# NTSB LAX01LA221: Cessna 172M, N1409V, Napa, CA, June 25, 2001 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 25, 2001, 09:20 local (16:20 UTC) - Place: Napa, CA - Coordinates: 38.2, -122.26667 - Nearby events: https://openairdocs.org/map.md?lat=38.2000&lon=-122.2667&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 28, 2001 - Report: Approved by Office Director - Parties: FEDERAL AVIATION ADMINISTRATION - NTSB case key (mKey): 53353 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX01LA221 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53353/pdf - Page: https://openairdocs.org/ntsb/LAX01LA221 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, missed approach (ifr) - engine assembly,valve,exhaust - movement restricted (cause) - engine assembly,push rod - bent (cause) - Forced landing, emergency descent/landing - Nose over, landing - 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](https://openairdocs.org/deregistered/N1409V-2017-05-31), registration cancelled 2017-05-31, S/N 17263554, built 1974 (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: 17263554 - Airframe hours: 5059 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: none; 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 - Student pilot; age 38; injuries: none; 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 (OpenAirDocs). - [Accident 20010625017179A](https://openairdocs.org/incident/20010625017179A), Jun 25, 2001: Cessna 172M, Napa, CA, Substantial damage. (-23) Post accident investigation revealed a bent pushrod on #1 cylinder exhaust valve. (.4) during the missed approach the engine lost power, was maneuvered… 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.