WPR23LA199

NTSB accident investigation · Cessna 172S · Casa Grande, AZ · May 24, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
May 24, 2023, 09:00 local (16:00 UTC)
Place
Casa Grande, AZ
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N60372Cessna 172S
Defining event
Approach: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
192231

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

An in-flight separation of the throttle linkage, which resulted in a loss of throttle control. Contributing to the accident was maintenance personnel’s failure to follow the maintenance manual inspection procedure for the throttle cable assembly.

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.

Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelCessna 172S: 1 caseAll aircraft: 167 casesProbable cause
Engine controls: power leverAircraft › Aircraft power plant · MalfunctionCessna 172S: 2 casesAll aircraft: 95 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 and safety pilot departed to practice simulated instrument approaches at a local airport. As they approached the airport, they observed that the throttle was in the full open position but the tachometer indicated 1,900 rpm. The safety pilot, a certificated flight instructor, took control of the airplane and attempted to cycle the throttle but was unsuccessful in his attempt to restore engine power. The engine speed remained at 1,900 rpm for the remainder of the flight regardless of the throttle position. During the emergency landing at the airport, the airplane touched down at a high rate of speed. The safety pilot reduced the mixture control to idle/cutoff and landed in a field at the end of the runway. The airplane impacted a tree, which resulted in substantial damage to the left wing. Postaccident examination of the airplane revealed that the throttle linkage had separated from the throttle arm. The threads on both the linkage and threaded section of the arm were intact and both jamnuts were loosely threaded to the linkage. The absence of any damage to the throttle assembly suggests that the linkage likely unthreaded itself from the throttle arm during the accident flight, which resulted in a loss of throttle control. The separation likely developed over the course of the airplane’s 680 flight hours since the throttle linkage was installed and should have been discovered during one of the subsequent required 50-hour inspection intervals or the airplane’s most recent 100-hour inspection. However, none of these inspections were accomplished in the 680 hours of operation.

Factual narrative

On May 24, 2023, about 0900 mountain standard time, a Cessna 172S, N60372, was substantially damaged when it was involved in an accident near Casa Grande, Arizona. The pilot and pilot-rated passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he was flying under simulated instrument flight rules using a view limiting device with a safety pilot (pilot-rated passenger) onboard. The safety pilot, who was also a certified flight instructor, stated that after one approach into Casa Grande airport (CGZ) they entered a hold at 5,500 ft mean sea level (msl). According to the safety pilot, they were operating in an area of uncontrolled airspace that was popular for instrument training, and each aircraft used the Common Traffic Advisory Frequency (CTAF) at CGZ to report when they were established in the hold, when they were descending in the hold, and when they left the hold to begin an approach. During the accident flight, the pilot descended to 5,000 ft msl after the other aircraft had announced their movements over the CTAF. After the airplane leveled out, the safety pilot observed a decrease in airspeed and noted that the throttle was in the full open position, but the engine speed was only 1,900 rpm. The pilot then advanced the mixture to the full rich position, engaged the fuel boost pump, and cycled the throttle, but did not observe any changes in engine power. At this time, the safety pilot announced over CTAF that they had experienced an engine anomaly and were heading direct inbound to CGZ to land the airplane. They reached the airport at 3,000 ft msl, at which point they started a circling descent. The safety pilot reported that the engine speed was still about 1,900 rpm when they turned to the final approach leg of the airport traffic pattern. The pilot also attempted to reduce throttle but was unsuccessful. They deployed flaps to slow the airplane while the safety pilot (who was now the pilot flying) started to assess landing options as they were unable to decelerate. After he decided to land in a field at the end of runway 5, he reduced the mixture to idle/cutoff and the engine stopped running. The airplane touched down normally in the field, but during the landing roll it impacted a fence, and the left wing subsequently impacted a tree, which resulted in substantial damage to the left wing and fuselage. Postaccident examination of the engine revealed that the throttle linkage had separated from the throttle arm at the fuel servo. Figure 1: Throttle linkage and throttle arm The throttle system can be advanced and retarded for power adjustments. Throttle action is achieved through a cable that connects the throttle lever to the throttle arm of the fuel servo mounted at a plenum below the oil sump. The throttle linkage is threaded into the rod end attached to the throttle arm. (See figures 1 and 2). Figure 2: Throttle linkage installation frommaintenance manual The airplane maintenance manual includes inspection criteria for the throttle control. According to the manual, the engine throttle assembly should be inspected every 50 hours. “Engine Controls and Linkage – Examine the general condition and freedom of movement through the full range. Complete a check for the proper travel, security of attachment, and for evidence of wear. Complete a check of the friction lock and vernier adjustment for proper operation. Complete a check to make sure the throttle, fuel mixture, and propeller governor arms operate through their full arc of travel. The maximum linear freeplay is 0.050 inch.” According to the engine logbook, the engine’s most recent major overhaul was completed 8 months before the accident, which was likely the last time the linkage would have been installed. The airplane’s last annual inspection predated the engine installation. A review of the maintenance records showed that the throttle linkage assembly inspection was not inspected in the timeline prescribed by the manufacturer. Further, the mechanic who had performed all of the subsequent maintenance after the engine overhaul and installation reported that he was not aware of the inspection interval for the throttle linkage. After reconnecting the throttle linkage to the arm, the engine operation was smooth and continuous when tested at run-up power and no mechanical anomalies were noted.

Aircraft

Registration
N60372
Reported as
Cessna 172S
Category
Airplane
Serial number
172S10216
Built
2006
Airframe hours
12,905
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 9, 2022 · 749 hours before
Departed
CHD · Chandler, AZ
Destination
Same as departure
Flight plan
VFR
Airport
CGZ · Casa Grande Muni, runway 05, 5,200 × 100 ft
Equipment
ADS-B, Auto-pilot, 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
Pilot
Age
59
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
March 24, 2023
Seat
Left
Restraint
3-point
Flight hours
250.7 total · 65.8 in this make and model · 170.1 as pilot in command · 22.1 in the last 90 days · 10.7 in the last 30 days
Role
Pilot
Age
22
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
October 15, 2020
Seat
Right
Restraint
3-point
Flight hours
1,233 total · 50 in this make and model · 1,129 as pilot in command · 142 in the last 90 days · 60 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 37 °F
Altimeter
29.91 inHg
Observed at
KCGZ, 1 nm away
METAR
KCGZ 241556Z AUTO 15003KT 10SM CLR 28/03 A2991 RMK AO2 SLP111 T02830033 PNO $

Docket · 13

The files NTSB released with the investigation on June 20, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.2 MB in all.