ERA21LA388

NTSB accident investigation · Cessna 172 · Port Orange, FL · September 29, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
September 29, 2021, 14:06 local (18:06 UTC)
Place
Port Orange, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N116SVCessna 172
Defining event
Enroute-descent: 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
FAA/FSDO
FAA report
20210929017389A
Case key
103998

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 separation of the nut from the stud and the fracture of the bolt that secured the crankshaft idler gear to the engine crankcase, which resulted in a total loss of engine power due to the inability of the left crankshaft idler gear assembly to drive of the camshaft.

Findings · 1

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.

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

After an uneventful 1-hour flight, the flight instructor and student pilot were returning to the airplane’s home base. The flight instructor pointed out to the student that the airplane had descended below the assigned altitude, and the student replied, “we have no power.” The flight instructor took over the flight controls and attempted to restore power. Because that effort was unsuccessful, the flight instructor pitched the airplane to achieve the best glide speed. After realizing that the airplane would not reach the nearest airport, he performed a forced landing in a field, and the airplane nosed over during the landing roll. Postaccident examination of the engine revealed that the camshaft was not being driven by the left crankshaft idler gear assembly because it was out of position. The nut that secured the idler gear to a stud at the left crankcase was separated, and a bolt that also secured the idler gear to the left crankcase was fractured. Extensive damage was noted to the left crankcase in the area that supported the idler gear and the area into which the securing bolt was threaded, indicating movement of the crankshaft idler gear shaft for an extended period of time. The available evidence for this investigation did not allow a determination regarding the reason for the separation of the nut from the stud and the fracture of the bolt that secured the idler gear to the crankcase. The engine was last overhauled about 11 years and 3,488 hours before the accident. The owner/operator of the airplane at the time of the accident stated that, during the time that he owned the airplane, maintenance personnel had not cut open the oil filter to inspect the filter element during each oil change. Photographic evidence showed the presence of non-ferrous particles in the oil filter element. It is likely that these particles were from the damaged left crankcase. If maintenance personnel had cut open the oil filter and inspected the filter element during each oil change (the most recent of which was during the last inspection of the engine 3 months before the accident), it is possible that they would have detected the presence of non-ferrous particles in the filter element and taken action to identify the source.

Factual narrative

On September 29, 2021, about 1406 eastern daylight time, a Cessna 172S, N116SV, was substantially damaged when it was involved in an accident near Port Orange, Florida. The flight instructor and the student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor stated that, earlier that day, the student pilot flew from Massey Ranch Airpark (X50), New Smyrna Beach, Florida, to Gainesville Regional Airport (GNV), Gainesville, Florida, and made an uneventful full-stop landing. Afterward, the airplane departed GNV to return to X50 with the student pilot at the controls. The airplane had an adequate supply of fuel, and the engine fuel-to-air ratio was leaned once the airplane climbed to 3,500 ft mean sea level (msl). The controller at Daytona Beach Approach Control cleared the flight to descend to 2,500 and then 1,600 ft msl. While the airplane descended with the power reduced to 1,900 rpm, the flight instructor informed the student pilot that the airplane was 100 ft below the assigned altitude, and the student pilot replied, “we have no power.” The flight instructor took over the flight controls and applied full throttle, but the engine rpm did not change. He confirmed that the mixture control was in the full rich position and that the fuel selector was in the “both” position. The flight instructor simultaneously pitched the airplane to achieve the best glide speed (68 knots) and told the student pilot to complete the checklist for an engine failure during flight. As the student pilot performed the checklist, the flight instructor advised the controller that the engine had lost power, and the controller provided information about nearby airports. Due to the airplane’s altitude and distance from those airports at the time, the flight instructor realized an off-airport landing was necessary. The flight instructor located a field and performed a forced landing. After the airplane rolled on the ground for a few feet, the nose landing gear contacted “something,” and the airplane nosed over, resulting in substantial damage to the left wing, the vertical stabilizer, and the bottom and left side of the fuselage near the horizontal stabilizer. The airplane was equipped with a Garmin G1000 multifunction display. No pertinent data from the accident flight could be recovered because the unit firmware version installed on the unit did not store data. Postaccident examination of the engine revealed that rotation of the crankshaft did not result in rotation of the camshaft. After removal of the accessory case, the left crankshaft idler gear assembly, which was driven by the crankshaft gear and drove the camshaft, was found out of position. Extensive damage was noted in the area of the left crankcase (which supported and secured the crankshaft idler gear shaft). The left crankcase (which received the securing bolt on the lower portion of the crankshaft idler gear shaft)exhibited extensive damage. A castellated nut (which secured the upper portion of the crankshaft idler gear shaft to a stud in the left crankcase) was separated, and a bolt (which secured the lower portion of the crankshaft idler gear shaft to the left crankcase) was fractured. The right crankshaft idler gear shaft remained secured to the crankcase by two bolts that were safety wired. A photograph of the oil filter element showed non-ferrous particles. The owner/operator of the airplane reported that maintenance personnel had not cut open the oil filter (to inspect the filter element) during each engine inspection performed while he owned the airplane. The engine had been overhauled by a repair station in December 2010 and was installed in the airplane several days later. The engine was removed from the airplane in July 2011 for a disassembly inspection due to a stuck valve and bent pushrods. The engine was reinstalled in the airplane on July 20, 2011, where it remained through the time of the accident. The engine accrued about 3,488 hours since June 25, 2021, which was the date of the engine’s last inspection and oil change. No evidence for this investigation allowed a determination regarding the engine time accrued between the last inspection and the accident.

Aircraft

Registration
N116SV
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S9815
Built
2005
Airframe hours
6,219
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Aviation Pacific Flight Training School
Registered owner
Trns Solutions LLC
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · June 25, 2021
Departed
GNV · Gainesville, FL
Destination
X50 · New Smyrna Beach, FL
Flight plan
VFR
Equipment
Electronic primary flight display, Electronic multifunction display, Data recorder, ADS-B, 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
22
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 24, 2021
Seat
Right
Restraint
3-point
Flight hours
320 total · 290 in this make and model · 170 as pilot in command · 38 in the last 90 days · 15 in the last 30 days · 2 in the last 24 hours
Role
Student pilot
Age
21
Injuries
None
Certificate
Student
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
83 total · 83 in this make and model · 2 as pilot in command · 30 in the last 90 days · 10 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 64 °F
Altimeter
30.02 inHg
Observed at
KDAB, 6 nm away
METAR
KDAB 291753Z COR 14003KT 10SM FEW042 SCT250 29/18 A3002 RMK AO2 SLP163 T02940183 10300 20211 58013 $

Docket · 8

The files NTSB released with the investigation on August 15, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.0 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.