SEA03LA187

NTSB accident investigation · Cessna 172RG · Blanchard, ID · September 6, 2003

Accident · No injuriesLimited investigationFinal report
Date
September 6, 2003, 13:40 local (20:40 UTC)
Place
Blanchard, ID
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6368RCessna 172RG
Weather
Visual (VMC) · Day
Status
Completed · report June 2, 2004
Report
Approved by Office Director
Parties
FAA FSDO
FAA report
20030906023039A
Case key
57913

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 oil as a result of the inadequate installation of the idler gear shaft set screw and the lack of a safety wire on the hex head (oil) plug. A contributing factor was the rough and uneven terrain.

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/malfunctionClimb
Fluid,oil - dumpedCause
Miscellaneous,dowel/pin - loose
Maintenance,installation - inadequateOther maintenance personnelCause
Miscellaneous,drain plug - not safetied
Maintenance,installation - not performedOther maintenance personnelCause
Miscellaneous,drain plug - disconnected
Forced landingDescent - emergency
Gear collapsedLanding - roll
Terrain condition - rough/unevenFactor

Analysis

The pilot reported that while climbing there was a loud bang and simultaneously a spray of oil across the front windscreen. Several seconds later smoke began to develop within the cockpit and the pilot secured the engine and executed an off airport landing. The aircraft encountered rough, deeply furrowed terrain on rollout during which the landing gear collapsed. Post crash examination of the aircraft's engine revealed that the three-quarter inch hex head plug at the front of the engine, which retains the propeller governor idler gear shaft, had backed out of its threaded insert. The plug, which was found in the bottom of the engine had no safety wire attached and no safety wire was observed on the tie down point on the engine. The propeller governor idler gear shaft setscrew was loose and the gear shaft itself was missing. With the hex head plug and propeller governor idler gear shaft released, engine oil, under pressure could exit the engine. The engine had been overhauled 248.2 hours prior to the accident and then subsequently repaired for a propeller strike. It could not be determined whether any action related to the safety wiring of the hex plug or any adjustment to the set screw had been conducted at the overhaul or prop strike repair.

Factual narrative

On September 6, 2003, approximately 1340 Pacific daylight time, a Cessna 172RG, N6368R, registered to Heart & Truss Eng. Inc., and being operated/flown by a commercial pilot (right seat) sustained substantial damage during an off airport emergency landing near Blanchard, Idaho, following the loss of engine oil while climbing through approximately 5,500 feet above mean sea level. The pilot and student pilot passenger (left seat) were uninjured. Visual meteorological conditions prevailed and no flight plan had been filed. The flight, which was personal, was operated under 14 CFR 91, and originated from Spokane (Felts Field), Washington, approximately 1315, and was destined for Bonners Ferry, Idaho.

The pilot reported that while climbing there was a loud bang and simultaneously a spray of oil across the front windscreen, which obstructed his forward vision. Several seconds later smoke began to develop within the cockpit and the pilot secured the engine and all electrical systems after which the smoke dissipated. The pilot selected an emergency landing site and set up for an off airport landing. He then maneuvered the aircraft over a six-foot deep ditch and then through an electrical fence before the aircraft encountered rough, deeply furrowed terrain. The landing gear collapsed during the landing roll (refer to photographs 1 and 2).

Post crash examination of the aircraft's Lycoming four cylinder O-360-F1A6 engine revealed that the three-quarter inch hex head plug at the front of the engine, which retains the propeller governor idler gear shaft, had backed out of its threaded insert (refer to photograph 3 and Attachment FAA R-I). The plug was later found in the bottom of the engine and, although it had a hole drilled in its head for a safety wire, no safety wire was found attached. Additionally, no safety wire segment/pieces were observed on the tie down point on the engine (refer to photograph 4). The propeller governor idler gear shaft, which is held in place by a setscrew accessible only when the engine case halves have been separated, was missing. The setscrew was observed to have partially backed off allowing longitudinal movement of the propeller governor idler gear shaft. With the propeller governor idler gear shaft absent, engine oil under pressure could drive oil overboard through the unplugged hex head plug port (refer to Attachment L-I). According to Textron Lycoming Service Instruction No. 1343A, the threads in the engine case that retain the setscrew are to be peened to prevent the setscrew from backing out (refer to Attachment SI-I).

According to the owner, the aircraft's engine had been overhauled on July 20, 1998, 248.2 hours prior to the accident. Additionally, the owner reported that the last inspection (annual) was conducted December 17, 2002, 78.9 hours prior to the accident. Copies from the aircraft's engine and airframe logbooks showed removal/repair of the engine on March 15, 2002, as a result of a prop strike.

Aircraft

Registration
N6368R
Reported as
Cessna 172RG
Category
Airplane
Serial number
172RG0171
Airframe hours
5,300
Engine
Lycoming O-360-F1A6, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Pierce, David A.
Registered owner
Heart Truss & Eng Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 17, 2002 · 79 hours before
Departed
SFF · Spokane, WA
Destination
65S · Bonners Ferry, ID

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
Pilot
Age
60
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
May 5, 2003
Seat
Right
Flight hours
2,212 total · 193 in this make and model · 1,850 as pilot in command · 154 in the last 90 days · 2 in the last 30 days
Role
Student pilot
Age
47
Injuries
None
Certificate
Student
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
2 total · 2 in this make and model · 0 as pilot in command · 2 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
90 °F, dew point 37 °F
Altimeter
29.88 inHg
Observed at
COE, 13 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.