FTW99LA110

NTSB accident investigation · Cessna 172N · Turrell, AR · April 7, 1999

Accident · No injuriesLimited investigationFinal report
Date
April 7, 1999, 10:45 local (15:45 UTC)
Place
Turrell, AR
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5171KCessna 172N
Weather
Visual (VMC) · Day
Status
Completed · report September 12, 2000
Report
Approved by Office Director
Case key
46040

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The total loss of engine power as the result of improper maintenance which led to the number one cylinder intake valve rocker assembly stud bolt backing out rendering the valve inoperative. A factor was the lack of suitable terrain for the forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfManeuvering
Engine assembly,rocker arm/tappet - loose part/bolt/nut/clamp/etcCause
Maintenance - improperOther maintenance personnelCause
Forced landingDescent - emergency
In flight collision with terrain/waterEmergency landing
Terrain condition - none suitableFactor
Terrain condition - wet
Terrain condition - soft
Terrain condition - rough/uneven
Nose downEmergency landing

Analysis

While maneuvering at a low altitude, there was a loss of engine power. During the forced landing to a rough/uneven road, the airplane's right main tire exited the road into a muddy ditch. The airplane nosed down in the adjacent soft field. Postaccident investigation revealed that the #1 cylinder intake valve rocker assembly stud bolt was backed out of the hole four turns, allowing the valve to become inoperative. Lycoming service bulletin 412B issued in March 1978, for replacing all rocker arm retaining studs with oversized studs was complied with at the factory before engine S/N L-7296-76 was shipped to Cessna in 1979. The original logbooks were reported lost; therefore, the complete history of the engine could not be verified. A review of reconstructed logbooks revealed that on February 12, 1998, the engine had accumulated '200 to 300 hours' since major overhaul. A 100-hour inspection maintenance entry for September 24, 1998, stated in part: 'Removed #1 cylinder, honed and installed new rings. #1 compression checked 68/80 at ground run. This engine determined to be in an airworthy condition.'

Factual narrative

On April 7, 1999, at 1045 central daylight time, a Cessna 172N, single engine airplane, N5171K, impacted terrain during a forced landing following a loss of engine power while maneuvering at low altitude near Turrell, Arkansas. The airplane was operated by Downtown Aviation, LLC, Memphis, Tennessee, under Code of Federal Regulations (CFR) Part 91. The commercial pilot/flight instructor and the student pilot were not injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed and a flight plan was not filed for the local instructional flight. The flight departed Memphis, Tennessee, at 1000.

During interviews, conducted by the FAA inspector, and on the Pilot/Operator Aircraft Accident Report (NTSB Form 6120.1/2), the operator and the pilot reported that the student was performing ground reference maneuvers at 1,200 feet msl when the flight instructor noticed a "bad vibration coming from the engine." The flight instructor performed the emergency procedures and diverted to an agricultural airstrip (approximately 12 miles west/southwest of the departure airport. Upon aligning the airplane with the runway to the north, he noticed a "strong tailwind" and observed 2 agricultural airplanes at the departure end of the runway. At this point, the engine produced partial power and he circled the airstrip for landing to the south on a dirt road (rough/uneven) that paralleled the airstrip. Prior to the touchdown, there was a total loss of engine power. The instructor stated that he prepared his student for a hard landing. Upon landing, the airplane "bounced and a gust of wind from the southeast blew the right main tire into the muddy ditch." Subsequently, the airplane rolled into an adjacent field, the nose gear sank into the soft dirt, and the airplane nosed down. The outboard left wing struck the ground before the airplane came to rest on the main landing gear.

The pilot reported the winds were from the south southeast at 10 to 15 knots. The National Weather Service (NWS) surface observation at Memphis, Tennessee, was reporting the winds from 150 degrees at 8 knots.

The operator and the FAA inspector examined the aircraft and found that the rear spar of the left wing was buckled outboard of the fuel tank. The FAA inspector found that the "number one cylinder intake valve rocker assembly stud bolt was backed out of the hole four turns, allowing the valve to become inoperative." See the enclosed inspector's report for additional details.

A Textron Lycoming Service Bulletin (SB 412B) was issued on March 10, 1978, for replacing all rocker arm retaining studs with oversized studs. This O-320-H2AD, serial number L-7296-76 was shipped from the factory on October 12, 1979; therefore, according to the manufacturer representative, the SB would have been complied with by the manufacturer.

The original logbooks were reported lost; therefore, the complete history of the engine, since shipment from the factory, could not be verified. A review of the reconstructed logbooks revealed that on February 12, 1998, the engine had accumulated "200 to 300 hours" since major overhaul. A 100-hour inspection maintenance entry for September 24, 1998, stated in part: "Removed #1 cylinder, honed and installed new rings. #1 cylinder compression checked 68/80 at ground run. This engine determined to be in an airworthy condition." The last 100 hour inspection was performed on March 9, 1999, at an accumulated aircraft time of 8,019.1 hours.

The airplane was released to the owner on May 5, 1999.

Aircraft

Registration
N5171K
Reported as
Cessna 172N
Category
Airplane
Serial number
73998
Airframe hours
8,019
Engine
Lycoming O-320-H2AD, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Curtis E. Brewer
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · March 9, 1999 · 16 hours before
Departed
MO1 · Memphis, TN

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
1,100 total · 700 in this make and model · 1,000 as pilot in command · 150 in the last 90 days · 60 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
135° at 10 knots
Visibility
15 statute miles
Temperature
75 °F
Altimeter
30.00 inHg