# NTSB ERA18LA259: Cessna 152, N6469P, St. Augustine, FL, September 8, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 8, 2018, 10:45 local (14:45 UTC) - Place: St. Augustine, FL - Coordinates: 29.741666, -81.473892 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.7417&lon=-81.4739&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: 1 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 98350 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA259 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98350/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98350 - Page: https://openairdocs.org/ntsb/ERA18LA259 ## 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 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); cases with it: [Cessna 152, 5 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2071835), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Cessna 152, 4 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=2071835), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Cessna 152, 6 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2071835), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 152, 21 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2071835), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: 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: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 152, 84 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071835), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Cessna 152, 1 case](https://openairdocs.org/ntsb-events/097/sequence.md?model=2071835), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md) ## 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](https://openairdocs.org/aircraft/N6469P), registered now, S/N 15285019, built 1981 (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: 15285019 - Year built: 1981 - Airframe hours: 8139.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 19; injuries: none; 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 ## 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 20180908016209A](https://openairdocs.org/incident/20180908016209A), Sep 8, 2018: Cessna 152, Ormond Beach, FL, Substantial damage. On September 08, 2018, about 1045 EDT, a Cessna ce 152, N6469P serial no. 15285019 departed palaka municipal-lt kay larkin airport (28J) enroute to Ormond… ## Other investigations on N6469P (1) 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. - [NTSB CHI96LA004](https://openairdocs.org/ntsb/CHI96LA004), Oct 9, 1995: Cessna 152II (N6469P), Troy, MI, substantial damage. Probable cause: the pilot's inadequate recovery from a bounced landing. A factor associated with the accident was the quartering tailwind condition and the pilot's selection of the wrong runway on which to land. ## Docket (6 files) The files NTSB released with the investigation on November 18, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98350. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478108&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement (item 2, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478113&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Memorandum for Record - Telephone Interview, Pilot (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478109&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Pilot-Master.PDF - Maintenance Records (item 4, .PDF, 566 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478110&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Investigative Photos (item 5, .PDF, 3 photos, 610 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478111&FileExtension=.PDF&FileName=Investigative%20Photos-Master.PDF - Memorandum for Record - NTSB Engine Exam (item 6, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478112&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20NTSB%20Engine%20Exam-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.