# NTSB ERA21LA261: Cessna 172, N2797E, Jupiter, FL, June 18, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: June 18, 2021, 18:32 local (22:32 UTC) - Place: Jupiter, FL - Coordinates: 26.9675, -80.154722 - Nearby events: https://openairdocs.org/map.md?lat=26.9675&lon=-80.1547&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, FAA/FSDO, Lycoming - ADs cited in the narratives: [AD 96-12-07](https://openairdocs.org/ad/96-12-07), [AD 2005-12-06](https://openairdocs.org/ad/2005-12-06) (OpenAirDocs) - NTSB case key (mKey): 103301 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA261 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103301/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103301 - Page: https://openairdocs.org/ntsb/ERA21LA261 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172N, 29 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2072434), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cessna 172N, 16 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2072434), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172N, 5 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072434), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172N, 6 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2072434), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 172N, 3 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2072434), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172N, 28 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072434), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 172N, 31 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072434), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172N, 134 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072434), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N2797E), registered now, S/N 17271324 (OpenAirDocs) - Reported make and model: CESSNA 172 (N) - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17271324 - Year built: 1978 - Airframe hours: 13164 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 22; injuries: serious; 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 - 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 ## 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 20210618007879A](https://openairdocs.org/incident/20210618007879A), Jun 18, 2021: Cessna 172N, Jupiter, FL, Destroyed. Part 141 operator certificate no. 9NCS068L, [privacy data omitted] preforming instruction operating Cessna CE-172N, registration N2797E, sn: 17271324 after… ## Other investigations on N2797E (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 CHI83LA222](https://openairdocs.org/ntsb/CHI83LA222), May 18, 1983: Cessna 172 (N2797E), Warsaw, IN, substantial damage ## Docket (9 files) The files NTSB released with the investigation on February 24, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103301. 7.9 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13137965&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Interview summaries (item 2, PDF, 2 pages, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13138425&FileExtension=pdf&FileName=Interview%20Summaries-Rel.pdf - Mechanic statement (item 3, PDF, 4 pages, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13138435&FileExtension=pdf&FileName=Mechanic%20Statement_Redacted-Rel.pdf - Excerpts from maintenance records (item 4, PDF, 3 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13138194&FileExtension=pdf&FileName=Mx%20Excerpts_Redacted-Rel.pdf - Excerpt from Cessna 172 service manual (item 5, PDF, 1 page, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13137663&FileExtension=pdf&FileName=Excerpt%20From%20172%20Service%20Manual-Rel.pdf - ADS-B data (item 6, XLSX, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13159380&FileExtension=xlsx&FileName=20210618_A2CB3D_457201345_ADSB-Rel.xlsx - ADS-B plots (item 7, PDF, 2 pages, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13158415&FileExtension=pdf&FileName=ADSB%20Plots-Rel.pdf - Photo array (item 8, PDF, 5 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13157330&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 10 pages, 579 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13138126&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.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.