ERA24LA271

NTSB accident investigation · Cessna 172 · Hernando, FL · June 21, 2024

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 21, 2024, 12:10 local (16:10 UTC)
Place
Hernando, FL
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N734XTCessna 172
Defining event
Maneuvering: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, FAA/FSDO
FAA report
20240621009259A
Case key
194519

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 improper installation of a cylinder rocker stud by maintenance personnel, which resulted in a partial loss of engine power and subsequent forced landing.

Findings · 2

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 172N: 5 casesAll aircraft: 371 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172N: 13 casesAll aircraft: 373 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

The flight instructor reported that, during an instructional flight, while maneuvering about 2,000 ft above ground level, the engine began to run rough and lost partial power. The airplane could not maintain altitude and the instructor was unable to restore engine power. He subsequently performed a forced landing on a road, during which the left wing impacted a tree and the airplane came to rest inverted. Subsequent examination of the engine revealed that the No. 3 exhaust valve rocker was loose and did not depress the exhaust valve when the pushrod was fully extended. The rocker and stud were removed and remnants of threads from the cylinder head were observed between the threads of the stud, consistent with over-tightening of the stud during installation. Review of maintenance records revealed that the No. 3 cylinder was replaced due to low compression about 13 months and 564 engine tachometer hours before the accident. Although the maintenance procedures specified that the stud be tightened to 150 ft-lbs of torque, the stud was likely over-tighten during installation, as was evident by cylinder thread material being pulled into the stud threads, which resulted in its looseness and inability of the rocker to open the exhaust valve.

Factual narrative

On June 21, 2024, about 1210 eastern daylight time, a Cessna 172N, N734XT, was substantially damaged when it was involved in an accident near Hernando, Florida. The flight instructor and commercial pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that the airplane departed about 20 minutes prior with 30 gallons of fuel. The commercial pilot and flight instructor were practicing commercial maneuvers at 2,000 ft mean sea level when they experienced extreme engine roughness and a loss of engine power. The flight instructor could not maintain altitude and could not correct the engine anomaly. He subsequently performed a forced landing on a road. During the landing, the left wing struck a tree and the airplane came to rest inverted. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the left wing and fuselage. The engine was further examined following wreckage recovery to a storage facility. During the examination, the propeller was rotated by hand and thumb compression was attained on all cylinders. Crankshaft, camshaft, and valvetrain continuity (with the exception of the No. 3 exhaust valve) was confirmed to the rear accessory section of the engine. The rocker covers were removed, and the No. 3 exhaust valve rocker was loose and did not depress the exhaust valve when the pushrod was fully extended. The rocker and stud were removed and remnants of threads from the cylinder head were observed between the threads of the stud, consistent with over-tightening of the stud during installation. All other rockers were secured in place and operated as expected. Review of maintenance records revealed that the No. 3 cylinder was replaced due to low compression on May 12, 2023, about 564 engine tachometer hours before the accident. According to the director of maintenance (DOM) of the repair station that performed the cylinder installation, he endorsed the maintenance logbook entries once the paperwork was complete and reviewed. The DOM added that a torque wrench was used to tighten the rocker stud to 150 ft-lbs per the Lycoming O-320 Operations Manual Maintenance Procedures, and he provided a copy of those procedures and the calibrated torque wrench serial number that was used to tighten the stud.

Aircraft

Registration
N734XT
Reported as
Cessna 172 (N)
Category
Airplane
Serial number
17269203
Built
1977
Airframe hours
8,309
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
American Aviation Inc
Registered owner
American Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · April 19, 2024
Departed
BKV · Brookville, FL
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
Flight instructor
Age
28
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 19, 2023
Seat
Left
Restraint
3-point
Flight hours
1,192 total · 1,000 in this make and model · 1,130 as pilot in command · 174 in the last 90 days · 55 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
23
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine sea
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
June 14, 2022
Seat
Right
Restraint
3-point
Flight hours
271 total · 100 in this make and model · 213 as pilot in command · 19 in the last 90 days · 10 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 4 knots
Visibility
7 statute miles
Lowest ceiling
3,400 ft overcast
Temperature
84 °F, dew point 73 °F
Altimeter
30.09 inHg
Observed at
INF, 23 nm away
METAR
KINF 211615Z AUTO 03004KT 7SM SCT026 OVC034 29/23 A3009

Docket · 8

The files NTSB released with the investigation on June 24, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.6 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.

Other investigations on N734XT · 1

Matched to the same aircraft by N-number and date.