SEA08LA155

NTSB accident investigation · Cessna 172M · Oakland, CA · June 30, 2008

Accident · Minor injuriesLimited investigationFinal report
Date
June 30, 2008, 12:50 local (19:50 UTC)
Place
Oakland, CA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N61736Cessna 172M
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 28, 2008
Report
Approved by Office Director
Parties
Federal Aviation Administration
Case key
68346

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

A loss of engine power due to oil starvation. The oil starvation event was due to the failure of maintenance personnel to tighten the mounting bolts for the newly installed vacuum pump.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Vacuum systemAircraft › Aircraft systems · Incorrect service/maintenanceCessna 172M: 1 caseAll aircraft: 12 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 172M: 3 casesAll aircraft: 371 casesProbable cause
Runway/land/takeoff/taxi surfaceEnvironmental issues › Physical environment · Not specifiedCessna 172M: 1 caseAll aircraft: 253 cases
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna 172M: 3 casesAll aircraft: 174 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

During cruise flight, the pilot noticed the engine was running rough along with a surge in power. He adjusted the mixture to the full rich position, which seemed to smooth the roughness. A few seconds later, he noticed that the engine oil temperature gauge was rising and he diverted towards a nearby airport. The pilot stated that while en route to the airport, the engine lost power and he initiated a forced landing to an open lot near his position. During the landing roll, the airplane struck a large mound of dirt. Examination of the airplane revealed structural damage to the fuselage. Only residual oil was found in the engine. Examination of the engine revealed evidence of an internal oil starvation induced catastrophic failure. The nuts securing the vacuum pump to the mounting pad were loose. About 10 psi of compressed air was applied to the oil cooler inlet port on the engine. Bubbling oil was observed originating from the vacuum pump mounting pad. No further anomalies were noted. Review of maintenance records revealed that the vacuum pump was replaced prior to the accident flight.

Factual narrative

On June 30, 2008, about 1240 Pacific daylight time, a Cessna 172M, N61736, was substantially damaged during a forced landing near Oakland, California. The commercial pilot and his passenger sustained minor injuries. The airplane was registered to and operated by Flying Vikings Inc. of Hayward, California under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local traffic watch flight that originated from the Hayward Executive Airport (HYW), Hayward, California at 1100. According to the pilot, during cruise flight, he noticed the engine was running rough along with a surge in power. The pilot adjusted the mixture to the full rich position, which seemed to smooth the roughness. A few seconds later, the pilot noticed that the engine oil temperature gauge was rising and diverted towards the Oakland International Airport (OAK), Oakland. The pilot stated that while en route to OAK, the engine lost power and he initiated a forced landing into an open lot near his position. During the landing roll, the airplane struck a large mound of dirt and came to rest upright. Examination of the airplane by a Federal Aviation Administration inspector revealed that the right wing and fuselage were structurally damaged. Oil was observed on the undercarriage of the airplane from the engine aft to the empennage. On July 24, 2008, the airframe and engine were examined by the NTSB investigator-in-charge at the facilities of Plane Parts, Pleasant Grove, Sacramento. The Lycoming O-320-E2D engine, serial number RL-40510-27A, remained attached to the airframe via all four engine mounts. All of the accessories and cylinders remained attached to the engine crankcase. All four nuts that secured the vacuum pump to the mount pad were found loose. Oil was observed on the rear accessory housing below the vacuum pump and between the left and right magneto. When removed, the oil dipstick indicated no oil within the oil sump. All open lines were plugged with end caps and about 10 psi of compressed air was applied to the oil cooler inlet line. Bubbling oil was observed originating from the vacuum pump mounting pad. The vacuum pump and both magnetos were removed from the engine. The bottom portion of the vacuum pump seal was saturated with oil. The crankshaft was rotated by hand using the propeller and was noted to be extremely stiff. Thumb compression was obtained on all four cylinders. The oil suction finger screen was removed and exhibited metallic debris inside the screen. The number one and three cylinders were removed and examined. Both cylinders exhibited a normal amount of combustion deposits within the cylinder dome. Both pistons were intact and exhibited scuffing on the piston skirt. All internal connecting rods visually appeared to be intact. The number three and four connecting rods along with the general area of the crankshaft exhibited thermal discoloration. The left magneto producedspark on all leads when the magneto drive shaft was rotated by hand with impulse coupling engagement. The right magneto produced spark on all leads when the magneto drive shaft was rotated using an electric hand drill. The propeller remained attached to the crankshaft propeller flange. One of the two blades was slightly bent aft about 10 degrees and the other propeller blade was undamaged. Review of the engine logbook revealed that the engine underwent its most recent 100-hour/annual inspection on June 16, 2008 at a tachometer time of 3,036.9 hours and 3,910.6 hours since major overhaul. A squawk sheet located within the airplane indicated that the vacuum pump was replaced after the most recent flight recorded prior to the accident flight on July 27, 2008. According to the FAA inspector who responded to the accident site, during a telephone interview, the airframe and power plant rated mechanic who installed the vacuum pump reported that he installed the vacuum pump and tightened all the nuts except for the bottom left, which he could not reach. The mechanic stated that he used a screwdriver and hammer to tighten the nut.

Aircraft

Registration
N61736
Reported as
Cessna 172M
Category
Airplane
Serial number
17264762
Airframe hours
13,036
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Registered owner
Flying Vikings
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 2008
Departed
KHWD · Hayward, CA

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
36
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
May 1, 2007
Seat
Left
Flight hours
992 total · 770 in this make and model · 926 as pilot in command · 311 in the last 90 days · 100 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 55 °F
Altimeter
30.05 inHg
Observed at
KHWD, 4 nm away

Other investigations on N61736 · 1

Matched to the same aircraft by N-number and date.