# NTSB MIA02LA057: Cessna R172E, N7878N, River Ranch, FL, February 1, 2002 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 1, 2002, 13:24 local (18:24 UTC) - Place: River Ranch, FL - Coordinates: 27.739999, -81.099998 - Nearby events: https://openairdocs.org/map.md?lat=27.7400&lon=-81.1000&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report March 30, 2004 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, USAF, Cessna Aircraft Company, Patrick AFB Aero Club, FAA FSDO - NTSB case key (mKey): 54122 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA02LA057 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54122/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54122 - Page: https://openairdocs.org/ntsb/MIA02LA057 ## Probable cause The reported loss of engine power due to undetermined reasons. Contributing factors in the accident were an improper flap setting, excessive landing speed, and terrain consisting of berms. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, cruise - normal - reason for occurrence undetermined (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency landing - in-flight planning/decision - poor, pilot in command(cfi) (contributing factor) - airspeed - excessive, pilot in command(cfi) (contributing factor) - terrain condition - berm ## Analysis The flight departed and proceeded uneventfully to the La Belle Municipal Airport where an uneventful landing was performed. The flight departed to return to the initial departure airport and during cruise flight, the certified flight instructor (CFI) noted a discrepancy with one of the fuel gauges. He landed uneventfully at a nearby airport, and with the engine running, the CFI checked for fuel leaks and checked both fuel tanks; no leakage was noted and both tanks were found to contain a sufficient quantity of fuel. The CFI elected to depart to the return to the original departure airport and approximately 15 minutes into the flight, oil spots were noted on the windshield. The CFI reported the engine lost power shortly after seeing the oil spots. The CFI maneuvered the airplane for a landing in a field maintaining 85 miles-per-hour (mph), and during the landing roll with the flaps retracted, the airplane collided with a berm and became airborne. The airplane then contacted another berm becoming airborne again for a short distance. The airplane then impacted the ground and came to rest upright. The CFI exited the airplane and obtained assistance for the student who remained in the airplane. Examination of the fuel system, fuel vent system, air induction system, exhaust system, and engine assembly revealed no evidence of preimpact failure or malfunction. The crankshaft fracture was noted to be from overstress. On engine testing of the ignition system components revealed no evidence of preimpact failure or malfunction. Bench testing of fuel injection system components and both magnetos revealed no evidence of preimpact failure, a discrepancy was noted with the condensers of both magnetos. Bench testing of the fuel selector valve and flexible fuel lines revealed no evidence of preimpact failure or malfunction. Testing of fuel from the facility that fueled the airplane revealed no discrepancies that would cause a loss of engine power. No determination was made as to the reason for the reported loss of engine power. Review of the "Flight Manual" for the airplane revealed that for forced landings on unprepared surfaces, full flaps should be used if possible with a 75 mph glide. ## Factual narrative On February 1, 2002, about 1324 eastern standard time, a Cessna R172E, N7878N, registered to the U.S. Air Force, operated by Patrick Air Force Base Aero Club, experienced collapse of the nose landing gear while landing in a field near River Ranch, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 instructional flight. The airplane was substantially damaged and the certified flight instructor (CFI) and student pilot were seriously injured. The flight originated about 1107, from Patrick Air Force Base (Patrick AFB), Florida. The CFI stated that he and his student departed from Patrick AFB and proceeded to the La Belle Municipal Airport where an uneventful landing was performed; he and the student took a break while at the airport. The flight departed from La Belle for Patrick AFB, and while en route, he noticed a discrepancy with the left fuel gauge. The flight proceeded to the Sebring airport where an uneventful landing was performed. While the engine remained running, the CFI exited the airplane and visually checked for fuel leaks and quantity of fuel in both tanks; no leaks were noted and approximately 18 gallons of fuel were noted in each tank. The CFI elected to depart to return to Patrick AFB, and approximately 15 minutes into the flight, the student asked him whether there was oil on the windshield. The CFI replied it was and checked the engine instruments; the oil pressure was in the "green" arc. The CFI further reported that at that time the engine surged, and he took control of the airplane from the student and contacted Patrick AFB air traffic control tower (Patrick AFB ATCT). He confirmed the ignition switch and fuel selector were on both, the mixture was full rich, the fuel pump was on low, and applied full throttle. The engine "power" increased momentarily then decreased to idle rpm. The flight continued and he maneuvered the airplane for an open field maintaining 85 miles-per-hour. After touchdown in the field during the landing roll, he noticed a rise in terrain and applied aft elevator control input. The airplane contacted the rising terrain, became airborne, and impacted the ground with the nose landing gear which sheared off. After the airplane came to rest he exited it and attempted to get the student out but was unable. Unable to establish two way radio communications to summon help, he activated the emergency locator transmitter and walked to a road where he stopped a passing motorist who in turn called 911. The student pilot stated that while proceeding direct to Patrick AFB, during straight and level flight "spots" appeared on the windshield. The CFI initially thought the spots were bird droppings but both concluded it was oil. Shortly after observing the