WPR17LA216

NTSB accident investigation · Cessna 172P · Tamuning · September 25, 2017

Accident · No injuriesLimited investigationFinal report
Date
September 25, 2017
Place
Tamuning
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N5448KCessna 172P
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Western Pacific Region
FAA report
20170925024089A
Case key
96149

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's inadequate preflight inspection, which resulted in oil exhaustion and a subsequent total loss of engine power during cruise flight.

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.

Eng oil sys (airframe furnish): quantityAircraft › Aircraft power plant · Not inspectedCessna 172P: 1 caseAll aircraft: 5 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotCessna 172P: 3 casesAll aircraft: 551 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 commercial pilot reported that, during the local sightseeing flight, he noticed fire sparks and smoke starting to fill the cabin. Shortly after, the engine lost all power, and the airplane started to shake violently. The pilot decided to return to the airport, and while en route, he attempted to restart the engine without success. When he realized there was insufficient altitude to land on the runway, he initiated a forced landing to a nearby field. The airplane impacted terrain short of the airport perimeter fence and sustained substantial damage. An engine examination revealed that the engine oil filler cap was not secured, and evidence of oil was found around the No. 4 cylinder and intake pipes. The pilot reported that he checked the oil level before the first flight of the day and then flew 10 more flights that day but did not check the oil level before those flights. The Pilot's Operating Handbook indicated that the oil quantity is to be confirmed and the oil filler cap is to be secured before each flight. It is likely that the pilot did not properly secure the oil filler cap during the preflight inspection before the first flight of the day and did not verify that it was secured before any of the following 10 flights, which resulted in a gradual leak of engine oil and subsequent engine seizure. Further, his failure to check the oil before the following 10 flights prevented him from identifying that the oil had leaked out and was at an insufficient level.

Factual narrative

On September 25, 2017, about 1715 local time, a Cessna 172P airplane, N5448K, sustained substantial damage when it impacted terrain following a loss of engine power near Guam International Airport (PGUM), Tamuning, Guam. The commercial pilot and two passengers were not injured. The airplane was registered to and operated by Sky Guam Aviation, Inc. as a Title 14 Code of Federal Regulations Part 91 sightseeing flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that originated from PGUM at 1650. The pilot reported that the accident flight was scheduled as a 20-minute local sightseeing flight, and that it was his last flight of the day. He conducted a normal preflight and reported no issues during the beginning of the flight. While enroute, the pilot noticed fire sparks with smoke on the left side and smoke started to fill the cabin. The pilot opened the left window to disperse the smoke. He did not observe fire, but the smoke continued to accumulate in the cockpit. Shortly after, the engine lost power and the airplane started to shake violently. The pilot decided to return to the airport and made a mayday call to inform the tower of the engine failure. While enroute to the airport, he attempted to restart the engine, but he was unsuccessful. The pilot realized he did not have sufficient altitude to land on the runway and initiated a forced landing to a nearby field. The airplane landed short of the airport perimeter fence. Due to the location of the accident, representatives from the National Transportation Safety Board and Federal Aviation Administration were not available for post-accident examination oversight. A local mechanic and an employee from Sky Guam Aviation, Inc. conducted the post-accident examination of the airplane. They stated that they found evidence of oil around the No.4 engine cylinder and observed that the intake pipes were wet and shiny. They found that the oil dipstick/filler cap was not screwed into the filler neck, and the oil quantity indicated zero. The pilot told them that he checked the oil level before the first flight of the day and had flown the airplane ten more times that day but did not check the oil level prior to those flights. The Pilot's Operating Handbook (POH) required the pilot to check the engine oil quantity and confirm that the oil dipstick/filler cap is secured before each flight.

Aircraft

Registration
N5448K
Reported as
Cessna 172P (P)
Category
Airplane
Serial number
17274115
Built
1980
Airframe hours
9,874.8
Engine
Lycoming O-320 SERIES, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Other work use · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · August 27, 2017
Departed
GUM · Tamuning
Destination
GUM · Tamuning
Airport
GUM · Guam International Airport, runway 06R, 10,014 × 150 ft, asphalt

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
35
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
February 22, 2016
Seat
Right
Flight hours
1,669 total · 1,469 in this make and model · 1,492 as pilot in command · 305 in the last 90 days · 101 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 6 knots
Visibility
10 statute miles
Temperature
79 °F, dew point 77 °F
Altimeter
29.85 inHg
Observed at
PGUM, 1 nm away

Docket · 5

The files NTSB released with the investigation on January 24, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 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.