LAX08LA009

NTSB accident investigation · Cessna 172L · Prescott, AZ · October 10, 2007

Accident · Minor injuriesLimited investigationFinal report
Date
October 10, 2007, 10:14 local (17:14 UTC)
Place
Prescott, AZ
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9897GCessna 172L
Weather
Visual (VMC) · Day
Status
Completed · report December 24, 2008
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20071010825299A
Case key
66894

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 failure of maintenance personnel to detect fatigue cracks in the number 3 exhaust rocker arm, which lead to a partial 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(partial) - mech failure/malfCruise
Maintenance,inspection - inadequateOther maintenance personnelCause
Engine assembly,rocker arm/tappet - fatigueCause
Engine assembly,rocker arm/tappet - fracturedCause
Forced landingEmergency descent/landing
On ground/water encounter with terrain/waterEmergency landing
Terrain condition - ditch
Nose overLanding - roll

Analysis

While in cruise flight, the engine had a sudden partial loss of power and made "clanging" noises. Although the engine continued to operate at a maximum of 900-1,100 revolutions per minute (rpm), insufficient power was available to maintain altitude. The pilot contacted the tower of a nearby airport, but determined that he would not be able to reach the runway. Due to power lines and a blind curve on a paved road, the pilot opted to land adjacent to the road. The airplane impacted a ditch and came to rest inverted. The engine had been overhauled 2.0 flight hours before the accident. A field overhaul had been performed on the engine due to a bent pushrod, stuck valve, and broken lifter for the number 3 cylinder. During the field overhaul, all four of the rocker arms had been magnetic particle inspected. Examination of the engine revealed that the number 3 cylinder exhaust rocker arm had separated into two pieces. A metallurgical examination was performed on the rocker arms by a Safety Board metallurgist. The number 3 exhaust rocker arm had fractured around the central pivot hole due to fatigue. The fatigue originated at the outer surface of the oil hole. The corners of the hole were sharp and had not been deburred, which increases the likelihood of fatigue cracking. The outer surface of the fatigued area was 0.31 inches long on the left side of the oil hole, and 0.21 inches long on the right side. The fractured exhaust rocker arm had been magnetic particle inspected for cracks during the field overhaul. The Safety Board metallurgist also noted staining on the cracks from the solution used during the magnetic particle inspection. Based on the staining, the cracks would have been detectable in size (about 0.2 inches) at the time of the inspection.

Factual narrative

History of flight

On October 10, 2007, at 1014 mountain standard time (MST), a Cessna 172L, N9897G, experienced a partial loss of engine power and made a forced landing near Williamson Valley Road at mile marker 6, near Prescott, Arizona. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane sustained substantial damage to the fuselage. The pilot, the sole occupant, received minor injuries. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight departed at 0900 from Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, with a planned destination of Ernest A. Love Field Airport (PRC), Prescott.

The pilot reported that he was about 9 miles west of Prescott, in cruise flight, when the engine suddenly lost power and made "clanging noises." The engine would not run higher than 900-1,100 revolutions per minute (rpm). The pilot tried increasing the mixture, checked the fuel, and added carburetor heat. He turned the airplane towards PRC, and contacted the tower. After passing Granite Mountain, he encountered gusty wind conditions and decided he was not going to make it to the airport. He attempted to land in a horse pasture, but the wind was too strong. The pilot did not want to land on a paved road due to a blind curve and power lines. He instead landed beside the road, where the airplane struck a ditch and nosed over. The airplane came to rest inverted and "bent in half" across the fuselage. The pilot did not have memory of the touchdown or his exit from the airplane. The pilot recommended that he should have spent more time trying to prepare for a landing and less time trying to get the engine to operate during this occurrence.

Tests and research

Visual examination of the engine by investigators revealed that the number 3 cylinder exhaust rocker arm had separated into two pieces. No other anomalies were found during the engine inspection.

A National Transportation Safety Board Materials Laboratory specialist examined all four exhaust rocker arms from the engine. The metallurgist reported that one arm was fractured at two locations through the central pivot hole. The inboard fracture went through the radial oiling hole. The outboard fracture was approximately diametrically opposed to the oiling hole. The outboard fracture had features typical of bending overstress.

The metallurgist noted that the inboard fracture was relatively flat and smooth. Both sides of the oiling hole displayed curved crack arrest marking indicative of fatigue progression. The crack arrest lines and radial fracture markings indicated that fatigue cracking initiated at opposite corners of the intersection of the oil hole and the outside surface. The fatigue progressed radially from these points through the wall of the pivot area to the bushing surface and toward the edges, but the fatigue regions did not reach the edges of the arm. The metallurgist measured the outer surface left fatigue region to be about 0.31 inches long and the outer surface right fatigue region to be 0.21 inches long. Both fatigue regions were stained and slightly darkened from the origins partially though to the propagation area. The remaining fracture surface displayed characteristics typical of overstress separation.

The metallurgist observed the corners of the oil hole at the fatigue origins to be sharp, and there were no indications of a radius or chamfer. They noted a raised lip or burr on the exterior edge around the oil hole. No evidence of deburring or hole edge machining was visible. The three intact rocker arms showed similar hole details at the outer surface.

Aircraft information

The pilot/owner reported that at the time of the accident, the 1971 single-engine Cessna 172L had a total time of 3,670 hours. The pilot reported that he had flown the airplane for about 2 hours since the field overhaul of the engine. The reason for the overhaul was due to a bent pushrod, stuck valve, and broken lifter for the number 3 cylinder.

The aircraft logbook entry for September 12, 2007, indicated that an annual inspection had been completed. An aircraft total time of 3,660.0 hours was recorded at the annual inspection. The engine logbook entry dated September 11, 2007, indicated that all connecting rods and rocker arms had been inspected, rebushed, overhauled, and certified by One Stop Aviation.

Aircraft

Registration
N9897G
Reported as
Cessna 172L
Category
Airplane
Serial number
17259797
Airframe hours
3,670
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · October 1, 2007 · 2 hours before
Departed
DVT · Deer Valley, AZ
Destination
PRC · Prescott, AZ

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
52
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 1, 2007
Seat
Left
Flight hours
398 total · 106 in this make and model · 345 as pilot in command · 33 in the last 90 days · 9 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 21 °F
Altimeter
30.15 inHg
Observed at
PRC, 9 nm away

FAA reports on this event · 1

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