WPR11LA362

NTSB accident investigation · Cessna 172S · Syracuse, UT · August 2, 2011

Accident · Minor injuriesLimited investigationFinal report
Date
August 1, 2011, 21:05 local (Aug 2, 2011, 03:05 UTC)
Place
Syracuse, UT
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N235GWCessna 172S
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Night
Status
Completed · report February 12, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20110801016179A
Case key
81365

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 failure of the maintenance technicians who installed the engine to properly tighten the fuel injection servo to a spider supply line, which caused a loss of engine power due to fuel starvation.

Findings · 2

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.

Engine fuel and control: fuel distributionAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172S: 1 caseAll aircraft: 55 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna 172S: 2 casesAll aircraft: 371 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

The pilot reported that during cruise flight, the engine started running rough and began losing power. The pilot manipulated the throttle and mixture controls, but the engine continued losing power. All engine power was lost on approach during the forced landing to an alfalfa field, and the airplane nosed over during the landing roll. The engine had received a factory major overhaul and was installed in the airplane about 14 operational hours before the accident. Since installation, it had not received any maintenance. Postaccident examination of the engine found that the B-nut fitting on the fuel supply hose that goes from the fuel injection servo to the distribution spider was loose, which caused a fuel starvation-induced loss of engine power. No other mechanical malfunctions or failures were identified that would have precluded normal operation.

Factual narrative

On August 1, 2011, about 2105 mountain daylight time, a Cessna 172S, N235GW, lost engine power and was substantially damaged when it nosed over in a field during landing rollout in Syracuse, Utah. The private pilot, the sole occupant, received minor injuries. The airplane was registered to Mount Olympus Aviation, LLC. It was operated by Leading Edge Aviation, Salt Lake City, Utah, under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed during the personal flight, and no flight plan was filed. The airplane departed Salt Lake City, Utah, about 2050 and was destined for Ogden, Utah. According to the pilot, during cruise flight the engine started running rough and began losing power. The pilot manipulated the throttle and mixture controls, but the engine continued losing power. All engine power was lost on approach during the forced landing in an alfalfa field. The engine had received a major overhaul and was installed in the pilot’s airplane about 14 operational hours prior to the accident. Since installation, it had not received any maintenance. Review of the airframe and engine maintenance records disclosed that the aircraft was a Cessna 172S, serial number 172S9235, which was manufactured in 2002. A Lycoming IO-360-L2A engine, serial number L-30858-51E, was installed in the airframe. The engine was overhauled by Lycoming Engines, on June 21, 2011, and installed on the aircraft on July 27, 2011 at a tach time of 1,830.8 hours. The tach time on the aircraft after the engine failure and crash landing was 1,845.0 hours. The annual inspection was accomplished on July 27, 2011. On August 4, 2011 the airframe and engine were inspected by a Federal Aviation Administration airworthiness inspector. The engine rotated easily with no noticeable resistance. The spark plugs were removed. The ones in the number 3 cylinder were oil soaked. There was some oil pooling in the bottom of the same cylinder and there was some scoring on the cylinder wall. It should be noted that the engine was upside down in the field where the landing occurred for several days. There was no external damage to the magnetos, which were Slick Magnetos, part number 66GC20SFNN. The magneto timing was checked. One magneto’s timing was 24 degrees BTDC and the other one was 27 degrees BTDC. The engine data plate states that the timing should be 25 degrees BTDC. The magnetos were installed on a test bench and tested satisfactory. The gascolator was found pushed back into the firewall. The outlet hose was still attached but the other end with fitting was pulled from the fuel pump housing. The fuel gascolator bowl and screen was removed. There was no fuel in the bowl. The screen had only a very small amount of foreign material in it. The fuel pump, part number LW-15473, was removed from the engine. Both the inlet and outlet fittings were torn from the housing during impact. The component could not be tested. The fuel injection servo, partnumber, P/N 61J22088-70, was examined. The two attachment points were broken during impact. The inlet and outlet fittings were torn from the servo housing. The hose B-nut attached to the outlet fitting was loose. This is the hose that goes to the distribution spider. The fuel servo diaphragm, part number AV2538295, was checked and was intact. This part number is not subject to AD 2011-15-10 that was was issued with an effective date of August 16, 2011. The fuel injection spider, part number 2576624-1, was examined. The B-nut on the inlet hose at the spider was not tight. The diaphragm was checked and it had a small amount of viscous fluid on the dry side which may be some kind of assembly fluid. There was fuel on the wet side. No impact damage was noted.

Aircraft

Registration
N235GW
Reported as
Cessna 172S
Category
Airplane
Serial number
172S9235
Airframe hours
4,153
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Leading Edge Aviation
Registered owner
Mount Olympus Aviation LLC
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
100 hour · July 27, 2011 · 14 hours before
Departed
SLC · Salt Lake City, UT
Destination
OGD · Ogden, UT

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
48
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 26, 2011
Seat
Left
Flight hours
560 total · 510 in this make and model · 510 as pilot in command · 20 in the last 90 days · 7 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
315° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 55 °F
Altimeter
30.15 inHg

Docket · 5

The files NTSB released with the investigation on December 11, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.