# NTSB ERA22LA412: Engineering & Research 415-C, N99209, Galion, OH, September 9, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: September 9, 2022, 18:45 local (22:45 UTC) - Place: Galion, OH · North of GQQ - Coordinates: 40.756198, -82.722024 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.7562&lon=-82.7220&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 105923 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA412 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105923/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105923 - Page: https://openairdocs.org/ntsb/ERA22LA412 ## Probable cause A partial loss of engine power due to an exhaust valve that was stuck in the open position. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Engineering & Research 415-C, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=0420302), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/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 (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Engineering & Research 415-C, 4 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=0420302), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Engineering & Research 415-C, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0420302), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The student pilot performed an engine run-up before departure that included a check of the magnetos and carburetor heat, noting normal rpm decreases for each. He initiated the takeoff, noting full rpm during the takeoff roll and normal takeoff distance. On the upwind leg of the airport traffic pattern, when the airplane was about 300 ft above ground level, the engine began to lose power. The pilot lowered the airplane’s nose to maintain airspeed then made a left turn to return to the airport. When the airplane was close to the airport the engine sustained a total loss of power and he realized that the airplane was too high to land on the runway. He flew over and then north of the airport, where he intended to land on an east/west oriented road. The airplane subsequently impacted a powerline pole and came to rest on the road, resulting in substantial damage to the fuselage and aft empennage. Postaccident examination of the engine revealed the loss of engine power was a result of the No. 2 cylinder exhaust valve being stuck in the open position. About 32 years before the accident, a reconditioned cylinder was installed at the No. 2 position, there were multiple maintenance record entries associated with the No. 2 cylinder citing either a stuck exhaust valve or work to the cylinder consistent valve problems, the most recent being nearly 3 years and about 63 engine hours earlier. Guidance from the engine manufacturer related to a stuck exhaust valve cited a need to clean the cylinder components and perform dimensional checks of specified components. It did not cite what to do for a repetitive problem. ## Factual narrative On September 9, 2022, about 1845 eastern daylight time, an Engineering & Research 415-C airplane, N99209, was substantially damaged when it was involved in an accident near Galion, Ohio. The student pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The student pilot stated that before departure he performed an engine run-up that included a check of the magnetos and carburetor heat, noting normal rpm decrease for each. He initiated the takeoff noting full rpm during the takeoff roll and the airplane became airborne about the usual location along the length of the runway. On the upwind leg of the airport traffic pattern when the airplane was about 300 ft above ground level, the engine began to lose power. The pilot lowered the airplane’s nose to maintain 65 knots then made a left turn to return to the airport. When the airplane was close to the airport the engine experienced a total loss of power and the student pilot realized that the airplane was too high to land on the runway. He flew over and then north of the airport where he intended to land on an east/west oriented road. The airplane subsequently impacted a powerline pole and came to rest on the road. Postaccident examination of the airplane following recovery revealed structural damage to the fuselage and aft empennage. Examination of the engine revealed the exhaust valve of the No. 2 cylinder was stuck open. Review of the engine maintenance records revealed that a reconditioned cylinder was installed at the No. 2 position in March 1990. About 6 ½ years and 79 hours later, the No. 2 cylinder was removed and the valves were ground. Although the engine was overhauled in January 1998, the only work done to the cylinders were that they were honed, and the valves were ground and lapped. Since the engine overhaul, the No. 2 cylinder was removed in 2005 and again in 2009. The entry in 2005 specified “stuck valves” while the reason for the valve removal in 2009 was not noted. Both entries specified cleaning and/or reaming of the valve guides. In September 2019, which was before the pilot owned the airplane, a “stuck open” exhaust valve of the No. 2 cylinder was reported, with a corrective action of reaming the guide and polishing the valve stem. The engine had accrued about 63 hours and nearly 3 years since the last exhaust valve incident was logged and over 32 years and about 628 hours since the reconditioned cylinder was installed on the engine. According to the engine manufacturer Standard Practice Maintenance Manual, the expected repair for an engine experiencing a stuck valve included cleaning of the parts of the cylinder and dimensional checks of the components. The manual did not have any guidance for a repetitive issue. ## Aircraft - Registration: [N99209](https://openairdocs.org/deregistered/N99209-2023-08-16), registration cancelled 2023-08-16, S/N 1832, built 1946 (OpenAirDocs) - Reported make and model: ENGINEERING & RESEARCH 415-C (NO SERIES) - Registry model: [Engineering & Research 415-C](https://openairdocs.org/model/engineering-research-415-c) (registry code 0420302) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1832 - Year built: 1946 - Airframe hours: 2883 - Engines: CONT MOTOR C85-12 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 9, 2022, 29 hours before - Airport: GQQ, Galion Municipal Airport, runway 23, 3,504 × 75 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: none; student; seat: left; restraint: lap only; flight hours: 102 total, 45 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 61 °F - Altimeter: 30.02 inHg - Observed at: KMFD, 10 nm away - METAR: METAR KMFD 092252Z 12007KT 10SM CLR 26/16 A3002 RMK AO2 SLP160 T02560161= ## 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 20220909017049A](https://openairdocs.org/incident/20220909017049A), Sep 9, 2022: Engineering & Research 415-C, Galion, OH, Substantial damage. [privacy data omitted]Departed gqq airport to remain in the area for a solo/ practice flight. Aircraft was airborne upwind from runway 23 at approximately… ## Docket (8 files) The files NTSB released with the investigation on January 30, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105923. 18.7 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14951189&FileExtension=pdf&FileName=6120_Recd%201%2012%202023-Rel.pdf - Record of NTSB conversation (item 2, PDF, 3 pages, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949329&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversation_Redacted-Rel.pdf - Memorandum for record - FAA engine examination results (item 3, PDF, 1 page, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949339&FileExtension=pdf&FileName=Memo%20For%20Record%20-%20FAA%20Engine%20Examination%20results-Rel.pdf - Memorandum for record - engine logbook review (item 4, PDF, 2 pages, 1 photo, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14955587&FileExtension=pdf&FileName=Memo%20For%20Record%20-%20Engine%20Logbook%20Review%20v02-Rel.pdf - Excerpts from engine logbooks (item 5, PDF, 9 pages, 11.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14951199&FileExtension=pdf&FileName=Excerpts%20Fm%20Engine%20Logbook_Redacted-Rel.pdf - Excerpt from engine manufacturer standard practice maintenance manual (item 6, PDF, 2 pages, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14952555&FileExtension=pdf&FileName=Excerpt%20Fm%20Standard%20Practice%20MM-Rel.pdf - Investigative photographs (item 7, PDF, 3 pages, 3 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14952934&FileExtension=pdf&FileName=Investigative%20Photographs_ERA22LA412-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15, and NTSB evidence control form (item 8, PDF, 2 pages, 812 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14957714&FileExtension=pdf&FileName=Wreckage%20Release%20%26%20Evidence%20Control%20Form_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.