MIA05LA046

NTSB accident investigation · Cessna 172M · Orlando, FL · January 11, 2005

Accident · FatalLimited investigationFinal report
Date
January 11, 2005, 16:47 local (21:47 UTC)
Place
Orlando, FL
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9336HCessna 172M
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2006
Report
Approved by Office Director
Parties
FAA Flight Standards District Office, NTSB, Cessna Aircraft Company, Textron Lycoming
FAA report
20050111001659A
Case key
60847

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 CFI to initiate a precautionary landing after noticing zero oil pressure with corresponding oil temperature increase, resulting in total loss of engine power due to oil exhaustion. A contributing factor in the accident was the failure of company maintenance personnel to replace the flexible oil cooler hoses during engine installation following overhaul, as recommended by the engine manufacturer.

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.

Airframe/component/system failure/malfunctionCruise - normal
Maintenance,replacement - not performedCompany maintenance personnelFactor
Lubricating system,oil hose - chafed
Lubricating system,oil hose - leak
Precautionary landing - delayedPilot in command(cfi)Cause
Loss of engine power(total) - mech failure/malfCruise - normal
Fluid,oil - exhaustion
Engine assembly,connecting rod bolt - failure
Engine assembly,connecting rod cap - failure
Forced landingDescent - emergency
In flight collision with objectDescent - emergency
Object - pole

Analysis

The airplane experienced a total loss of engine power and collided with wires and a power line pole while descending for a forced landing. The pilot-rated student reported that while returning to the departure airport (KORL), he noted a smell of something burning which triggered him to look at the engine gauges; he noted "...that we had no oil pressure." No oil was noted by the student on the windscreen or on the sides of the airplane. The flight continued towards KORL, and 5 minutes 3 seconds after an occupant first advised the controller of having no oil pressure, an occupant advised the controller that the engine quit. The CFI took the controls and maneuvered the airplane towards a nearby golf course for a forced landing. He made several s-turns to lose altitude with full flaps extended, but while maneuvering to possibly land on a nearby road, the airplane collided with power lines, then a power pole. Postaccident, an oil film was noted on the exterior surface of the fuselage bottom skin, and in the engine compartment area on the aft side of the baffling. During postaccident testing, a leak was noted from a flexible hose near the oil cooler end; the cure date of the hose was the 3rd quarter 1981. Ten ounces of oil were drained from the engine, which exhibited internal evidence of oil exhaustion with resulting failure of the No. 2 cylinder connecting rod cap and bolt. The engine was overhauled last in 2001. The engine manufacturer recommends replacement of oil hoses at normal engine overhaul. A note in the airplane maintenance manual indicates that rubber engine compartment hoses are to be replaced every 5 years or at engine overhaul, whichever occurs first. Examination of the hose by the NTSB Materials Laboratory revealed a .7 inch long crack located approximately 4.25 inches from the oil cooler adapter end. The crack was oriented "slightly away from the longitudinal axis." Bench binocular microscope (BBM) examination of the hose revealed the woven fiber strands were missing in the cracked area. Scanning electron microscope (SEM) and BBM examination of the face of the crack revealed the thickness of the outer layer of rubber was reduced, and a portion of the reduced outer layer of rubber that was located midspan of the crack was missing. Additionally, the fiber strands that were located between the inner and outer rubber layers were fractured. The inner layer of rubber was found to contain fracture lines that emanated from the outer surface layer in an area that contained an impression of fiber strands from the fibers between the 2 rubber layers. The lines on the surface crack indicated that cracking of the inner layer propagated towards the inner diameter of the hose; cracking on a flat plane was noted to within .01 inch of the inside surface of the hose. Examination of other areas of the inside surface of the hose revealed extensive longitudinal cracks. Additionally, the exterior surface of the contained abrasion damage in three areas other than the cracked area of the hose; the abrasion damage did not extend through the outer layer of rubber.

Factual narrative

History of flight

On January 11, 2005, about 1647 eastern standard time, a Cessna 172M, N9336H, registered to Grady and Francis, Inc., operated by CAP Flying, Inc., experienced a total loss of engine power and collided with wires and a power line pole while descending for a forced landing near Orlando, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 instructional, local flight, from the Orlando Executive Airport, Orlando, Florida. The airplane was substantially damaged and the certified flight instructor (CFI) was fatally injured, while the pilot-rated student (student) sustained serious injuries. The flight originated about 1526, from the Orlando Executive Airport.

