# NTSB WPR11LA362: Cessna 172S, N235GW, Syracuse, UT, August 2, 2011 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: August 1, 2011, 21:05 local (Aug 2, 2011, 03:05 UTC) - Place: Syracuse, UT - Coordinates: 41.108612, -112.071113 - Nearby events: https://openairdocs.org/map.md?lat=41.1086&lon=-112.0711&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report February 12, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - ADs cited in the narratives: [AD 2011-15-10](https://openairdocs.org/ad/2011-15-10) (OpenAirDocs) - NTSB case key (mKey): 81365 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA362 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81365/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81365 - Page: https://openairdocs.org/ntsb/WPR11LA362 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=2072439), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 172S, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072439), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/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 (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 172S, 10 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=2072439), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Approach-VFR pattern final: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cessna 172S, 19 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072439), [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 172S, 15 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072439), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 172S, 34 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072439), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N235GW-2014-04-10), registration cancelled 2014-04-10, S/N 172S9235, built 2002 (OpenAirDocs) - Reported make and model: CESSNA 172S - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S9235 - Airframe hours: 4153 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: minor; 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 ## 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 20110801016179A](https://openairdocs.org/incident/20110801016179A), Aug 1, 2011: Cessna 172S, Syracuse, UT, Substantial damage. The pilot departed the slc international airport and headed to Ogden airport to practice ILS approach. While been vectored for an ILS landing the engine… ## Docket (5 files) The files NTSB released with the investigation on December 11, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81365. 6.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353960&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Engine Exam Report by FAA (item 2, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383466&FileExtension=.PDF&FileName=Engine%20Exam%20Report%20by%20FAA-Redacted.PDF - Engine Exam Report by Fair Air (item 3, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383467&FileExtension=.PDF&FileName=Engine%20Exam%20Report%20by%20Fair%20Air-Redacted.PDF - Photo 1. Aircraft as found in field. (item 4, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383468&FileExtension=.PDF&FileName=Photo%201.%20Aircraft%20as%20found%20in%20field.-Master.PDF - Photo 2. Detail view of engine compartment. (item 5, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383469&FileExtension=.PDF&FileName=Photo%202.%20Detail%20view%20of%20engine%20compartment.-Master.PDF 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.