# NTSB SEA03LA187: Cessna 172RG, N6368R, Blanchard, ID, September 6, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 6, 2003, 13:40 local (20:40 UTC) - Place: Blanchard, ID - Coordinates: 48.006389, -116.941108 - Nearby events: https://openairdocs.org/map.md?lat=48.0064&lon=-116.9411&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 2, 2004 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 57913 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA03LA187 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57913/pdf - Page: https://openairdocs.org/ntsb/SEA03LA187 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - fluid,oil - dumped (cause) - miscellaneous,dowel/pin - loose - maintenance,installation - inadequate, other maintenance personnel (cause) - miscellaneous,drain plug - not safetied - maintenance,installation - not performed, other maintenance personnel (cause) - miscellaneous,drain plug - disconnected - Forced landing, descent - emergency - Gear collapsed, landing - roll - terrain condition - rough/uneven (contributing factor) ## 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](https://openairdocs.org/deregistered/N6368R-2013-08-19), registration cancelled 2013-08-19, S/N 172RG0171, built 1979 (OpenAirDocs) - Reported make and model: Cessna 172RG - Registry model: [Cessna 172RG](https://openairdocs.org/model/cessna-172rg) (registry code 2072438) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172RG0171 - Airframe hours: 5300 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: none; 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 - Student pilot; age 47; injuries: none; 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 (OpenAirDocs). - [Accident 20030906023039A](https://openairdocs.org/incident/20030906023039A), Sep 6, 2003: Cessna 172RG, Spirit Lake, ID, Substantial damage. (-23) The aircraft was on a dual instruction cross country at 5500 MSL from spokane felts field (sff) to sandpoint, Idaho (S86) just north of Spirit Lake, ID… 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.