According to a transcription of communications with Orlando Executive Airport (KORL) Air Traffic Control Tower (ATCT), the CFI contacted the facility at 1639:36, and advised the controller, "yeah we are about 8 miles northwest of you ah we are showing no oil pressure we are coming in we would like to ah do a straight in on one three." The controller cleared the flight for a straight in landing on runway 13, which was acknowledged. The flight continued and at 1641:48, the controller stated, "cessna three six hotel I just want ah to verify you are ah having you are getting no oil pressure indication or low oil." The CFI responded, "ah looks like zero oil indication", which the controller acknowledged. At 1642:01, the controller advised the flight crew that the equipment was responding and, "you will see them standing by"; the CFI acknowledged that transmission. At 1644:39, or 5 minutes 3 seconds after the CFI first advised the controller of having no oil pressure, the CFI stated, "executive tower niner three three six hotel just had an engine failure ahm looks like we are coming in on runway one three." The controller advised the flight crew that they were number one cleared to land on runway 13, and provided wind information. At 1645:01, the CFI stated, "doesn't look like we're going to make the runway so we are going to turn around for the golf course." The controller acknowledged that transmission, and established contact with a news helicopter that was airborne in the area at 1645:34. The controller requested that the flight crew of the helicopter maintain visual contact with the aircraft and track the flight for him. At 1647:03, a flight crew member of the news helicopter advised the controller, "... he just crossed Edgewater high real bad."

The student seated in the left seat stated in writing that they had been practicing commercial maneuvers, and after completion, decided to return to the airport for some 180-degree power off approaches. On the flight back to the airport he smelled something burning, which "... triggered me to look at my gauges and notice that we had no oil pressure." The CFI contacted the KORL ATCT, and advised the controller of the situation. Both he and the CFI continued to look for a place to land if required, and the flight climbed a little bit to have more altitude to allow for a longer "glide time." He reported that a few minutes passed, and they started a slow descent for the airport. When leaving approximately 2,000 feet, the engine quit. The CFI took the controls of the aircraft, and advised the controller of the engine failure and his intention to land on a golf course. He (student) turned off the fuel, mixture, magnetos, and the alternator, but left the battery on for communications. When the flight was close to the ground "...we realized that we were going to have to make a steep approach. Dan put in all the flaps and did his best to fly down the fairway, keeping clear of all people and obstacles. Dan made a last minute decision to go to the left to possibly fly and land on the road, when we collided with the power lines, then the power pole which is where we came to rest. I remember very little after that."

The student verbally advised the Federal Aviation Administration (FAA) inspector-in-charge (IIC) that no oil was noted on the windscreen or on the sides of the airplane after noting there was no oil pressure. He also reported beginning to descend when the flight was approximately 4 miles northwest of KORL, and while flying at an altitude of approximately 1,500 feet, the engine began to vibrate then failed. The CFI took the controls and maneuvered the airplane towards the Dubsdread Golf Course which was to the left of their position at the time of the engine failure. The CFI made several s-turns to lose altitude, an approached the golf course fairways from an easterly to westerly direction. It appeared that the aircraft was going to overfly the point of intended landing, but the CFI did not slip the aircraft to lose altitude. The flight crossed trees at the easterly end of the golf course fairways, and was too high. The CFI maneuvered the aircraft in an attempt to find a suitable location to land, and the left-wing collided with wires causing the airplane to rotate approximately 90 degrees to the right. He did not see the wires prior to the collision, and does not remember the collision with the power pole.

Personnel information

The left seat occupant is the holder of a commercial pilot certificate with airplane multiengine land, and instrument airplane ratings. He also holds a single-engine land rating at the private level. He was issued a first-class medical certificate on May 27, 2003, with no limitations. He listed on the NTSB "Pilot/Operator Aircraft Accident Report" that he had a total flight time of 654 hours, of which 175 were in the accident make and model airplane.

The right seat occupant was the holder of a commercial pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. He was also the holder of a flight instructor certificate with airplane single-engine, and instrument airplane ratings. He was issued a first-class medical certificate on September 2, 2004, with a restriction "must wear corrective lenses." He listed a total time of 1,620 hours on the last medical certificate application.

Aircraft information

The airplane was manufactured by Cessna Aircraft Company in 1975, as a 172M, and designated serial number 17266094. It was certificated in the normal and utility categories, and was equipped with a 150 horsepower Lycoming O-320-E2D engine, and a McCauley 1C160/DTM7553 fixed pitch propeller.

The airplane and engine were last inspected on November 4, 2004, when they received a 100-hour inspection. At the time the accident, the airplane had accumulated approximately 91 hours since the last inspection, and 6, 620 total flight hours.

Meteorological information

A METAR weather observation taken at the Orlando Executive Airport, Orlando, Florida, at 1653, or approximately 6 minutes after the accident, indicates the wind was from 190 degrees at 3 knots, the visibility was 10 statute miles, scattered clouds existed at 6,000 feet, the temperature and dewpoint were 26 and 15 degrees Celsius, respectively, and altimeter setting was 30.18 inHg.

Communications

There were no reported communication difficulties.

