Pilot Debrief

DEHAVILLAND TIGER MOTH DH 82A near Fontana, CA — 2012-06-24

Final reportWPR12LA275
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Date
2012-06-24
Location
Fontana, CA, USA
Airport
RIR
Aircraft
DEHAVILLAND TIGER MOTH DH 82A
Registration
N523R
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Initial climb

Probable cause

Partial loss of engine power during cruise flight due to a failed engine cylinder rocker assembly clamping bolt. Contributing to the accident was the failure of unknown maintenance personnel to perform a modification to the assembly that would have prevented the failure.

NTSB narrative

During cruise flight, the engine lost partial power. The pilot performed a forced landing into a field, and the airplane nosed over. Postaccident examination of the engine revealed that a rocker bracket assembly clamping bolt had failed in fatigue, causing the assembly to partially detach from the cylinder head. The detachment prevented the exhaust valve from actuating. Peening damage sustained to the bolt revealed that it most likely failed during a prior flight, at an undetermined time before the ultimate displacement of the bracket assembly. No airworthiness directives existed for the antique engine, which was overhauled 46 years prior to the accident. However, a “modification news sheet” was issued by the manufacturer 16 years before the overhaul, which detailed a design change intended to preclude the failure of the clamping bolts. The modification was not performed on the failed cylinder; however, the three other cylinders exhibited an undocumented modification to their rocker valve assemblies, which appeared to perform the same function.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have checked engine performance before takeoff.

NTSB coding

Evidence available

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

Docket documents10

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