# NTSB NYC05FA069: Cessna 152, N24779, Williamsburg, OH, April 11, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 11, 2005, 13:08 local (17:08 UTC) - Place: Williamsburg, OH - Coordinates: 39.018611, -84.00389 - Nearby events: https://openairdocs.org/map.md?lat=39.0186&lon=-84.0039&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 20, 2005 - Report: Approved by Office Director - Parties: FAA FSDO-05, Cessna Aircraft Company, Lycoming Engines, Sporty's Academy - Safety recommendations: Yes - NTSB case key (mKey): 61280 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC05FA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61280/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=61280 - Page: https://openairdocs.org/ntsb/NYC05FA069 ## Probable cause An improperly installed rudder bumper, which resulted in a rudder jam during spin training and subsequent uncontrolled descent into terrain. A factor was the operator did not comply with the service bulletin. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - flt control syst,rudder control - improper (cause) - maintenance,service bulletin/letter - not complied with, company/operator management (contributing factor) - flight control,rudder - jammed - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The certificated flight instructor and student pilot were practicing spins about 3,000 feet agl, and did not recover. The airplane subsequently descended in a nose down spiral, and impacted a field. Examination of the wreckage revealed that the rudder was jammed beyond its left travel limit. Further examination revealed that the two rudder bumpers had been installed inverted, and the right side rudder bumper had traveled over and beyond the rudder stop, and locked behind it. Review of the maintenance records revealed no specific mention of the rudder bumpers during the 28-year history of the airplane. However, work had been performed near the rudder bumpers on several occasions. Additionally, the paint on the inverted rudder bumpers was consistent with a paint job completed about 8 years prior to the accident. The investigation could not determine if the rudder bumpers were inverted at the time of production, or if they had been inverted during the maintenance history of the airplane. The airplane manufacturer issued a service bulletin about 3 1/2 years prior to the accident. The purpose of the service bulletin was to provide an enhanced rudder stop, bumper, doubler and attachment hardware designed to assist in preventing the possibility of the rudder overriding the stop bolt during full left or right operation of the rudder. Specifically, the new rudder stop was much larger than the original rudder stop. The service bulletin had not been complied with on the accident airplane, and under 14 CFR Part 91, was not required. ## Factual narrative HISTORY OF FLIGHT On April 11, 2005, at 1308 eastern daylight time, a Cessna 152, N24779, was substantially damaged when it impacted a field near Williamsburg, Ohio. The certificated flight instructor (CFI) and student pilot were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight conducted under 14 CFR Part 91. According to another company CFI, prior to takeoff, the accident pilots were discussing "hood work and spin training." The flight departed Clermont County Airport (I69), Batavia, Ohio, about 1230, and proceeded to a practice area approximately 10 miles east of the airport. A witness, who was driving in his car about the time of the accident, observed the accident airplane "falling out of the sky...nose first," and did not appear to have any power. Another witness, who was standing near her residence, heard engine noise oscillate about three times, followed by no engine noise at all. The witness looked up and observed the accident airplane spiraling downward. A third witness was standing near her mailbox, and observed the accident airplane spiraling downward. The witnesses could not confirm the direction of rotation as the airplane was spiraling. Review of radar data provided by the Federal Aviation Administration (FAA), revealed a target displaying a 1200 transponder code, traveling south at 4,000 feet msl. The target began a right turn toward north about 1306:38, and began to descend about 1307:25. The last target was recorded at 1308:01, at a position about 1/8-mile from the accident site. The last target indicated an altitude of 2,100 feet msl. The accident occurred during the hours of daylight; located about 39 degrees, 01.12 minutes north latitude, and 84 degrees, 00.24 minutes west longitude. PERSONNEL INFORMATION The CFI held a commercial pilot certificate and flight instructor certificate, with ratings for single engine land and instrument airplane. He had a total flight experience of approximately 468 hours, of which, about 88 hours were in the same make and model as the accident airplane. Additionally, he had approximately 192 hours of experience as a flight instructor. The flight instructor's most recent FAA third class medical certificate was issued on September 12, 2002. The student pilot held a student pilot certificate. He had a total flight experience of approximately 47 hours, of which, about 2 hours were in the same make and model as the accident airplane. The student pilot's most recent FAA first class medical certificate was issued on October 5, 2004. AIRCRAFT INFORMATION The airplane was