# NTSB NYC08LA137: Cessna 150F, N6651F, Middlesboro, KY, March 13, 2008 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 13, 2008, 15:20 local (19:20 UTC) - Place: Middlesboro, KY - Coordinates: 36.610553, -83.73722 - Nearby events: https://openairdocs.org/map.md?lat=36.6106&lon=-83.7372&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report November 25, 2008 - Report: Approved by Office Director - Parties: FAA/FSDO - NTSB case key (mKey): 67664 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC08LA137 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67664/pdf - Page: https://openairdocs.org/ntsb/NYC08LA137 ## Probable cause The mechanic's improper maintenance installation of the No. 1 cylinder rocker arms which led to oil starvation and a loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 150F, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2071814), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 150F, 3 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2071814), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 150F, 12 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2071814), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 150F, 14 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2071814), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Cessna 150F, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=2071814), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis During a period of 6 months, a major engine overhaul and annual inspection was being performed on the pilot's airplane. The work was being performed by the pilot's friend, who was an airframe and powerplant mechanic with an inspector authorization. The accident flight was the first flight after the work was completed. About 10 minutes after departure, the engine began vibrating and lost all power during cruise flight. The major overhaul had included the installation of new cylinders. Proper installation of the new cylinders required that the exhaust valve rocker arms have a small orifice to allow oil to pass and lubricate the valves. The intake valve rocker arms did not have an orifice. Examination of the accident engine revealed that the No. 1 cylinder intake valve was stuck open, and exhibited features consistent with oil starvation. Further examination revealed that the No. 1 cylinder had an intake rocker arm (no orifices) on both the intake and exhaust valves. The No. 3 cylinder had an exhaust valve rocker arm (with orifice) on both the intake and exhaust valves. Review of a make and model engine overhaul manual revealed a caution, noting that the exhaust valve rocker arms have an orifice. Further examination of the cylinder did not reveal any additional mechanical anomalies. ## Factual narrative On March 13, 2008, about 1520 eastern daylight time, a Cessna 150F, N6651F, was substantially damaged during a forced landing, following a total loss of engine power in cruise flight near Middlesboro, Kentucky. The certificated commercial pilot was seriously injured. No flight plan was filed for the personal flight conducted under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight that departed Middlesboro-Bell County Airport (1A6), Middlesboro, Kentucky; destined for Pike County Airport (PBX), Pikeville, Kentucky. The pilot owned and operated the airplane. He stated that the airplane was based at PBX, but had been at 1A6 for about 6 months, while undergoing a major engine overhaul and annual inspection. The work was being performed by the pilot's friend, who was an airframe and powerplant mechanic with an inspector authorization. The accident flight was the first flight after the work was completed. The pilot was attempting to ferry the airplane back to PBX. About 10 minutes after departure, the engine began vibrating and lost all power during cruise flight. The pilot attempted a forced landing; however, the airplane struck utility wires. The airplane then pitched up, descended inverted, and impacted the ground. The airplane was equipped with a Teledyne Continental Motors (TCM) O-200, 100-horsepower engine. The major overhaul included the installation of Airmotive Engineering Corporation (AEC) cylinders. According to a Federal Aviation Administration (FAA) inspector, the exhaust valve rocker arms, for cylinders on that model engine, had a small orifice to allow oil to pass and lubricate the valves. The intake valve rocker arms did not have an orifice. Examination of the accident engine by the FAA inspector revealed that the No. 1 cylinder intake valve was stuck open, and exhibited features consistent with oil starvation. Further examination revealed that the No. 1 cylinder had an intake rocker arm (no orifices) on both the intake and exhaust valves. The No. 3 cylinder had an exhaust valve rocker arm (with orifice) on both the intake and exhaust valves. Review of a TCM overhaul manual for the O-200 model engine revealed, "CAUTION...Exhaust rocker has an oil orifice in the valve stem end for valve stem lubrication." Further examination of the No. 1 cylinder, at the cylinder manufacturer, under the supervision of an FAA inspector, did not reveal any additional mechanical anomalies with the cylinder. The reported weather at K1A6, at 1515, was: wind from 180 degrees at 15 knots, gusting to 19 knots; visibility 10 miles; scattered clouds at 9,000 feet; temperature 22 degrees Celsius (C); dew point 4 degrees C; altimeter 29.86 inches of mercury. ## Aircraft - Registration: [N6651F](https://openairdocs.org/deregistered/N6651F-2010-08-03), registration cancelled 2010-08-03, S/N 15063251, built 1966 (OpenAirDocs) - Reported make and model: CESSNA 150F - Registry model: [Cessna 150F](https://openairdocs.org/model/cessna-150f) (registry code 2071814) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15063251 - Airframe hours: 4029 - Engines: Continental O-200 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Emory C Hurley - Airworthiness certificate: Standard, Utility - Last inspection: Annual, March 1, 2008 - Departed: 1A6, Middlesboro, KY - Destination: PBX, Pikeville, KY - Airport: 1A6, Middlesboro-Bell County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 3, unknown; last flight review October 1, 2007; seat: left; flight hours: 742 total, 72 in this make and model, 742 as pilot in command, 5 in the last 90 days, 1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 15 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 39 °F - Altimeter: 29.86 inHg - Observed at: 1A6 ## 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 20080313012699A](https://openairdocs.org/incident/20080313012699A), Mar 13, 2008: Cessna 150F, Middlesborough, KY, Substantial damage. (-23) The pilot [privacy data omitted] arrived at middlesboro, KY on March 13, 2008 to pick up his aircraft after engine overhaul. After take-off the aircraft… 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.