# NTSB ERA23LA141: Cessna 172M, N64535, Miami, FL, March 7, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: March 7, 2023, 17:22 local (22:22 UTC) - Place: Miami, FL · In the Everglades National Park 13 SW of TMB - Restricted Area - Coordinates: 25.647564, -80.433225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.6476&lon=-80.4332&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 106844 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA141 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106844/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106844 - Page: https://openairdocs.org/ntsb/ERA23LA141 ## Probable cause A total loss of engine power due to a lack of oil lubrication. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 172M, 4 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2072418), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Cessna 172M, 3 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=2072418), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172M, 19 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072418), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 172M, 33 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072418), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The flight instructor was conducting an instructional flight when the engine began to make a “knocking” noise, followed by a total loss of oil pressure and subsequent loss of engine power. The instructor reported they were unable to return to the airport and made a forced landing to a marsh area. The nose wheel of the airplane dug into the soft/wet terrain and the airplane slowly flipped over, resulting in substantial damage to an engine mount. Postaccident examination of the airplane revealed there were no major oil streaks on the lower engine cowling and fuselage; however, there was some dark oily residue noted on the right underbelly of the airplane that appeared to have been there for an extended period of time. The engine did not seize and crankshaft rotated freely when the propeller was manually rotated. Examination of the engine’s oil system revealed no obvious mechanical failures; however, damage signatures were observed that were consistent with a lack of lubrication. The instructor said they departed for the flight with 6 quarts of oil; however, about one quart of dark oil was drained from the engine following the accident. Pieces of metal were found throughout the oil system consistent with high heat, friction, and metal-to-metal contact within the engine. A review of the engine maintenance records revealed the engine was 55 hours past its last 100-hr inspection. Based on the instructor’s report that the engine was “knocking,” followed by a loss of oil pressure and a power loss, and evidence of high heat, friction, and metal-to-metal contact within the engine with no sign of leaks in the oil system, the engine was likely being operated with an inadequate oil level at the time of the power loss. Though the engine did not fully seize, the damage found throughout the engine most likely contributed to a loss of engine power. ## Factual narrative On March 7, 2023, about 1722 eastern standard time, a Cessna 172, N64535, was substantially damaged when it was involved in an accident near Miami, Florida. The flight instructor and the private pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor said that, about 30 to 40 minutes into the flight, the engine began to make a “knocking” noise followed by a total loss of oil pressure. The engine then stopped producing power and the propeller “locked up.” The instructor said they were unable to return to the airport and made a forced landing in the Everglades National Park. The nose wheel of the airplane dug into the soft/wet terrain and slowly flipped over, resulting in substantial damage to an engine mount. The airplane was recovered from the Everglades about seven days after the accident and taken to a secure facility. Examination of the airplane revealed there were no major oil streaks on the lower engine cowling and fuselage; however, there was some dark oily residue noted on the right underbelly of the airplane that appeared to have been there for an extended amount of time. The engine was not seized and the crankshaft rotated freely when the propeller was manually rotated. When the propeller was rotated, valvetrain continuity and thumb compression were observed on each cylinder. Examination of the engine’s oil system revealed no obvious mechanical failures; however, damage was observed that was consistent high heat and friction due to a lack of lubrication. The flight instructor said that there were six quarts of oil on the airplane before they departed; however, about one quart of dark-colored oil was drained from the oil sump after the accident. The oil suction screen was removed and several pieces of metallic debris were observed. The filter was also removed and was filled with dark-colored oil. The element was removed and small flecks of carbon were observed. The oil pump was removed and all gearing was intact. The oil sump was partially exposed when the accessory gear box was removed and several large pieces of metal debris were observed. The oil filter tube was found slightly loose but was being held in place by safety-wire. Some oil was observed on the engine case around and below where the tube connected to the engine case. Review of the engine maintenance records revealed the last 100-hour inspection was completed on December 20, 2022, at an engine total time of 1,124 hours. At the time of the accident the engine had accrued 1,279 hours, which was 55 hours past its next required 100-hr inspection. ## Aircraft - Registration: [N64535](https://openairdocs.org/aircraft/N64535), registered now, S/N 17265291, built 1975 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17265291 - Year built: 1975 - Airframe hours: 1124 - Engines: Lycoming O-320-E2D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Panair Flying Club Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 20, 2022 - Departed: Miami, FL - Equipment: Electronic multifunction display, Satellite tracking device, Onboard weather, Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 66; injuries: none; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; flight hours: 7,306 total, 4,518 in this make and model, 7,248 as pilot in command, 30 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours - Student pilot; age 28; injuries: none; private; airplane ratings: single-engine land; medical: class 1; seat: left; flight hours: 216 total, 216 in this make and model, 180 as pilot in command, 5 in the last 90 days, 4 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 9 knots - Visibility: 10 statute miles - Temperature: 81 °F, dew point 70 °F - Altimeter: 29.98 inHg - Observed at: KTMB - METAR: METAR KTMB 072253Z 10009KT 10SM FEW090 27/21 A2998 ## 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 20230307008399A](https://openairdocs.org/incident/20230307008399A), Mar 7, 2023: Cessna 172M, Homestead, FL, Substantial damage. Part 91 operation Cessna 172M, [privacy data omitted], serial number 17265291 lost engine power and oil pressure with one pilot and one student pilot on board.… ## Docket (6 files) The files NTSB released with the investigation on May 2, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106844. 10.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16704000&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - Investigative photos (item 2, PDF, 4 pages, 3 photos, 665 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16703360&FileExtension=pdf&FileName=Photos%20-%20Airplane-Rel.pdf - NTSB engine examination (item 3, PDF, 3 pages, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16703960&FileExtension=pdf&FileName=NTSB%20Engine%20Examination%20Report-Rel.pdf - FAA inspector statement (item 4, PDF, 4 pages, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16704010&FileExtension=pdf&FileName=FAA%20Inspector%20Statement_Redacted-Rel.pdf - Excerpts of maintenance records (item 5, PDF, 3 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16704480&FileExtension=pdf&FileName=Photos%20-%20Maintenance%20Records%20-%20Last%20Annual%20Inspections_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 775 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16704490&FileExtension=pdf&FileName=NTSB%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.