# NTSB ERA21LA359: Cessna 172S, N782JA, Venice, FL, September 9, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: September 9, 2021, 09:30 local (13:30 UTC) - Place: Venice, FL · Past departure end rwy 23 at VNC. - Coordinates: 27.07, -82.44 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.0700&lon=-82.4400&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 103865 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA359 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103865/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103865 - Page: https://openairdocs.org/ntsb/ERA21LA359 ## Probable cause Maintenance personnel’s failure to use the correct throttle linkage hardware when reinstalling the engine, resulting in a disconnection of the throttle during flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel controlling system](https://openairdocs.org/ntsb-findings/01057320): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/01057320/cases.md?model=2072439), [All aircraft, 59 cases](https://openairdocs.org/ntsb-findings/01057320/cases.md) - [Maintenance: replacement](https://openairdocs.org/ntsb-findings/02062020): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/02062020/cases.md?model=2072439), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR final approach: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Cessna 172S, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=2072439), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 172S, 34 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072439), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that, during the descent for landing, the engine did not respond when he attempted to level off and increase power. Further attempts to adjust the throttle were unsuccessful and engine rpm remained at 1,900. As the airplane was over the runway, the pilot was unable to slow it down, so he forced the nose down onto the grass that was beyond the runway end. After the airplane touched down, it bounced twice, collided with a fence, and nosed over. The airplane was substantially damaged and the pilot and passenger were unhurt. The Federal Aviation Administration inspector who responded to the scene confirmed the substantial damage and found that the connecting hardware for the linkage between the fuel injector servo and the throttle cable were missing. The missing bolt, washer, and nut were subsequently found loose, inside the engine cowling; however, the nut was inconsistent with the nut required by the aircraft illustrated parts manual. The engine had been overhauled and reinstalled about 50 operating hours before the accident. ## Aircraft - Registration: [N782JA](https://openairdocs.org/aircraft/N782JA), registered now, S/N 172S10560, built 2007 (OpenAirDocs) - Reported make and model: CESSNA 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S10560 - Year built: 2007 - Airframe hours: 11298 - Engines: Lycoming IO-360-L2A 180 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Florida Flight Training Center - Registered owner: Florida Flight Training Center - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 16, 2021, 50 hours before - Flight plan: IFR - Airport: VNC, Venice Muni, runway 05/23, 5,000 × 150 ft, asphalt - Equipment: Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 22; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review April 6, 2021; seat: left; restraint: 3-point; flight hours: 149 total, 86 in this make and model, 86 as pilot in command, 21 in the last 90 days, 18 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 11 knots - Visibility: 8 statute miles - Lowest ceiling: 3,900 ft broken - Temperature: 86 °F, dew point 77 °F - Altimeter: 29.98 inHg - Observed at: KVNC - METAR: KVNC 091355Z AUTO 24011KT 8SM SCT022 SCT029 BKN039 30/25 A2998 RMK AO2 ## 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 20210909013089A](https://openairdocs.org/incident/20210909013089A), Sep 9, 2021: Cessna 172S, Venice, FL, Substantial damage. On 09/09/2021, at approximately 09:51 EST, N782JA, a 2007 Cessna 172S, s/n: 172S10560 [privacy data omitted], to provide flight instruction. The aircraft… ## Docket (4 files) The files NTSB released with the investigation on April 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103865. 8.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12887511&FileExtension=pdf&FileName=1-Rel.pdf - NTSB memorandum for record FAA inspector statement (item 2, PDF, 1 page, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12885826&FileExtension=pdf&FileName=2%20NTSB%20Memorandum%20for%20Record%20-%20FAA%20Inspector%20Statement-Rel.pdf - Excerpts - maintenance logbooks (item 3, PDF, 3 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12887236&FileExtension=pdf&FileName=3%20Mx%20Log%20Excerpts_Redacted-Rel.pdf - Photo array (item 4, PDF, 6 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13756686&FileExtension=pdf&FileName=4%20Photo%20Array%20(1)-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.