Pilot Debrief

CESSNA 172K near Pensacola, FL — 2012-03-16

Final reportERA12LA234
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Date
2012-03-16
Location
Pensacola, FL, USA
Aircraft
CESSNA 172K
Registration
N79509
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Maneuvering

Probable cause

A total loss of engine power due to the improper installation of the crankshaft gear bolt or lockplate by maintenance personnel. Contributing to the accident was the lack of suitable terrain for a forced landing.

NTSB narrative

During the training flight, the single-engine airplane was in cruise flight about 1,000 feet above ground level when the engine stopped operating. The flight instructor assumed control of the airplane and unsuccessfully attempted to restart the engine while descending for an emergency landing. He ditched the airplane into a nearby bay. The airplane sustained substantial damage to the windshield during the accident sequence and was submerged in salt water. Postaccident examination of the engine revealed that the bolt or lockplate, which attaches the crankshaft gear to the aft end of the crankshaft, was missing. Further, the alignment dowel was fractured across about one-third of the cross-sectional area. The bolt and lockplate were likely either not installed or were improperly installed, which would allow the bolt to loosen and become disengaged. Measurements of the dowel, pilot flange, and counterbore recess diameters were all within the manufacturer's specifications; the dowel also met the manufacturer's hardness requirement. Because the components were within manufacturer's specifications, it is likely that the components did not have any preexisting wear or manufacturing issues. Additionally, wear marks on the crankshaft, dowel, and gear were likely caused by the newly installed gear and were consistent with either no installation or improper installation of the bolt or lockplate. Therefore, it is likely that when the wear on the dowel had proceeded through about one-third of the cross-section, the stresses in the dowel became sufficiently high to initiate fatigue cracks at the base of the worn part of the dowel and eventually led to a fatigue fracture. The evidence is consistent with the failure of maintenance personnel to install, or properly install, the bolt and lockplate during the engine’s last overhaul, which resulted in the crankshaft gear becoming separated from the crankshaft and a total loss of engine power. If the engine had failed at a point that would have allowed the pilot to land the airplane on land, the airplane damage is less likely to have been substantial; therefore, contributing to the accident was the lack of suitable terrain.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly securing the crankshaft gear with lockplate and bolt during maintenance.

NTSB coding

Evidence available

  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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