LAX01LA221

NTSB accident investigation · Cessna 172M · Napa, CA · June 25, 2001

Accident · No injuriesLimited investigationFinal report
Date
June 25, 2001, 09:20 local (16:20 UTC)
Place
Napa, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1409VCessna 172M
Weather
Visual (VMC) · Day
Status
Completed · report November 28, 2001
Report
Approved by Office Director
Parties
FEDERAL AVIATION ADMINISTRATION
FAA report
20010625017179A
Case key
53353

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

Loss of engine power due to the restricted movement of the number 1 exhaust valve that subsequently bent the exhaust push rod and push rod housing.

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 powerMissed approach (ifr)
Engine assembly,valve,exhaust - movement restrictedCause
Engine assembly,push rod - bentCause
Forced landingEmergency descent/landing
Nose overLanding - roll
Terrain condition - soft
Terrain condition - ground

Analysis

During the missed approach the engine lost power, was maneuvered to land, and came to rest inverted after the nose wheel touched down in soft dirt. The purpose of the flight was to conduct instrument training at local area airports. The flight had departed home base approximately an hour away from the accident airport. No discrepancies were noted with the engine during the flight or the approach to land. As the student reached MDA the CFI instructed the student to conduct the missed approach. They climbed straight ahead to 500 feet msl and initiated a left-hand turn for compliance with the missed approach procedure. The engine began to lose power. The CFI declared an emergency and conducted the emergency checklist. She turned towards the runway and slipped the airplane down land on the runway. Due to the altitude, she knew they would not make the runway, so she attempted to land in a grassy area past the departure end of the runway. Again, the airplane was too high for landing and she had to maneuver to avoid the airport perimeter fence. The CFI turned away from the fence. When she returned the airplane to wings level flight the wheels touched down. The nose wheel dug into the soft dirt and the airplane flipped over. Examination of the engine revealed that the exhaust push rod housing and exhaust push rod were bent. The crankshaft was manually rotated establishing valve training continuity. No further discrepancies were noted with the engine.

Factual narrative

On June 25, 2001, at 0920 hours Pacific daylight time a Cessna 172M, N1409V, experienced a loss of engine power and made a forced landing at the Napa County Airport, Napa, California. The airplane was operated by Airline Transport Professionals Corp. of USA, located in Florida, under the provisions of 14 CFR Part 91, and sustained substantial damage. The certified flight instructor (CFI) and private pilot were not injured. Visual meteorological conditions prevailed for the local area instructional flight and a flight plan had not been filed. The flight departed the Sacramento Executive Airport, Sacramento, California, at 0815. The flight was scheduled to terminate at the Sacramento airport.

The Safety Board investigator interviewed the CFI. The CFI stated that the purpose of the flight to was to conduct instrument training at Napa and other local area airports. The accident occurred on the first approach into Napa. The CFI reported that they were on the localizer approach for runway 36L. The student leveled the airplane at the minimum descent altitude (MDA). Prior to reaching the runway, she instructed the student to conduct the missed approach. They climbed straight ahead to 500 feet msl. As the student initiated a left-hand turn for the missed approach procedure, the engine started to lose power. They conducted the emergency procedures per the airplane flight manual for loss of engine power.

The CFI contacted Napa tower and declared an emergency. The flight was cleared to land on any runway. She turned the airplane towards runway 6, and slipped the airplane to make it down to the runway. The airplane did not have enough time to descend and land on the runway, so she attempted to land in a grassy area past the departure end of the runway. She noted that the airplane was still too high to land in the grassy area, and they were approaching the airport perimeter fence. The CFI initiated a left turn to avoid the fence, and as she leveled the wings the wheels touched down. As the nose wheel contacted the ground it dug into the soft dirt and the airplane came to rest inverted.

The engine was examined by a Federal Aviation Administration (FAA) inspector, with the assistance of an airframe and power plant mechanic at the Napa airport on June 25, 2001. The examination revealed that the exhaust push rod housing and exhaust push rod for the number 1 cylinder was bent. The FAA inspector noted that the rocker arm and shaft were in good condition. The valve was manually depressed to ascertain that it was not stuck. The valve functioned normally. The engine was manually rotated on July 2, 2001. Manual rotation of the crankshaft produced thumb compression of the cylinders as well as valve train continuity of the engine. There was no binding of the valve on the number 1 cylinder observed during the rotation of the crankshaft.

There were no more mechanical abnormalities observed with the engine.

Aircraft

Registration
N1409V
Reported as
Cessna 172M
Category
Airplane
Serial number
17263554
Airframe hours
5,059
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Registered owner
Airline Transport Professionals Corp. of USA
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 25, 2001 · 83 hours before
Departed
SAC · Sacramento, CA
Destination
APC · Napa, CA
Airport
APC · Napa County Airport, runway 36L, 5,931 × 150 ft, concrete

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
23
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--w/ waivers/lim
Last flight review
October 28, 2000
Seat
Right
Flight hours
898 total · 343 in this make and model · 843 as pilot in command · 237 in the last 90 days · 64 in the last 30 days · 6 in the last 24 hours
Role
Student pilot
Age
38
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 1, Valid Medical--no waivers/lim.
Last flight review
February 28, 2001
Seat
Left
Flight hours
100 total · 95 in this make and model · 90 as pilot in command · 27 in the last 90 days · 22 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 52 °F
Altimeter
29.98 inHg
Observed at
APC

FAA reports on this event · 1

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