WPR17LA176

NTSB accident investigation · Cessna 172S · Seattle, WA · July 31, 2017

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
July 31, 2017, 12:30 local (19:30 UTC)
Place
Seattle, WA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N957TACessna 172S
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lycoming Engines
FAA report
20170731010209A
Case key
95729

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 total loss of engine power due to oil starvation as a result of the loose right magneto, which allowed oil to escape and the engine to seize. Contributing to the accident was inadequate maintenance, which failed to identify the loose magneto bolt.

Findings · 6

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.

Fluids: oilAircraft › Fluids/misc hardware · Fluid levelCessna 172S: 1 caseAll aircraft: 174 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Related maintenance infoCessna 172S: 1 caseAll aircraft: 174 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelCessna 172S: 1 caseAll aircraft: 320 casesProbable cause
Engine (reciprocating): recip eng rear sectionAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172S: 2 casesAll aircraft: 42 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · Incorrect service/maintenanceCessna 172S: 1 caseAll aircraft: 101 casesProbable cause
Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomeCessna 172S: 3 casesAll aircraft: 97 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 an instructional flight, the engine started running rough and, shortly after the oil pressure light illuminated, subsequently quit. The pilot elected to ditch the airplane in the water close to the shoreline. An onsite examination of the engine revealed that the top bolt of the right magneto was loose and had backed off, which allowed the magneto to become partially separated, leaving a 3/8-inch gap at the top of the magneto where it mounted to the case, which allowed oil to exit the engine. Metal shavings were observed throughout the engine. A review of the maintenance records indicated that the magnetos were removed and overhauled about 9 months before the accident during a 500-hour inspection, which was 420.5 hours of flight time before the accident. The airplane had accumulated about 22 hours of flight time since its last annual inspection, and the loose magneto bolt should have been able to be identified at that time.

Factual narrative

On July 31, 2017, about 1230 Pacific daylight time, a Cessna 172S, N957TA, was substantially damaged in an accident about 5 nautical miles northwest of Seattle International Airport (SEA), Seattle, Washington. The flight instructor and student pilot receiving instruction sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The flight instructor reported that after completing air work they were returning to Boeing Field/King County International Airport (BFI), Seattle, Washington, when the engine started running rough. During the descent, the engine started to run rougher and it continued to lose rpm. Shortly thereafter the low oil pressure light illuminated, and 10 to 15 seconds later the engine quit. When the pilot attempted to restart the engine and the propeller would not move, he elected to ditch the airplane in the water close to the shoreline; the landing resulted in the deformation of the engine mount. The following day the airplane was recovered to a secured facility for further examination. According to a Federal Aviation Administration (FAA) aviation safety inspector who was on site during the recovery process the day following the accident, as the airplane was removed from the water and the engine cowling was removed, he observed that the top bolt of the right magneto was loose and had backed off, which created a 3/8" gap between the magneto and its mounting pad. An external visual examination of the engine revealed no catastrophic damage; however, the engine was seized and would not rotate. The muffler was damaged slightly, the right magneto was canted aft from its mounting pad at the top right position, with the attachment nut observed loose. The lower mounting nut was loose at the bottom of the mount. There were 4 accessory case bolts missing from the accessory case, three from the right side at the bottom of the case, one on the left bottom and one bolt on the left side was protruding halfway out. When the loose right magneto was removed from its mounting pad, there was no noticeable damage to the magneto gear, although there were metal flakes observed inside the magneto, and its gasket was torn. When the left magneto was removed, it was observed to be tight in its mount; metal flakes were detected on the gears. The remainder of the accessories were removed from the accessory section of the engine. While no damage was observed to any of the accessories, metal flakes were detected within and around them. After the accessory case bolts had been removed, a visual inspection of each bolt revealed no stress signatures to their respective threads. An examination of the right magneto's top right bolt that had backed out, revealed that no stress signatures were observed on the bolt's threads. During removal of the accessory case bolts, it was observed that more than half of the bolts were not tight. The manufacturer's maintenance manual stipulates that all bolts shouldbe properly torqued; the bolts have a star lock washer, however, no safety wire. No stress was found on any of the bolt threads or their respective mount threads. Each bolt had the appropriate washer. When the engine case was disassembled, it was observed that the crankshaft had broken in half at the middle bearing. A large section of the crankshaft had separated, which was subsequently located in the bottom of the case. When the crankshaft was removed, it was observed that the bearing had become welded to the shaft. Additionally, heat stress signatures were observed. A representative of the engine manufacturer reported that based on the findings, it was his opinion that when the right magneto came loose and backed out of its mount, it allowed all of the oil to exit at the magneto mounting hole. Maintenance records revealed that the zero-time rebuilt engine was installed on the airplane, December 29, 2015. At the time of the accident, the engine had accumulated a total of 917.5 hours, with 22.4 hours since its last annual inspection, dated July 25, 2017. It was noted that both the left and right magnetos were removed and overhauled on November 3, 2016, during a 500-hour inspection, which was 497 hours after the engine was installed, and 420.5 hours before the failure of the engine. Maintenance records also revealed that 122 hours before the accident, the accessory case was removed in order to replace the oil pump body, as well as the drive and impeller. When the case was removed during the examination of the engine, there were no anomalies noted with any of the previously referred to components.

Aircraft

Registration
N957TA
Reported as
Cessna 172S (S)
Category
Airplane
Serial number
172S9057
Built
2002
Airframe hours
5,539.9
Engine
Lycoming IO-360-L2R, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 25, 2017 · 22 hours before
Departed
BFI · Seattle, WA
Destination
BFI · Seattle, WA
Equipment
Stall warning system

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
Flight instructor
Age
24
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
April 4, 2017
Seat
Right
Restraint
3-point
Flight hours
490 total · 57 in this make and model · 373 as pilot in command · 206 in the last 90 days · 64 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Age
30
Injuries
Minor
Certificate
Student
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
0 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 52 °F
Altimeter
30.23 inHg
Observed at
BFI, 5 nm away

Docket · 8

The files NTSB released with the investigation on August 24, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.2 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.