LAX06LA230

NTSB accident investigation · Cessna 152 · Pacoima, CA · July 14, 2006

Accident · Minor injuriesLimited investigationFinal report
Date
July 14, 2006, 15:00 local (22:00 UTC)
Place
Pacoima, CA
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N25512Cessna 152
Weather
Visual (VMC) · Day
Status
Completed · report November 29, 2007
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20060714014669A
Case key
64119

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

a loss of engine power due to the failure of maintenance personnel to tighten the top spark plugs, and install the leads for the ignition harness to the top spark plugs.

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(partial) - mech failure/malfTakeoff - initial climb
Ignition system,spark plug - looseCause
Ignition system,ignition harness - not installedCause
Maintenance,installation - improperOther maintenance personnelCause
Forced landingEmergency landing after takeoff
On ground/water encounter with terrain/waterEmergency landing after takeoff
Terrain condition - soft
Nose overEmergency landing after takeoff

Analysis

The airplane nosed over during an off airport forced landing following a loss of engine power in the takeoff initial climb. The student and certified flight instructor (CFI) departed on runway 14 for pattern work, and made a full stop landing. They taxied back, and took off again. About 150 feet above ground level (agl), the engine lost a little power. They turned back toward the airport. During the turn the engine lost more power, and the airplane could not maintain altitude. The CFI took control, and elected to land in a dry pond. The airplane touched down good, but the nose wheel dug into the soft dirt, and the airplane nosed over. Examination revealed that none of the ignition leads were connected to the top spark plugs. The number 3 cylinder top plug was missing with oil on the upper cowling above the hole, and the top spark plugs for the remaining cylinders were loose, with most only engaged by one or two threads. Two hours prior to the accident flight, a mechanic performed work, including installation of a new left magneto and new spark plugs.

Factual narrative

On July 14, 2006, about 1500 Pacific daylight time, a Cessna 152, N25512, nosed over during an off airport forced landing near Pacoima, California. The student pilot/owner was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) sustained minor injuries; the student pilot was not injured. The airplane sustained substantial damage. The local instructional flight departed Whiteman Airport, Los Angeles, about 1459. Visual meteorological conditions prevailed, and no flight plan had been filed.

The CFI stated that engine roughness and a loss of power occurred about 100 feet above ground level (agl) while departing runway 12 following a touch-and-go. The CFI notified local air traffic control of his situation, and was cleared to land runway 30. Unable to reach the runway, the CFI elected to land in an area of spreading ponds about 3/4 mile southeast of Whiteman.

The student pilot/owner stated that he and the instructor flew the airplane 2 days before the accident. The engine had about 600 hours since new. A mechanic had recently replaced the left magneto, adjusted the valves, and replaced the alternator.

The student said that they departed on runway 14, and were past Osborne. They planned to do a touch-and-go, but the touchdown was a little long, so they made it a full stop landing. They taxied back, and took off again. About 150 feet above ground level (agl), the engine lost a little power (about 150 rpm). The airplane would not climb, but it could maintain altitude. They turned back toward the airport. During the turn the engine lost more power, and they could not maintain altitude. The CFI took control, and elected to land in a dry pond. The airplane touched down good, but the nose wheel dug into the soft dirt, and the airplane nosed over. The student thought that the CFI tried to put the flaps down, but doesn't think that they were full down. The engine was still running when they touched down.

The fire department turned off the master switch, ignition switch, the fuel selector valve, and ELT. There was no fuel leak; they pinched the fuel outlet.

The FAA and Textron Lycoming were parties to the investigation.

Investigators examined the wreckage at Aircraft Recovery Service, Littlerock, California, on July 17, 2006, under the supervision of the National Transportation Safety Board investigator-in-charge (IIC).

When the recovery agent picked the airplane up, it was inverted. He placed it inverted onto his trailer, and offloaded it at his yard in the same orientation with the damaged cowling still in place. Under the supervision of the IIC, the agent righted the airplane, and removed the cowling.

Investigators noted that none of the ignition leads were connected to the top spark plugs. Top plug number 3 was missing, and the cowling was oily in this area. The heli-coil thread insert of this spark plug bore was pulled out slightly near the terminating end of the heli-coil. All of the other top plugs were finger loose with about 1 1/2 threads engaged. The number 3 spark plug was not recovered.

All spark plugs were clean with no mechanical deformation. The spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head.

Investigators manually rotated the crankshaft with the propeller. The crankshaft rotated freely, and the valves moved approximately the same amount of lift in firing order. The gears in the accessory case turned freely. Investigators obtained thumb compression on all cylinders in firing order.

Investigators manually rotated the magnetos, and both magnetos produced spark at all posts. They checked the magneto to engine timing utilizing a timing box (syncrophaser) device. The left magneto was at 20 degrees before top dead center (BTDC) on the number one cylinder, while the right was at 25 degrees BTDC. The engine data plate indicated 20 degrees spark advance.

An engine logbook entry dated July 10, 2006, noted that a mechanic adjusted the valve clearance, changed the oil and filter, and installed a new left magneto, new spark plugs, new muffler, new crankcase oil seal, new voltage regulator, and an overhauled alternator. The tachometer time was 616.8. The tachometer read 618.8 at the post accident examination.

Aircraft

Registration
N25512
Reported as
Cessna 152
Category
Airplane
Serial number
15280706
Airframe hours
598
Engine
Lycoming O-235-L2C, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Natividad Flores
Registered owner
Holmes Bo
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · January 1, 2006 · 2 hours before
Departed
WHP · Los Angeles, CA
Destination
WHP · Los Angeles, CA
Airport
WHP · Whiteman, runway 12, 4,120 × 75 ft, asphalt

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
37
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1
Last flight review
February 1, 2006
Seat
Right
Flight hours
1,834 total · 274 in this make and model · 1,739 as pilot in command · 181 in the last 90 days · 48 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
50
Injuries
None
Certificate
Student
Medical
Class 3
Seat
Left
Flight hours
100 total · 65 in this make and model · 67 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
99 °F, dew point 52 °F
Altimeter
29.86 inHg
Observed at
BUR

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 N25512 · 1

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