spots on the windshield, the engine lost "rpm" and the CFI took the controls of the airplane. He believed the propeller stopped rotating before the CFI landed the airplane in a field that looked "...fairly smooth." He further reported he, "... did not see any fence or ditch until just before we crossed the ditch during rollout." The CFI left to get help while he remained in the airplane for 2-3 hours before being evacuated via helicopter. According to a transcription of communications with Patrick AFB ATCT, two-way communications were established with that facility and at 1321:29, an occupant advised, "we are 30 miles out with an engine failure." The controller acknowledged the transmission and asked the position of the airplane. An occupant responded, "we are 30 about 30 miles south of melbourne", followed immediately with, "we are losing our engine power and altitude." The controller responded by first advising the flightcrew to contact Daytona Approach, which was acknowledged, but the controller then advised the flightcrew to contact Miami. The last transmission from the controller was not acknowledged by the flight crew. The accident site was examined by the FAA inspector-in-charge (FAA IIC), along with representatives of the United States Air Force, and Patrick AFB Aero Club. A representative of Cessna Aircraft Company examined the site after the airplane was recovered. According to the FAA IIC, after touchdown in the field, the airplane rolled approximately 400 feet where it collided with a berm. The airplane became airborne traveling approximately 65 feet where it impacted another berm causing the nose landing gear to separate. The airplane became airborne again traveling 5 feet where it impacted the ground nose first creating a 6-inch deep trench. The airplane came to rest in an upright position with the empennage elevated approximately 108 feet from the point of contact with the first berm; the airplane was recovered for further examination. Examination of the airplane and engine following recovery was performed by the parties to the investigation with FAA oversight. The left and right fuel tanks were found to contain approximately 8 gallons and 9 gallons of 100 low lead fuel, respectively. The fuel reservoir tank was found to be empty; a fractured fuel line was noted between the reservoir tank and the fuel strainer. The gascolator was found to be full of fuel, no water was present. No obstructions of the fuel vent system, air induction system, or exhaust system were noted. With the exception of the fractured fuel line between the reservoir tank and fuel strainer, fuel system continuity was confirmed. The auxiliary fuel pump operationally checked good. The fuel selector was found in the detent of the both position. A light coating of oil was noted on the fuselage belly skins. Examination of the engine revealed the propeller appeared initially to be attached to the engine but separated when the FAA IIC attempted to verify if the propeller was secured. The crankshaft was fractured aft of the propeller mounting flange, continuity was established from the fracture surface to the accessory section. Camshaft, and valve train continuity was confirmed by rotation of an adapter installed at the vacuum pump pad location, suction and compression were noted in all cylinders with rotation of the adapter. No discrepancies were noted with the magnetos, ignition harness, or ignition switch when tested. A total of 8 quarts of oil were drained from the engine; the oil was clean and gold in color (oil capacity is 10 quarts). The crankshaft, manifold valve, fuel injector nozzles and lines, mechanical fuel pump, both magnetos, throttle and metering unit, fuel selector valve, and flexible fuel lines were retained for further examination. Metallurgical examination of the fractured crankshaft was performed by the NTSB Materials Laboratory, located in Washington, DC. The results of the examination indicate the fracture surface exhibited evidence of overstress separation; no fatigue was noted. Examination and bench testing of the mechanical fuel pump, manifold valve, throttle and metering unit, and fuel injector nozzles and lines was performed with NTSB oversight. Bench testing of the mechanical fuel pump revealed leakage from the damaged mixture shaft. The discharge pressure was higher than specified at 600 and 2,200 rpm. The discharge pressure in terms of pounds-per-hour (pph) was less than specified when tested twice at different fuel flow rates at 2,200 rpm. Bench testing of the manifold valve with the fuel injector nozzles and lines revealed the unit flowed greater than specified when tested at 50 and 100 pph, respectively. The metering unit which was received partially disassembled was reassembled for bench testing which revealed the unit flowed greater than specified at all test points. The NTSB investigator who witnessed the tests reported the metering unit could be adjusted to flow within limits. Examination and bench testing of the magnetos was also performed with NTSB oversight. Bench testing revealed both magnetos produced spark at all termi ## Aircraft - Registration: [N7878N](https://openairdocs.org/deregistered/N7878N-2002-07-26), registration cancelled 2002-07-26, S/N R172-0269, built 1967 (OpenAirDocs) - Reported make and model: Cessna R172E - Registry model: [Cessna R172E](https://openairdocs.org/model/cessna-r172e) (registry code 2072413) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: R172-0269 - Airframe hours: 14281.97 - Engines: Continental IO-360-DB 210 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Patrick AFB Aero Club - Registered owner: U.S. Air Force - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, January 26, 2002, 5.97 hours before - Departed: COF, Patrick AFB, FL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 26; injuries: serious; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review November 26, 2001; seat: right; flight hours: 1,000 total, 350 in this make and model, 800 as pilot in command, 350 in the last 90 days, 150 in the last 30 days - Student pilot; injuries: serious ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 70 °F - Altimeter: 30.13 inHg - Observed at: MLB, 32 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 (OpenAirDocs). - [Accident 20020201014329A](https://openairdocs.org/incident/20020201014329A), Feb 1, 2002: Cessna R172E, Riverranch, FL, No damage. (-23) N7878N departed sebring airport with the student flying a VFR cross-country to patrick air force base at 2000'. At about 20 minutes into the flihgt the… ## Docket (26 files) The files NTSB released with the investigation on February 6, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54122. 