LAX99LA279

NTSB accident investigation · Bellanca 7ECA · Livermore, CA · August 21, 1999

Accident · No injuriesLimited investigationFinal report
Date
August 21, 1999, 16:30 local (23:30 UTC)
Place
Livermore, CA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N88408Bellanca 7ECA
Weather
Visual (VMC) · Day
Status
Completed · report August 14, 2001
Report
Approved by Office Director
FAA report
19990821013259A
Case key
47144

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 the no. 3 cylinder exhaust valve due to the operator's failure to adhere to recommended overhaul periods set by the engine manufacturer. A factor in the accident was the operator's failure to comply with the manufacturer's mandatory service bulletin.

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/malfTakeoff - initial climb
Engine assembly,valve,exhaust - failure,totalCause
Maintenance,overhaul - not performedCompany/operator managementCause
Maintenance,service bulletin/letter - not complied withCompany/operator managementFactor
Forced landingEmergency landing after takeoff
In flight collision with terrain/waterEmergency landing after takeoff

Analysis

During the takeoff initial climb a partial loss of power was experienced, with the rpm's decreasing to 1,500 accompanied by roughness. The CFI took the controls from the student, made a 180-degree turn back to the runway, and landed hard on a taxiway. Both pilots indicated that there were no discrepancies noted with the preflight, engine start, taxi, or run-up. During the engine examination the number 3 exhaust valve was found broken, and the head found embedded in the piston. A review of the engine logbook revealed that the engine had accumulated 3,711.0 hours since the last major overhaul, which took place on November 30, 1993. According to the engine manufacturer, 2,400 hours or 12 calendar years is the maximum recommended time between overhaul. A Lycoming Mandatory Service Bulletin addresses the need to inspect exhaust valves and valve guides to prevent sticking and possible failure due to excessive guide wear. The bulletin recommends an inspection at 400-hour intervals. No record was found in the logbooks of compliance with the bulletin.

Factual narrative

On August 21, 1999, at 1630 hours Pacific daylight time, a Bellanca 7ECA, N88408, experienced a loss of engine power in the takeoff initial climb at the Livermore, California, airport. During the attempted return to runway maneuver, the aircraft landed hard on a taxiway, ran off the pavement, and into a ditch. The aircraft, operated by Attitude Aviation under the provisions of 14 CFR Part 91 as an instructional flight, sustained substantial damage. The certified flight instructor (CFI) and a private pilot were not injured. Visual meteorological conditions existed for the recurrent training flight and no flight plan was filed.

The CFI stated that the engine start and run-up were normal. At 500 feet above ground level (agl) in the initial climb, a partial loss of power was experienced. The CFI stated that the engine rpm's dropped suddenly from 2,600 to 1,500 "with roughness." He said that he took the controls from the student and found that an emergency landing could not be conducted straight ahead due to obstacles. He elected to perform a 180-degree turn back to the runway. As the turn was completed, a complete lost of engine power was experienced. Due to an airplane already on the runway, he aimed for the taxiway, and landed hard on the pavement.

In the private pilot's written statement to the Safety Board, he said that the preflight, engine start, and taxi were normal. During the run-up, at 1700 rpm, a magneto check was conducted per the checklist procedures. He noted that the drop was approximately 100 rpm on each magneto, and the oil pressure and engine temperature were normal. They were cleared for takeoff and right closed traffic. When power was added it seemed normal and no discrepancies were noted with the acceleration to rotation speed. As they were climbing through 400 feet agl the engine began to run rough and subsequently a partial loss of power was experienced. The CFI immediately took the controls and declared an emergency. The pilot stated that the CFI entered a descending steep left turn to make it to runway 7R. He indicated that there "appeared to be no power from the engine," and the rate of descent was "too great." The CFI then contacted the tower to inform them that he was going to land on the adjacent taxiway for 7R. The pilot stated that there was insufficient altitude, the rate of descent was too fast, and the airplane struck the runway in a nose down left bank attitude. After the airplane departed the taxiway it came to rest in a drainage ditch parallel to the runway.

The airplane was inspected by a Federal Aviation Administration (FAA) inspector on August 25, 1999, at Attitude Aviation. The investigation revealed that the number 3 exhaust valve of the Lycoming O-235-C1 engine had failed. The stem was found broken at the lower portion of the head. The FAA inspector reviewed the engine logbook and found that the engine had accumulated 3,711.0 hours since the last major overhaul, which was accomplished on November 30, 1993.

In the CFI's written report to the Safety Board, he had requested on several separate occasions that the engine should be overhauled. He stated that the owner of the flight school stated that they would keep an eye on it.

According to Textron-Lycoming Service Instruction number 1009AN dated November 5, 1999, the recommended time between overhaul periods for the O-235 model's (except F, G and J) is 2,400 hours. The Service Instruction letter indicates that all engines that do not accumulate the hourly period of time between overhauls specified in the letter are recommended to be overhauled in the twelfth year.

A Textron Lycoming Mandatory Service Bulletin (SB) number 388B, issued on May 13, 1992, addresses the procedure to determine exhaust valve and guide condition. Compliance time for the engine inspections was specified to be at 400-hour intervals, or earlier, if valve sticking is suspected. The SB indicated that the failure to comply with the provisions in the publication could result in engine failure due to excessive carbon build-up between the valve guide and valve stem resulting in sticking exhaust valves or; broken exhaust valves which result from the excessive wear of the exhaust valve guide.

No record of compliance with MSB 388B was noted during the logbook review.

Aircraft

Registration
N88408
Reported as
Bellanca 7ECA
Category
Airplane
Serial number
1062-75
Engine
Lycoming O-235-C1, 115 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Attitude Aviation
Registered owner
Freedom Enterprises, Inc.
Airworthiness certificate
Standard, Aerobatic; Standard, Normal
Last inspection
100 hour · August 12, 1999
Departed
LVK
Airport
LVK · Livermore Airport, runway 25R, 5,255 × 100 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
27
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Rear
Flight hours
2,800 total · 600 in this make and model · 2,600 as pilot in command · 120 in the last 90 days · 40 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 57 °F
Altimeter
29.00 inHg
Observed at
LVK

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 N88408 · 2

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