ERA21LA261

NTSB accident investigation · Cessna 172 · Jupiter, FL · June 18, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
June 18, 2021, 18:32 local (22:32 UTC)
Place
Jupiter, FL
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2797ECessna 172
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, FAA/FSDO, Lycoming
FAA report
20210618007879A
Case key
103301

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 flight instructor’s failure to obtain the proper touchdown point during a forced landing. Contributing to the accident was the improper service and subsequent inadequate inspection of the single-drive, dual magneto, which resulted in a total loss of engine power.

Findings · 5

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.

Action: incorrect action performancePersonnel issues › Action/decision · PilotCessna 172N: 29 casesAll aircraft: 1,386 casesProbable cause
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Incorrect use/operationCessna 172N: 16 casesAll aircraft: 809 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 172N: 5 casesAll aircraft: 371 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 172N: 6 casesAll aircraft: 320 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172N: 3 casesAll aircraft: 101 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

During a local instructional flight, about 2,700 ft above ground level, the engine lost total power. The instructor was unable to restart the engine and attempted to land on a grass field; however, the airplane overflew the field and collided with a fence and trees before coming to rest nose-down in a creek. Review of flight track data revealed that the airplane overflew several fields, ranging in length from approximately 1,500 ft to 2,500 ft before the collision. Examination of the wreckage revealed that the single-drive, dual output magneto had separated from the rear accessory section of the engine. The nuts, clamps, and lock washers that secured the magneto to the studs were not recovered and the studs did not exhibit any stripping or damage of the threads. Cuts in the magneto housing were consistent with the magneto vibrating over time, possibly due to tightening at an angle between the two studs. The magneto was removed and reinstalled as part of an inspection completed about 3 months (215 hours) before the accident. The mechanic who completed the inspection and reinstalled the magneto stated that the reinstallation included clamps and nuts that were used, but serviceable, and new lock washers. The mechanic added that there were no defects noted at the time of the inspection. An annual inspection of the airplane was completed about 1 month (74 flight hours) before the accident. The mechanic that completed the annual inspection stated he followed the Code of Federal Regulations Part 43 checklist, which does not specifically include magnetos; however, he checked with his hand (by trying to wiggle all the accessories) that the magneto was secure.

Factual narrative

On June 18, 2021, about 1832 eastern daylight time, a Cessna 172N, N2797E, was substantially damaged when it was involved in an accident near Jupiter, Florida. The flight instructor sustained serious injuries and the student pilot sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. Due to his injuries, the instructor was unable to provide a statement. Attempts to contact the student pilot were unsuccessful. According to a Federal Aviation Administration (FAA) inspector, about 10 minutes after takeoff, at 2,700 ft mean sea level, the airplane experienced a total loss of engine power. The instructor was unable to restart the engine and attempted to land on a grass field; however, the airplane overflew the field and collided with a fence and trees before coming to rest nose-down in a creek. Review of automatic dependent surveillance – broadcast (ADS-B) data revealed that the airplane overflew several fields, ranging in length from approximately 1,500 ft to 2,500 ft, before the collision. Examination of the wreckage by an FAA inspector and representative from the airframe manufacturer revealed oil streaks along the fuselage. Further examination revealed that the single-drive, dual output magneto had separated from the rear accessory section of the engine. The nuts, clamps, and lock washers that secured the magneto to the studs were not recovered and the studs did not exhibit any stripping or damage of the threads. Additionally, cuts in the magneto housing were consistent with the magneto vibrating over time, possibly due to tightening at an angle between the two studs. Review of maintenance records revealed that the magneto was serviced on March 4, 2021, and the airplane’s most recent annual inspection was completed on May 17, 2021. The airplane had been operated about 215 hours and 74 hours since those dates, respectively. Additionally, a 100-hr inspection was performed on April 9, 2021. The mechanic that serviced the magneto on March 4 stated that he did so as part of a pre-buy inspection. The mechanic had advised the seller that Airworthiness Directive (AD) 96-12-07 was superseded by AD 2005-12-06, which was not applicable to the model and serial number magneto; however, the mechanic was requested to perform the original AD anyway, to satisfy the buyer. The original AD was a 500-hr inspection of the magneto impulse couplings. The mechanic removed and reinstalled the magneto as part of the AD. The reinstallation included clamps and nuts that were used, but serviceable, and new lock washers. The mechanic added that there were no defects noted at the time of the inspection. The mechanic who performed the subsequent annual inspection on May 17, 2021, stated that, when the magneto was previously removed and replaced, that mechanic (using a torque wrench) would tighten its two steel nuts and each nut has a star lock washer. The mechanic added that during the annual inspectionhe followed the CFR Part 43 checklist, which does not specifically include magnetos; however, he checked with his hand (by trying to wiggle all the accessories) that the magneto was secure. The Cessna checklist includes magnetos, but it is up to the operator to request that checklist be used, as it results in more labor during inspections and thus more cost for the inspection.

Aircraft

Registration
N2797E
Reported as
Cessna 172 (N)
Category
Airplane
Serial number
17271324
Built
1978
Airframe hours
13,164
Engine
Lycoming O-320, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Aamro Aviation
Registered owner
Palm Beach Flyers
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 17, 2021 · 74 hours before
Departed
F45 · West Palm Beach, FL
Equipment
Handheld GPS, Stall warning system, ADS-B

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
Flight instructor
Age
22
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 1, 2021
Seat
Right
Restraint
3-point
Flight hours
1,000 total
Role
Student pilot
Age
23
Injuries
Serious
Seat
Left
Restraint
3-point
Flight hours
3 total · 3 in this make and model · 3 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 7 knots
Visibility
10 statute miles
Lowest ceiling
19,000 ft broken
Temperature
84 °F, dew point 73 °F
Altimeter
30.06 inHg
Observed at
KPBI, 17 nm away
METAR
METAR KPBI 182253Z 09007KT 10SM BKN190 OVC230 29/23 A3006

Docket · 9

The files NTSB released with the investigation on February 24, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.9 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 N2797E · 1

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