Pilot Debrief

CESSNA 150 near San Juan, PR — 2024-06-01

Final reportERA24LA239
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Date
2024-06-01
Location
San Juan, PR, USA
Airport
SIG
Aircraft
CESSNA 150
Registration
N6198K
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Initial climb

Probable cause

A partial loss of engine power due to the failure of the No. 2 cylinder rocker shaft bosses from fatigue cracking.

NTSB narrative

The student pilot and flight instructor reported that the engine lost power shortly after takeoff. ADS-B data showed that the airplane reached a maximum altitude of 213 ft above ground level (agl) before entering a descending left turn back toward the runway. The airplane impacted the ground before reaching airport property. Examination of the wreckage found substantial damage to the engine mounts, fuselage, both wings, the right horizontal stabilizer, and elevator. Examination of the engine revealed that the rocker shaft bosses for the No. 2 cylinder had failed. Metallurgical examination found that a portion of the cylinder head, which contained the rocker arm shaft, fractured due to fatigue cracking that had initiated along the bore for the shaft. Once this section of the cylinder head fractured, the remainder of the cylinder head holding the rocker shaft fractured from overstress, freeing the shaft and rocker arms. These fractures would prevent the proper function of the drivetrain, preventing the valves from opening and leading to the failure of the No. 2 cylinder. The housing boss bore walls exhibited wear significant enough to allow for movement of the bushings and shaft. The bore exhibited wear marks consistent with rotational and lateral movement of the shaft, and the adjacent bushings exhibited lateral wear marks. Many of these marks matched those observed on the shaft, indicating movement along these surfaces. This uneven wear likely led to the rocker arms pushing erratically on the valves, as evidenced by the off-center wear marks on the rocker arm and valve stem faces. This uneven movement and wear likely led to wobbling and sliding. This created more wear, which eventually resulted in fatigue cracking and the subsequent failure of the rocker shaft bosses. A review of maintenance records was unable to determine the number of hours on the cylinder. The review found no record of the No. 2 cylinder being removed and reinstalled on the engine. While the logs described that about 7 years before the accident three unspecified cylinders had been removed and replaced, no information regarding which position they were installed to, or their serial numbers were recorded. The engine was subject to an FAA airworthiness directive (AD), which stated that the cylinder rocker shaft bosses must be inspected “At the next cylinder removal from the engine, or engine overhaul, whichever occurs first, after the effective date of this AD, inspect the cylinder rocker shaft bosses for cracks….” Based on the records, it could not be determined whether the No. 2 cylinder had been inspected in accordance with the AD.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Inspection of engine components prior to the flight could have prevented the failure.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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