycoming Service Instruction No. 1458G, "Nuts to be assembled with flat face side touching the connecting rod." The caution associated with the orientation of the connecting rod nuts at installation stated: CORRECT INSTALLATION OF THE NEW NUT ON EACH NEW CONNECTING ROD BOLT IS NECESSARY FOR CORRECT CONNECTING ROD ASSEMBLY. EACH CONNECTING ROD NUT HAS TWO DIFFERENT SURFACES, ONE SURFACE IS FLAT AND THE OTHER HAS A RAISED LIP. BE SURE TO INSTALL EACH NUT ON THE CONNECTING ROD BOLT WITH THE FLAT FACE TOUCHING THE ROD AS SHOWN IN FIGURE 2. THE RAISED LIP SURFACE IS AWAY FROM THE ROD. THE CONNECTING ROD BOLT CANNOT BE TIGHTENED CORRECTLY IF THE NUT ON THE CONNECTING ROD IS INSTALLED INCORRECTLY.

Aircraft

Registration
N94292
Reported as
Cessna 152 (NO SERIES)
Category
Airplane
Serial number
15285643
Built
1982
Airframe hours
3,782.7
Engine
Lycoming O-235 SERIES, 110 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Dean International INC
Registered owner
Air Christian Inc
Airworthiness certificate
Standard, Utility
Last inspection
100 hour · November 3, 2016 · 52 hours before
Departed
LAL · Lakeland, FL
Destination
TMB · Miami, FL
Flight plan
VFR

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
23
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
212.5 total · 212.5 in this make and model · 122 in the last 90 days
Role
Pilot
Age
20
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Without waivers/limitations
Seat
Right
Flight hours
128.3 total · 128.3 in this make and model · 107 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 59 °F
Altimeter
30.03 inHg
Observed at
KFXE, 26 nm away

Docket · 5

The files NTSB released with the investigation on December 21, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.8 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.