NYC07LA125

NTSB accident investigation · Cessna 172E · Leesburg, VA · May 23, 2007

Accident · Minor injuriesLimited investigationFinal report
Date
May 23, 2007, 16:55 local (20:55 UTC)
Place
Leesburg, VA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3982SCessna 172E
Weather
Visual (VMC) · Day
Status
Completed · report December 24, 2008
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20070523016289A
Case key
65862

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 loss of engine power that resulted from the failure of an exhaust valve rocker arm during cruise.

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
Engine assembly,rocker arm/tappet - cracked
Engine assembly,rocker arm/tappet - failureCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterEmergency descent/landing
Terrain condition - ditch

Analysis

The pilot was relocating a Cessna 172E for the airplane's annual maintenance inspection. During the flight, the engine suffered a partial loss of power and began to "shake and misfire violently." The pilot then attempted to control the engine by adjusting the throttle and mixture controls, without result. As the airplane descended, the pilot looked for a place to land and spotted an open field. After turning final, he extended his wing flaps to the 40-degree position and touched down. During the emergency landing the airplane approached a ditch. The pilot attempted to get over the ditch by raising the flaps, but the airplane struck the far side of the ditch. During a postaccident examination of the engine, it was discovered that the No.2 cylinder's exhaust valve rocker arm was fractured and had separated into two parts. The initial fracture on the exhaust valve rocker arm was on the push rod side of the arm. This fracture had features indicative of overstress. The fracture on the valve side of the arm was secondary to the overstress fracture on the push rod side. The fatigue cracking at this location appeared to be the result of bending loads generated after the fracture on the push rod side was created. The fracture on the push rod side of the arm was generated from some type of high load event, possibly during an overhaul 34.8 hours prior to the accident. The pilot/owner had purchased one of the cylinders on "eBay," and there were discrepancies in the engine maintenance records.

Factual narrative

On May 23, 2007, about 1655 eastern daylight time, a Cessna 172E, N3982S, was substantially damaged during a forced landing, shortly after takeoff from Leesburg Municipal Airport (JYO), Leesburg, Virginia. The certificated private pilot received minor injuries. Visual meteorological conditions prevailed and a visual flight rules (VFR) air defense identification zone (ADIZ) flight plan was filed for the flight destined for Culpeper Regional Airport (CJR), Culpeper, Virginia. The personal flight was conducted under 14 Code of Federal Regulations Part 91.

According to the pilot, the purpose of the flight was to relocate the airplane to CJR for the airplane’s annual maintenance inspection. After departure from runway 17, the pilot started a turn to the west and made his initial call to air traffic control (ATC). After the airplane crossed state route 15, the pilot made a power reduction to 2,400 rpm. The engine "without warning lost most of its power" and began to "shake and misfire violently."

The pilot attempted to control the engine by adjusting the throttle and mixture controls, without result. He then declared an emergency with ATC and began to receive vectors from the controller. He looked for a place to land and spotted an open field. He obtained best glide speed, turned on to a base leg for the field he had selected, and after turning on to a final leg, extended his wing flaps to the 40-degree position and touched down. The airplane passed through a row of trees located halfway down the field; however, a ditch existed on the opposite side. The pilot attempted to get over the ditch by raising the flaps, but the airplane struck the far side of the ditch, the nose gear collapsed and the airplane was substantially damaged.

The pilot held a private pilot certificate with a rating for airplane single-engine land. He had accumulated 235.7 total hours of flight experience; 53.1 hours of which were in the accident airplane make and model.

According to Federal Aviation Administration and maintenance records, the airplane was manufactured in 1964. The airplane’s most recent annual inspection was completed on May 18, 2006, and at the time of the accident, it had accumulated 4017.3 total hours of operation.

According to the pilot, the engine had accumulated 2,996.5 total hours of operation at the time of the accident. An overhaul of the engine had been completed on March 25, 2005. The time since overhaul was 34.8 hours and the engine had been operated 6.9 hours since the most recent annual inspection.

Examination of the airplane and engine by National Transportation Safety Board investigators revealed no preimpact malfunctions of the airplane or its systems; however, during examination of the engine, it was discovered that the No.2 cylinder’s exhaust valve rocker arm was fractured and had separated into two parts.

The fractured exhaust valve rocker arm, rocker shaft, push rod, and intact intake valve rocker arm were examined by the Safety Board’s Materials Laboratory. The examination revealed that the exhaust valve rocker arm had fractured at two locations through the rocker shaft hole, with about one-third of the pivot hole circumference on one piece of the arm and two-thirds on the other. Both fractures intersected oil holes on the inside diameter of the rocker shaft hole.

The features on the push rod side fracture emanated from a single location at the forging flash line on the inboard side of the arm. This fracture propagated into the arm, turning into the inside diameter of the arm’s central pivot hole. The fractographic features were rough, and when viewed optically, were indicative of overstress. No crack arrest positions were noted. Examination of this fracture with a scanning electron microscope did not revealed any features conclusively indicative of other cracking modes.

Optical examination of the fracture on the valve side of the rocker arm revealed that more than half of the fracture contained features that were typical of fatigue cracking. Fatigue initiation was from the pivot hole inner surface adjacent to the oil hole. Fatigue propagation extended approximately 5 millimeters from the pivot hole inner surface into the arm. Fracture features beyond that depth were typical of overstress. Compression damage on the portion of the fracture furthest from the origin area, and scuffing damage on the bushing adjacent to this fracture, were consistent with the exhaust valve side fracture being secondary to the fracture on the push rod side of the arm.

The wear pattern on the exhaust valve contact surface on the exhaust valve rocker arm was off-center and blurred. Two overlapping wear patterns were noted on the intake valve contact surface on the intact intake valve rocker arm.

No unusual wear patterns were noted on the push rod contact area on either of the rocker shafts. No damage or unusual wear patterns were noted on the rocker shaft. The push rod however, exhibited a bend measuring approximately 0.005 inch.

According to the owner, one of the cylinders was purchased on "eBay." During examination of the accident airplane’s engine maintenance records, no serviceable tags for the engine cylinders were discovered.

Further examination of the engine maintenance records revealed that the engine removed previously was listed as serial No. 33130-D-5-D. The engine listed as having been installed after overhaul was serial No. 33150-D-5-D. Examination of the engine revealed that the data plate on the engine was flat, did not conform to the shape of the case, was held on with two rivets, and displayed the serial number as 33130-D-5-D.

Aircraft

Registration
N3982S
Reported as
Cessna 172E
Category
Airplane
Serial number
17251182
Airframe hours
4,017.3
Engine
Continental O-300-D, 145 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 18, 2006 · 6.9 hours before
Departed
JYO · Leesburg, VA
Destination
CJR · Culpeper, VA
Flight plan
VFR
Airport
JYO · Leesburg Municipal Airport, runway 17, 5,500 × 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
39
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Flight hours
236 total · 53 in this make and model · 236 as pilot in command · 4 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 10 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 54 °F
Altimeter
30.37 inHg
Observed at
JYO, 4 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.