22.3 MB in all. - Supplement E (item 1, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175358&FileExtension=.PDF&FileName=Supplement%20E-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388783&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Materials Laboratory 15 - Factual Report (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175360&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report-Master.PDF - System 9 - Factual Report (item 4, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388784&FileExtension=.PDF&FileName=System%209%20-%20Factual%20Report-Redacted.PDF - Transcript of Radio Communications (item 5, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175362&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Master.PDF - Reports from Federal Agencies (item 6, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388785&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-Redacted.PDF - Report from Cessna Aircraft Company (item 7, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40183185&FileExtension=.PDF&FileName=Report%20from%20Cessna%20Aircraft%20Company-Master.PDF - Report from Teledyne Continental Motors (item 8, .PDF, 903 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388786&FileExtension=.PDF&FileName=Report%20from%20Teledyne%20Continental%20Motors-Redacted.PDF - Report from Teledyne Continental Motors (fuel system components examination). Photos included. (item 9, .PDF, 11.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175509&FileExtension=.PDF&FileName=Report%20from%20Teledyne%20Continental%20Motors%20(fuel%20system%20components%20examination).%20%20Photos%20included.-Master.PDF - Documents from Patrick AFB, Air Traffic Control Tower (item 10, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388787&FileExtension=.PDF&FileName=Documents%20from%20Patrick%20AFB,%20Air%20Traffic%20Control%20Tower-Redacted.PDF - Fuel Analysis Report (item 11, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388788&FileExtension=.PDF&FileName=Fuel%20Analysis%20Report-Redacted.PDF - Record of conversation with Carl E. Johnson (item 12, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388789&FileExtension=.PDF&FileName=Record%20of%20conversation%20with%20Carl%20E.%20Johnson-Redacted.PDF - Excerpt from Maintenance Records and Discrepancy Sheets (item 13, .PDF, 493 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388790&FileExtension=.PDF&FileName=Excerpt%20from%20Maintenance%20Records%20and%20Discrepancy%20Sheets-Redacted.PDF - Fuel facility filter information (item 14, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40175528&FileExtension=.PDF&FileName=Fuel%20facility%20filter%20information-Master.PDF - Crankshaft illustration with parts listing (item 15, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182949&FileExtension=.PDF&FileName=Crankshaft%20illustration%20with%20parts%20listing-Master.PDF - Excerpts from Flight Manual. (item 16, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40204989&FileExtension=.PDF&FileName=Excerpts%20from%20Flight%20Manual.-Master.PDF - Cessna Model R172E Flight Handbook (item 17, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40205132&FileExtension=.PDF&FileName=Cessna%20Model%20R172E%20Flight%20Handbook-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 18, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388791&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 19, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388792&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site. (item 20, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182639&FileExtension=.PDF&FileName=Photo%201%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site.-Master.PDF - Photo 2: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site. (item 21, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182642&FileExtension=.PDF&FileName=Photo%202%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site.-Master.PDF - Photo 3: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site. (item 22, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182643&FileExtension=.PDF&FileName=Photo%203%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site.-Master.PDF - Photo 4: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site. Note the separated nose landing gear. (item 23, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182644&FileExtension=.PDF&FileName=Photo%204%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site.%20%20Note%20the%20separated%20nose%20landing%20gear.-Master.PDF - Photo 5: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site, note the resting position of the fuselage. (item 24, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182645&FileExtension=.PDF&FileName=Photo%205%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site,%20note%20the%20resting%20position%20of%20the%20fuselage.-Master.PDF - Photo 6: Photograph provided by FAA inspector, no negative. View of the airplane at the accident site. Note the fractured crankshaft. (item 25, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182646&FileExtension=.PDF&FileName=Photo%206%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20airplane%20at%20the%20accident%20site.%20%20Note%20the%20fractured%20crankshaft.-Master.PDF - Photo 7: Photograph provided by FAA inspector, no negative. View of the engine cowling, note the dirt adhering to the oil on top of the cowling. (item 26, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182647&FileExtension=.PDF&FileName=Photo%207%3A%20Photograph%20provided%20by%20FAA%20inspector,%20no%20negative.%20View%20of%20the%20engine%20cowling,%20note%20the%20dirt%20adhering%20to%20the%20oil%20on%20top%20of%20the%20cowling.-Master.PDF 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.