LAX01LA123

NTSB accident investigation · Cessna 172RG · Stanford, CA · March 20, 2001

Accident · No injuriesLimited investigationFinal report
Date
March 20, 2001, 15:00 local (23:00 UTC)
Place
Stanford, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6307RCessna 172RG
Weather
Visual (VMC) · Day
Status
Completed · report November 28, 2001
Report
Approved by Office Director
Parties
FEDERAL AVIATION ADMINISTRATION
FAA report
20010320005549A
Case key
51939

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

Failure of company maintenance personnel to properly install and safety wire the oil filter, which subsequently lead to a loss of engine power.

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/malfCruise - normal
Maintenance,annual inspection - inadequateCompany maintenance personnelCause
Lubricating system,oil filter/screen - not safetiedCause
Fluid,oil - loss,totalCause
Powerplant - seized
Forced landingDescent - emergency
Nose overLanding - roll
Terrain condition - soft
Terrain condition - open field

Analysis

On the landing roll out following an emergency landing, the nose landing gear dug into the soft dirt and the airplane nosed over. During cruise, the CFI asked the student if he heard knocking. The student replied that he did hear the knocking. Both pilots saw the oil pressure gage reading zero, simultaneously the knocking increased, and then the engine quit. The external examination of the engine revealed that the bottom of the fuselage, firewall, and the rear of the engine were coated with oil. The inspection further revealed that the oil filter had not been tightened or safety wired to the engine. Review of the engine logbook disclosed that an oil change was completed the day prior to the accident.

Factual narrative

On March 20, 2001, at 1500 hours Pacific standard time, a Cessna 172RG, N6307R, lost engine power and made an emergency landing in an open dirt field in Stanford, California, where it came to rest inverted. The airplane was operated by the West Valley Flying Club as an instructional flight under the provisions of 14 CFR Part 91, and sustained substantial damage. The certified flight instructor (CFI) and the private student pilot were not injured. Visual meteorological conditions prevailed for the local area flight. The flight departed from the Palo Alto Airport of Santa Clara County, Palo Alto, California, at 1416. No flight plan had been filed. The flight was scheduled to terminate at the Palo Alto airport.

The purpose of the flight was to provide instruction for a complex airplane checkout. The CFI stated that they were over Webb Ranch, about 2,000 feet msl, when he noted a loss of oil pressure. He contacted the Palo Alto Air Traffic Control Tower and declared an emergency. He stated the engine stopped at 1,600 feet. He and the student pilot shutdown the airplane systems. He noted at one point the cockpit filled with smoke and they had to open the windows. The CFI set up for the emergency landing on a side road. A truck entered the road, and he had to maneuver the airplane onto an adjacent open field. On the landing rollout the nose landing gear dug into the soft dirt and the airplane nosed over.

The student pilot stated that they were getting ready to go back to home base when the CFI asked him if he heard knocking. He replied that he heard the knocking. They both observed the oil pressure was at zero. The knocking continued to increase in intensity. The CFI declared an emergency and landed in an open field.

A Federal Aviation Administration (FAA) inspector inspected the engine. A Textron Lycoming engine manufacturer's representative, who was a party to the investigation, assisted the FAA. They found that the oil filter had not been tightened or safety wired to the engine. The bottom of the fuselage, firewall, and the rear of the engine were coated with oil. The engine was seized.

A Safety Board investigator conducted a review of the airframe and engine logbooks. It was noted that the last annual inspection was completed on March 21, 2000. On March 19, 2001, maintenance was performed on the airplane that included an oil change.

Aircraft

Registration
N6307R
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0158
Airframe hours
9,120
Engine
Lycoming O-360-F1A6, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
West Valley Flying Club
Registered owner
Mark Conover
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 19, 2001 · 4 hours before
Departed
PAO · Palo Alto, CA
Destination
PAO

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
Pilot
Age
35
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Last flight review
February 13, 2001
Seat
Right
Flight hours
409 total · 100 in this make and model · 360 as pilot in command · 90 in the last 90 days · 45 in the last 30 days · 2 in the last 24 hours
Role
Student pilot
Age
40
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
65 total

Weather

Conditions
Visual (VMC) · Day
Wind
340° at 8 knots
Visibility
12 statute miles
Lowest ceiling
25,000 ft broken
Temperature
75 °F, dew point 54 °F
Altimeter
29.93 inHg
Observed at
PAO

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.