manufactured in 1977. It's most recent annual inspection was performed on February 11, 2005. At that time, the airplane had accumulated approximately 10,681 hours of operation. The airplane accumulated approximately 38 hours of operation from the time of the last inspection, until the accident. METEOROLOGICAL INFORMATION The reported weather at Lunken Field (LUK), Cincinnati, Ohio, at 1253, was: wind variable at 5 knots; visibility 10 miles; sky clear; temperature 81 degrees F; dew point 46 degrees F; altimeter 29.99 inches Hg. WRECKAGE AND IMPACT INFORMATION The wreckage was examined on April 11 and 12, 2005, and all major components of the airplane were accounted for at the scene. The wreckage was intact, oriented about a 100-degree heading, and resting upright in a field. The field elevation at the accident site was approximately 915 feet above sea level. There was no observed debris path or horizontal ground scars at the accident site. No fuel was found in the two fuel tanks. However, both tanks had ruptured, and fueling records indicated that the airplane was completely fueled prior to takeoff. With the exception of the left aileron, flight control continuity was confirmed from all control surfaces to the cockpit area. Flight control continuity was confirmed from the left aileron bellcrank to the cockpit area. The bellcrank rod arm was separated from the left aileron, consistent with overstress. An FAA inspector stated that emergency personnel had to cut control cables and manipulate the wreckage to recover the pilots. The elevator trim jackscrew corresponded to an approximate 8-degree nose-down setting, and the elevator trim cable was separated near the cockpit area consistent with a cut. The right wing exhibited compression damage, and the damage was more severe near the leading edge. The right flap was found retracted, and the right aileron was approximately neutral. The left wing also exhibited compression damage, and the damage was more severe near the leading edge. The left flap was found retracted, and the left aileron was approximately neutral. The cockpit area was crushed, a portion of the fuel selector lever was separated, and the selector was found in the "ON" position. The flap switch was found near the 10-degree extension position, and the flap indicator was in the flaps retracted position. The mixture control was found in the lean position, the throttle control was full throttle, and the ignition key was selected to "BOTH." The carburetor heat selector was found in the mid-range position. Both seatbelts and shoulder harnesses were fastened, and were cut by emergency personnel. The tachometer needle was observed near the 1,000-rpm position. The altimeter face was found separated from the unit; the needle indicated 1,300 feet, and 30.00 was displayed in the Kollsman window. The attitude indicator displayed an approximate 90-degree left bank, and 10-degree nose-up attitude. The directional gyro indicated approximately 100 degrees. The airspeed indicator needle had separated, and was not recovered. The face of the turn coordinator had separated from the unit, and was found near the 90-degree right bank position. The vertical speed indicator was not recovered. The propeller remained attached to the engine. One propeller blade was bent forward near the tip, and the other blade was bent aft. Minor rotational damage was observed on the blades. The spark plugs, propeller, and valve covers were removed from the engine for inspection. Oil was present throughout the engine and in the oil filter. The spark plugs appeared light gray in color, and their electrodes were intact. The propeller flange was rotated by hand, using a crowbar. Camshaft, crankshaft, and valve train continuity in the engine were confirmed. Thumb compression was obtained on all cylinders. The right magneto was partially separated from the engine. When the right magneto was rotated by hand, it produced spark at all leads. The left magneto remained attached to the engine, and produced spark at all leads while the crankshaft was rotated by hand. The vacuum pump remained attached to the engine. The vacuum pump was disassembled, and the rotor was observed fractured. The oil filter was examined, and no metallic contamination was noted. Fuel was recovered from the carburetor, and was consistent in odor and color to 100 low lead aviation gasoline. The carburetor fuel screen was absent of debris. The empennage was found separated from the airplane, and resting upright. The empennage was buckled on the left side, and the rudder was deflected full left. The Ohio State Police photographed the wreckage prior to its manipulation by emergency personnel. The photographs revealed that the empennage remained partially attached to the airplane, and the rudder was deflected full left. Further examination of the rudder revealed that it was jammed beyond its full left travel limit. The rudder bumper had traveled over and beyond the rudder stop, and had locked behind it. Further examination of the two rudder bumpers revealed that they were installed inverted. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilots by the Brown County Coroner's ## Aircraft - Registration: [N24779](https://openairdocs.org/deregistered/N24779-2017-06-07), registration cancelled 2017-06-07, S/N 15280373, built 1977 (OpenAirDocs) - Reported make and model: Cessna 152 - Registry model: [Cessna 152](https://openairdocs.org/model/cessna-152) (registry code 2071835) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 15280373 - Airframe hours: 10681 - Engines: Lycoming O-235 110 hp reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Sporty's Academy - Registered owner: Eastern Cincinnati Aviation, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2005, 38 hours before - Departed: I69, Batavia, OH ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 21; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review December 1, 2004; seat: right; toxicology performed; flight hours: 486 total, 88 in this make and model, 425 as pilot in command, 156 in the last 90 days, 41 in the last 30 days, 0 in the last 24 hours - Student pilot; age 19; injuries: fatal; student; medical: class 1, without waivers/limitations; seat: left; toxicology performed; flight hours: 47 total, 2 in this make and model, 33 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 0° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 46 °F - Altimeter: 29.98 inHg - Observed at: LUK, 15 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 20050411008939A](https://openairdocs.org/incident/20050411008939A), Apr 11, 2005: Cessna 152, Williamsburg, OH, Destroyed, 2 fatal. (-23) Aircraft was seen spinning nose down, then impacted the ground. Damage was incurred to the prop, fuselage (engine & cabin area), left wing leading edge,… ## Docket (22 files) The files NTSB released with the investigation on October 4, 2005, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=61280. 19.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383420&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383421&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Interview Summaries (item 3, .PDF, 431 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383422&FileExtension=.PDF&FileName=Interview%20Summaries-Redacted.PDF - Excerpts from Airframe and Engine Logbooks (item 4, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383424&FileExtension=.PDF&FileName=Excerpts%20from%20Airframe%20and%20Engine%20Logbooks-Redacted.PDF - Fueling Record (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237317&FileExtension=.PDF&FileName=Fueling%20Record-Master.PDF - NTSB Radar Plot (item 6, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237318&FileExtension=.PDF&FileName=NTSB%20Radar%20Plot-Master.PDF - Radar Plot Provided by Cessna Aircraft Company (item 7, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237319&FileExtension=.PDF&FileName=Radar%20Plot%20Provided%20by%20Cessna%20Aircraft%20Company-Master.PDF - Excerpt from Cessna Aircraft Company Parts Catalog (item 8, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237320&FileExtension=.PDF&FileName=Excerpt%20from%20Cessna%20Aircraft%20Company%20Parts%20Catalog-Master.PDF - Drawing of Rudder Horn Provided by Cessna Aircraft Company (item 9, .PDF, 651 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237323&FileExtension=.PDF&FileName=Drawing%20of%20Rudder%20Horn%20Provided%20by%20Cessna%20Aircraft%20Company-Master.PDF - Cessna Aircraft Company Service Bulletin SEB01-1 (item 10, .PDF, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237325&FileExtension=.PDF&FileName=Cessna%20Aircraft%20Company%20Service%20Bulletin%20SEB01-1-Master.PDF - Transport Canada Airworthiness Directive CF-2000-20R2 (item 11, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383425&FileExtension=.PDF&FileName=Transport%20Canada%20Airworthiness%20Directive%20CF-2000-20R2-Redacted.PDF - Toxicological Reports (item 12, .PDF, 698 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383426&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 484 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383427&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 14, .PDF, 237 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383428&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1 - Left Side View of Wreckage (item 15, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237344&FileExtension=.PDF&FileName=Photo%201%20-%20Left%20Side%20View%20of%20Wreckage-Master.PDF - Photo 2 - Right Side View of Wreckage (item 16, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237346&FileExtension=.PDF&FileName=Photo%202%20-%20Right%20Side%20View%20of%20Wreckage-Master.PDF - Photo 3 - Front View of Wreckage (item 17, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237347&FileExtension=.PDF&FileName=Photo%203%20-%20Front%20View%20of%20Wreckage-Master.PDF - Photo 4 - Rudder (item 18, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237349&FileExtension=.PDF&FileName=Photo%204%20-%20Rudder-Master.PDF - Photo 5 - Right Side Rudder Bumper (item 19, .PDF, 837 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237351&FileExtension=.PDF&FileName=Photo%205%20-%20Right%20Side%20Rudder%20Bumper-Master.PDF - Photo 6 - Left Side Rudder Bumper (item 20, .PDF, 829 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237352&FileExtension=.PDF&FileName=Photo%206%20-%20Left%20Side%20Rudder%20Bumper-Master.PDF - Photo 7 - Propeller (item 21, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237353&FileExtension=.PDF&FileName=Photo%207%20-%20Propeller-Master.PDF - Photo 8 - Engine (item 22, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40237354&FileExtension=.PDF&FileName=Photo%208%20-%20Engine-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.