ERA22LA369

NTSB accident investigation · Cessna 172 · Jamestown, NY · August 12, 2022

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
August 11, 2022, 22:58 local (Aug 12, 2022, 02:58 UTC)
Place
Jamestown, NY
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4751FCessna 172
Defining event
Enroute-climb to cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Night
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Lycoming, FAA/FSDO, Textron Aviation
FAA report
20220811018969A
Case key
105726

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

A partial loss of engine power for reasons that could not be definitively determined.

Findings · 3

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.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentCessna 172N: 6 casesAll aircraft: 435 cases
Not determinedNot determined › Not determined · Unknown/Not determinedCessna 172N: 24 casesAll aircraft: 2,247 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 night cross-country instructional flight, the pilot receiving instruction performed a touch-and-go maneuver. Shortly afterward, during the climb to cruise flight on the return leg, the engine began to lose power. The flight instructor briefly attempted to troubleshoot the engine (including applying carburetor heat); however, he was unable to restore engine power, which remained at idle with the propeller windmilling. Because the airplane would be unable to reach an airport, the flight instructor established the airplane’s best glide speed. The airplane subsequently impacted trees. Postaccident examination of the engine revealed that the single-drive dual magneto, which remained attached to the engine, would not produce a spark when the engine’s crankshaft was rotated. Internal examination revealed that, when the magneto’s input drive was rotated, neither set of contact points opened. The magneto manufacturer’s service support manual stated that the magneto should be inspected every 500 hours with particular attention focused on rotating parts, bearings, and electrical components. The maintenance logbooks showed no record of 500-hour magneto inspections having been completed during the almost 2,000 hours that the airplane was operated since the operator had purchased it. The weather conditions about the time of the accident were conducive to carburetor icing at cruise and glide engine power settings, and while the instructor applied carburetor heat with no engine power improvement after the engine had begun to faulter, it is possible that the engine might not have been developing sufficient heat by that point to deice an accumulation of ice in the carburetor. Thus, it could not be determined whether the anomalous operation of the magneto’s points that was observed during the postaccident examination, the possible formation of carburetor ice, or a combination of both these factors ultimately resulted in the partial loss of engine power during the accident flight.

Factual narrative

On August 11, 2022, about 2258 eastern daylight time, a Cessna 172N, N4751F, was substantially damaged when it was involved in an accident near Jamestown, New York. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the flight instructor, the flight was scheduled as a night cross-country flight from Lake County Executive Airport (LNN), Willoughby, Ohio, to Chautauqua County/Jamestown Airport (JHW), Jamestown, New York. The airplane was fully fueled before departure, and the instructor noted no issues during the flight to JHW. During the climb to cruise altitude after the touch-and-go procedure at JHW, the engine began to “sputter.” The pilot receiving instruction pitched the airplane for the best glide speed and circled back toward JHW while attempting to restore engine power. He applied carburetor heat, but the engine did not regain power and seemed to be “at idle, just sputtering” with the propeller windmilling. Air traffic control advised the pilots of a private airstrip below the airplane’s location, and the flight instructor took control of the airplane to “spiral” down to the airstrip. The pilots were unable to locate the airstrip; as a result, the instructor “maintained best glide [speed] and went forward into the trees.” The airplane came to rest nose down at the base of a tree in the yard of a private residence. The fuselage, empennage, and both wings sustained substantial damage. Postaccident examination of the engine revealed that the single-drive dual magneto, which remained attached to the engine, would not produce a spark when the engine crankshaft was rotated. Internal examination of the magneto revealed that, when the magneto input drive was rotated, its drive cam lobe pushed the felt padding on both sides but that neither set of contact points opened. A screwdriver was applied to the hold-down screws for the contact points, and they appeared to be torqued. The maintenance logbooks showed no engine overhaul information or time-in-service information for the magneto. The operator thought that the engine had been overhauled before purchasing the airplane in 2016; however, they had no record of the overhaul. The airplane’s pre-purchase inspection entry on May 19, 2016, showed a tachometer time of 2,110.6 hours. At the time of the accident, the tachometer time was 4,020.3 hours. The logbooks contained no entries indicating that 500-hour inspections had been completed on the magneto. The most recent magneto repair occurred on June 26, 2019, at a tachometer time of 2,893.8 hours. The maintenance entry read, “Removed magneto unit for timing issues; installed magneto and adjusted timing per engine manual.” The Continental Ignition Systems Service Support Manual stated the following: Inspect all magnetos according to the “500 Hour Inspection” in Section 6-2.3, at the first 500 hours in service and every500 hours thereafter. If the magneto has more than 500 hours, inspection as outlined above must take place within the next 100 hours, or at the next scheduled inspection period, whichever occurs first, and at 500-hour intervals thereafter. Make an appropriate logbook entry signifying compliance with this paragraph and referencing the magneto serial numbers involved after completing the inspections. Ignition systems are subject to the same environmental conditions and wear as the engine. Therefore, overhaul the magnetos and replace the ignition harnesses at the same time as the engine. Engine overspeed, sudden stoppage or other unusual circumstances may require engine overhaul prior to engine manufacturer's recommendations. In such circumstances overhaul the magneto, regardless of “in service time”, with particular attention focused on rotating parts, bearings and electrical components. Inspect magnetos and harnesses for airworthiness at the expiration of four years, without regard to the accumulated operating hours since new or last overhaul. At 2256, the weather reported at JHW, which was about 7 miles northeast of the accident site, included a temperature of 60.8° F and a dew point of 53.6° F. The calculated relative humidity at this temperature and dewpoint was about 77.16%. Review of the icing probability chart contained within Federal Aviation Administration Special Airworthiness Information Bulletin CE-09-35 revealed the atmospheric conditions at the time of the accident were conducive to “serious icing at glide and cruise power.”

Aircraft

Registration
N4751F
Reported as
Cessna 172 (N)
Category
Airplane
Serial number
17273078
Built
1979
Airframe hours
3,996.6
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Vector Aviation LLC
Registered owner
Vector Aviation LLC
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · August 4, 2022 · 23.7 hours before
Departed
JHW · Jamestown, NY
Destination
LNN · Wiloughby, OH
Airport
NY89 · Goose Creek Airport
Equipment
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
63
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 24, 2022
Seat
Left
Restraint
Lap only
Role
Flight instructor
Age
25
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 26, 2022
Seat
Right
Restraint
Lap only
Flight hours
254.6 total · 19.2 in this make and model · 198.6 as pilot in command · 36.6 in the last 90 days · 25.4 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
360° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 54 °F
Altimeter
30.12 inHg
Observed at
JHW, 7 nm away
METAR
KJHW 120256Z AUTO 36005KT 10SM CLR 16/12 A3012 RMK AO2 SLP198 T01610117 51017

Docket · 15

The files NTSB released with the investigation on January 4, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.