# NTSB WPR17LA216: Cessna 172P, N5448K, Tamuning, September 25, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 25, 2017 - Place: Tamuning - Coordinates: 13.477777, 144.777496 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=13.4778&lon=144.7775&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Western Pacific Region - NTSB case key (mKey): 96149 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17LA216 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96149/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96149 - Page: https://openairdocs.org/ntsb/WPR17LA216 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Eng oil sys (airframe furnish): quantity](https://openairdocs.org/ntsb-findings/01057932): Aircraft › Aircraft power plant · Not inspected (probable cause); cases with it: [Cessna 172P, 1 case](https://openairdocs.org/ntsb-findings/01057932/cases.md?model=2072436), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/01057932/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 172P, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2072436), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Cessna 172P, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=2072436), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 172P, 14 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072436), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## 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](https://openairdocs.org/deregistered/N5448K-2019-09-06), registration cancelled 2019-09-06, S/N 17274115, built 1980 (OpenAirDocs) - Reported make and model: CESSNA 172P (P) - Registry model: [Cessna 172P](https://openairdocs.org/model/cessna-172p) (registry code 2072436) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17274115 - Year built: 1980 - Airframe hours: 9874.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: none; 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 ## 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 20170925024089A](https://openairdocs.org/incident/20170925024089A), Sep 25, 2017: Cessna 172P, Barrigada, GU, Substantial damage. Aircraft was on 20 minute local sightseeing flight. After take-off, proceeded to two lovers point, held for other traffic over tumon bay for @ 5 minutes, then… ## Docket (5 files) The files NTSB released with the investigation on January 24, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96149. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 546 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480225&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480226&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Post-Accident Exam (item 3, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480227&FileExtension=.PDF&FileName=Post-Accident%20Exam-Master.PDF - Preflight - Oil Check (POH Excerpt) (item 4, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480228&FileExtension=.PDF&FileName=Preflight%20-%20Oil%20Check%20(POH%20Excerpt)-Master.PDF - Photos from FAA (item 5, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480229&FileExtension=.PDF&FileName=Photos%20from%20FAA-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.