# NTSB ERA17LA044: Cessna 152, N94292, Miami, FL, November 13, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 13, 2016, 14:00 local (18:00 UTC) - Place: Miami, FL - Coordinates: 26.336944, -80.625274 - Nearby events: https://openairdocs.org/map.md?lat=26.3369&lon=-80.6253&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 4, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 94370 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA044 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94370/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94370 - Page: https://openairdocs.org/ntsb/ERA17LA044 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 152, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2071835), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2071835), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Runway/land/takeoff/taxi surface: soft surface](https://openairdocs.org/ntsb-findings/03023020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna 152, 5 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=2071835), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) ## 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 (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 152, 30 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2071835), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 152, 35 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071835), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 152, 37 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071835), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/aircraft/N94292), registered now, S/N 15285643, built 1982 (OpenAirDocs) - Reported make and model: CESSNA 152 (NO SERIES) - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15285643 - Year built: 1982 - Airframe hours: 3782.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: none; 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 - Pilot; age 20; injuries: none; 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 ## 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 20161113018619A](https://openairdocs.org/incident/20161113018619A), Nov 13, 2016: Cessna 152, Ft. Lauderdale, FL, Substantial damage. On 11/13/2016 at approximately 19:33Z a Cessna 152, N94292, enroute from klal to ktmb crashed into the everglades 30 miles wnw of kfll. Two souls onboard… ## Docket (5 files) The files NTSB released with the investigation on December 21, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94370. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469784&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement Engine Prelim (item 2, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469785&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement%20Engine%20Prelim-Master.PDF - FAA Inspector's Statement Memo for Record (item 3, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469786&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement%20Memo%20for%20Record-Master.PDF - Lycoming Engine Service Instruction (item 4, .PDF, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469787&FileExtension=.PDF&FileName=Lycoming%20Engine%20Service%20Instruction-Master.PDF - Photos (item 5, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469788&FileExtension=.PDF&FileName=Photos-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.