Wreckage and impact information

Examination of the accident site and wreckage by an FAA Aviation Safety Inspector revealed the airplane came to rest at the base of a concrete power pole located at 28 degrees 34.94 minutes North latitude and 081 degrees 22.96 minutes West longitude. The airplane was recovered for further examination.

Examination of the airplane and engine following recovery was performed by representatives of the airframe and engine manufacturer with NTSB and FAA oversight. The examination of the airplane revealed no evidence of flight control preimpact failure or malfunction; the flaps were fully extended. The right side of the cabin, and the airplane forward of the instrument panel was crushed. Both front seats

Aircraft

Registration
N9336H
Reported as
Cessna 172M
Category
Airplane
Serial number
17266094
Airframe hours
6,619.53
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
CAP Flying, Inc.
Registered owner
Grady And Francis, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · November 1, 2004 · 91.4 hours before
Departed
KORL · Orlando, FL
Destination
KORL

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
33
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
1,620 total
Role
Student pilot
Age
26
Injuries
Serious
Certificates
Commercial, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2003
Seat
Left
Flight hours
654 total · 175 in this make and model · 544 as pilot in command · 28 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 59 °F
Altimeter
30.18 inHg
Observed at
KORL

Docket · 33

The files NTSB released with the investigation on November 14, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.6 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 378 KBMaterials Laboratory Factual Report 05-79Item 2 · .PDF · 1.3 MBTranscript of Radio CommunicationsItem 3 · .PDF · 113 KBFAA Inspector StatementItem 4 · .PDF · 176 KBOrlando Police Dept. ReportItem 5 · .PDF · 1.7 MBReport From Cessna Aircraft CompanyItem 6 · .PDF · 526 KBReport from LycomingItem 7 · .PDF · 264 KBRecord of NTSB ConversationsItem 8 · .PDF · 76 KBStatement from Bonnie SchroederItem 9 · .PDF · 162 KBExcerpts from Illustrated Parts CatalogItem 10 · .PDF · 4.7 MBRadar DataItem 11 · .PDF · 98 KBExcerpt from Engine Overhaul Manual and Lycoming Service Bulletin No. 240SItem 12 · .PDF · 187 KBExcerpts from Maintenance ManualItem 13 · .PDF · 116 KBExcerpts from Engine LogbooksItem 14 · .PDF · 515 KBExcerpts from Pilot's Operating HandbookItem 15 · .PDF · 579 KBStatement of Party Representatives to NTSB InvestigationItem 16 · .PDF · 103 KBToxicological ReportItem 17 · .PDF · 99 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 18 · .PDF · 75 KBPhoto 1: Digital photograph provided by FAA. View of the airplane at the accident site.Item 19 · .PDF · 2.7 MBPhoto 2: Digital photograph provided by FAA. View of the airplane at the accident site.Item 20 · .PDF · 2.8 MBPhoto 3: Digital photograph provided by FAA. View of the airplane at the accident site.Item 21 · .PDF · 2.6 MBPhoto 4: Digital photograph provided by FAA. View showing oil film on the exterior surface of the fuselage bottom skin.Item 22 · .PDF · 2.6 MBPhoto 5: Digital photograph provided by FAA. View of the airplane at the accident site.Item 23 · .PDF · 2.9 MBPhoto 6: Digital photograph provided by FAA. Close-up view showing oil film on the exterior surface of the fuselage bottom skin.Item 24 · .PDF · 2.8 MBPhoto 7: Digital photograph provided by FAA. View showing the propeller and upper surface of the engine cowling.Item 25 · .PDF · 2.6 MBPhoto 8: Digital photograph provided by Cessna. View showing the airplane following recovery.Item 26 · .PDF · 687 KBPhoto 9: Digital photograph provided by Lycoming. Arrow points to hose that leaked during postaccident testing. Note, caption and arrow added to picture by NTSB.Item 27 · .PDF · 84 KBPhoto 10: Digital photograph provided by Lycoming. View showing testing of the oil hose, note the soap bubbles indicating leakage.Item 28 · .PDF · 675 KBPhoto 11: Digital photograph provided by Lycoming. View showing contamination in the oil sump.Item 29 · .PDF · 621 KBPhoto 12: Digital photograph provided by Lycoming. View showing the No. 2 cylinder, connecting rod, connecting rod cap, and connecting rod bolt.Item 30 · .PDF · 619 KBPhoto 13: Digital photograph taken by NTSB. View showing the oil quantity drained from the oil sump.Item 31 · .PDF · 234 KBPhoto 14: Digital photograph taken by NTSB. View showing heat discoloration of the No. 2 crankpin.Item 32 · .PDF · 232 KBPhoto 15: Digital photograph taken by NTSB. View showing heat discoloration, and damage to the No. 2 connecting rod and connecting rod cap.Item 33 · .PDF · 224 KB

FAA reports on this event · 1

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