ERA18LA259

NTSB accident investigation · Cessna 152 · St. Augustine, FL · September 8, 2018

Accident · No injuriesLimited investigationFinal report
Date
September 8, 2018, 10:45 local (14:45 UTC)
Place
St. Augustine, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6469PCessna 152
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA
FAA report
20180908016209A
Case key
98350

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 partial loss of engine power due to a fractured exhaust valve, which resulted in a forced landing on unsuitable terrain and a subsequent rollover.

Findings · 2

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 · Fatigue/wear/corrosionCessna 152: 5 casesAll aircraft: 373 casesProbable cause
TerrainEnvironmental issues › Physical environment · Effect on operationCessna 152: 4 casesAll aircraft: 267 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 was conducting a personal, cross-country flight. He reported that, when the airplane was about 12 miles from the departure airport, the engine started running roughly, and the airplane was "violently shaking." He decided to conduct a forced landing in a field, during which the nose landing gear dug into the soft ground, and the airplane flipped over. Postaccident examination of the engine revealed that the No. 4 cylinder exhaust valve was fractured, and although the head of the exhaust valve was not recovered, the fracture features on the exhaust valve stem were consistent with fatigue. A review of maintenance records revealed that the exhaust valves were installed during an overhaul of the engine about 28 years before the accident. The engine manufacturer recommended that the engine be overhauled every 12 years or 2,400 hours, whichever comes first.

Factual narrative

On September 8, 2018, about 1045 eastern daylight time, a Cessna 152, N6469P, was substantially damaged after it impacted terrain during a forced landing in St. Augustine, Florida. The private pilot was not injured. The airplane was owned and operated by Sunshine Aviation. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that originated from the Palatka Municipal Airport (28J), Palatka, Florida, about 1030, destined for Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.According to the pilot, he departed OMN at 1000 and flew to 28J. He practiced some landings and started his return back to OMN. About 12 miles east of 28J, at 2,000 ft., the engine started running rough and the airplane was "violently shaking." He also heard "clanking" that "sounded like something was loose in the engine." He saw a field to the right side of the airplane and set up for an off-airport landing. At 1,000 ft. he tried to apply power to the engine, but the engine started violently shaking again so he reduced the power. At 800 ft. he secured the airplane by turning off the magnetos, shutting the fuel off, and turning the avionics master switch off. When the airplane was 200 ft. above the field, the pilot could see crops that were higher than he thought, but he could not turn away at that point. The airplane touched down on the main landing gear and when the nose landing gear touched down in the soft ground, it dug into the ground and the airplane flipped over. The pilot subsequently egressed through the door. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane sustained damage to the firewall and cockpit floor. The nose landing gear was fractured off, the right-wing leading edge was crushed, and the outboard main spar was wrinkled. The oil filter was removed and cut open. Metallic pieces were noted in the filter element. Examination of the engine by a National Transportation Safety Board investigator revealed that the No. 4 cylinder exhaust valve was fractured, and the fracture features observed on the valve stem were consistent with fatigue. The piston, cylinder head, and cylinder walls were gouged consistent with repeated contact with the exhaust valve; however, no portions of the valve head remained in the cylinder. The two-seat, single-engine, high-wing airplane was built in 1981, and equipped with a Lycoming O-235-series engine. The most recent annual inspection was completed on June 11, 2018. Review of maintenance records revealed that at the time of the accident, the airframe total time was 8,139.7 hours. The airplane had flown 95.4 hours since its last annual inspection and the engine had accumulated 1,608.7 hours since major overhaul. The last engine overhaul was performed in 1995; however, the parts replaced did not include the exhaust valves. The exhaustvalves were replaced on June 4, 1990 during an engine overhaul with a total engine time of 5,186.4 hours. The engine manufacturer recommended that the engine be overhauled every 12 years or 2,400 hours, whichever comes first. The pilot held a private pilot certificate, with a rating for airplane single-engine land. His most recent FAA second class medical certificate was issued on March 5, 2018. He reported 228 total hours of flight experience at the time of the accident.

Aircraft

Registration
N6469P
Reported as
Cessna 152 (No Series)
Category
Airplane
Serial number
15285019
Built
1981
Airframe hours
8,139.7
Engine
Lycoming O-235 SERIES, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 11, 2018 · 95 hours before
Departed
28J · Palatka, FL
Destination
OMN · Ormond Beach, FL
Equipment
Stall warning system

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
19
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
August 31, 2018
Seat
Left
Restraint
3-point
Flight hours
228 total · 200 in this make and model · 159 as pilot in command · 121 in the last 90 days · 43 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Lowest ceiling
2,000 ft broken
Temperature
84 °F, dew point 75 °F
Altimeter
29.98 inHg
Observed at
KSGJ, 15 nm away

Docket · 6

The files NTSB released with the investigation on November 18, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 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.

Other investigations on N6469P · 1

Matched to the same aircraft by N-number and date.