# NTSB ERA22LA369: Cessna 172, N4751F, Jamestown, NY, August 12, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: August 11, 2022, 22:58 local (Aug 12, 2022, 02:58 UTC) - Place: Jamestown, NY - Coordinates: 42.0748, -79.3833 - Nearby events: https://openairdocs.org/map.md?lat=42.0748&lon=-79.3833&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Lycoming, FAA/FSDO, Textron Aviation - SAIBs cited in the narratives: [SAIB CE-09-35](https://openairdocs.org/saib/CE-09-35) (OpenAirDocs) - NTSB case key (mKey): 105726 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA369 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105726/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105726 - Page: https://openairdocs.org/ntsb/ERA22LA369 ## Probable cause A partial loss of engine power for reasons that could not be definitively determined. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Failure; 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) - [Temp/humidity/pressure: conducive to carburetor icing](https://openairdocs.org/ntsb-findings/03031030): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Cessna 172N, 6 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md?model=2072434), [All aircraft, 435 cases](https://openairdocs.org/ntsb-findings/03031030/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna 172N, 24 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2072434), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 172N, 23 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2072434), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Enroute: 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) ## 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](https://openairdocs.org/deregistered/N4751F-2023-10-18), registration cancelled 2023-10-18, S/N 17273078, built 1979 (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: 17273078 - Year built: 1979 - Airframe hours: 3996.6 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: serious; 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 - Flight instructor; age 25; injuries: serious; 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 ## 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 20220811018969A](https://openairdocs.org/incident/20220811018969A), Aug 11, 2022: Cessna 172N, Ashville, NY, Destroyed. Engine failed while at 5000 feet. Flight instruction flight for commercial rating. Pilot made emergency landing in trees approximately 75' from a house.… ## Docket (15 files) The files NTSB released with the investigation on January 4, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105726. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 9.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636372&FileExtension=pdf&FileName=ERA22LA369%206120%20Final_Redacted-Rel.pdf - Pilot statements (item 2, PDF, 4 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636711&FileExtension=pdf&FileName=Pilot%20Statements_Redacted-Rel.pdf - Mechanic statement (item 3, PDF, 1 page, 581 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14635534&FileExtension=pdf&FileName=ERA22LA369%20ROC%20Mechanic_Redacted-Rel.pdf - FAA inspector statement (item 4, PDF, 1 page, 581 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14637794&FileExtension=pdf&FileName=FAA%20Inspector%20Statement-Rel.pdf - Magneto service manual excerpts (item 5, PDF, 2 pages, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14635544&FileExtension=pdf&FileName=CMI%20Magneto%20Service%20Support%20Manual%20Excerpts-Rel.pdf - Airframe maintenance logs (item 6, PDF, 68 pages, 11.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14644692&FileExtension=pdf&FileName=Last%205-Years%20Airframe%20Logs_Redacted-Rel.pdf - Memorandum of record spark plug replacement and magneto maintenance (item 7, PDF, 1 page, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14673027&FileExtension=pdf&FileName=ERA22LA369%20Spark%20plug%20and%20magneto%20repair-Rel.pdf - Engine maintenance logs (item 8, PDF, 57 pages, 37.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14642277&FileExtension=pdf&FileName=N4751F-Last%205-Years%20Engine%20Logs_Redacted-Rel.pdf - Carburetor icing probability charts (item 9, PDF, 2 pages): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14641525&FileExtension=pdf&FileName=Carburetor%20Icing%20Probability%20Chart%20-Rel.pdf - Overhaul correspondence memorandum (item 10, PDF, 3 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636390&FileExtension=pdf&FileName=ERA22LA369%20Overhaul%20Correspondence_Redacted-Rel.pdf - Investigative photographs (item 11, PDF, 7 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636741&FileExtension=pdf&FileName=ERA22LA369%20Photo%20Array-Rel.pdf - Final flight path (item 12, PDF, 1 page, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636318&FileExtension=pdf&FileName=Final%20Flight%20Path-Rel.pdf - Wreckage examination reports (item 13, PDF, 9 pages, 595 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636637&FileExtension=pdf&FileName=ERA22LA369%20Examination%20Summary-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 10 pages, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636792&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14636647&FileExtension=pdf&FileName=ERA22LA369%20Final%20Wreckage%20Release_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.