Cessna Crash NTSB
MIA05LA046
HISTORY OF FLIGHT
On January 11, 2005, about 1647 eastern standard time, a Cessna 172M,
N9336H, registered to Grady and Francis, Inc., operated by CAP Flying, Inc.,
experienced a total loss of engine power and collided with wires and a power
line pole while descending for a forced landing near Orlando, Florida.
Visual meteorological conditions prevailed at the time and no flight plan
was filed for the 14 CFR Part 91 instructional, local flight, from the
Orlando Executive Airport, Orlando, Florida. The airplane was substantially
damaged and the certified flight instructor (CFI) was fatally injured, while
the pilot-rated student (student) sustained serious injuries. The flight
originated about 1526, from the Orlando Executive Airport.
According to a transcription of communications with Orlando Executive
Airport (KORL) Air Traffic Control Tower (ATCT), the CFI contacted the
facility at 1639:36, and advised the controller, "yeah we are about 8 miles
northwest of you ah we are showing no oil pressure we are coming in we would
like to ah do a straight in on one three." The controller cleared the flight
for a straight in landing on runway 13, which was acknowledged. The flight
continued and at 1641:48, the controller stated, "cessna three six hotel I
just want ah to verify you are ah having you are getting no oil pressure
indication or low oil." The CFI responded, "ah looks like zero oil
indication", which the controller acknowledged. At 1642:01, the controller
advised the flight crew that the equipment was responding and, "you will see
them standing by"; the CFI acknowledged that transmission. At 1644:39, or 5
minutes 3 seconds after the CFI first advised the controller of having no
oil pressure, the CFI stated, "executive tower niner three three six hotel
just had an engine failure ahm looks like we are coming in on runway one
three." The controller advised the flight crew that they were number one
cleared to land on runway 13, and provided wind information. At 1645:01, the
CFI stated, "doesn't look like we're going to make the runway so we are
going to turn around for the golf course." The controller acknowledged that
transmission, and established contact with a news helicopter that was
airborne in the area at 1645:34. The controller requested that the flight
crew of the helicopter maintain visual contact with the aircraft and track
the flight for him. At 1647:03, a flight crew member of the news helicopter
advised the controller, "... he just crossed Edgewater high real bad."
The student seated in the left seat stated in writing that they had been
practicing commercial maneuvers, and after completion, decided to return to
the airport for some 180-degree power off approaches. On the flight back to
the airport he smelled something burning, which "... triggered me to look at
my gauges and notice that we had no oil pressure." The CFI contacted the
KORL ATCT, and advised the controller of the situation. Both he and the CFI
continued to look for a place to land if required, and the flight climbed a
little bit to have more altitude to allow for a longer "glide time." He
reported that a few minutes passed, and they started a slow descent for the
airport. When leaving approximately 2,000 feet, the engine quit. The CFI
took the controls of the aircraft, and advised the controller of the engine
failure and his intention to land on a golf course. He (student) turned off
the fuel, mixture, magnetos, and the alternator, but left the battery on for
communications. When the flight was close to the ground "...we realized that
we were going to have to make a steep approach. Dan put in all the flaps and
did his best to fly down the fairway, keeping clear of all people and
obstacles. Dan made a last minute decision to go to the left to possibly fly
and land on the road, when we collided with the power lines, then the power
pole which is where we came to rest. I remember very little after that."
The student verbally advised the Federal Aviation Administration (FAA)
inspector-in-charge (IIC) that no oil was noted on the windscreen or on the
sides of the airplane after noting there was no oil pressure. He also
reported beginning to descend when the flight was approximately 4 miles
northwest of KORL, and while flying at an altitude of approximately 1,500
feet, the engine began to vibrate then failed. The CFI took the controls and
maneuvered the airplane towards the Dubsdread Golf Course which was to the
left of their position at the time of the engine failure. The CFI made
several s-turns to lose altitude, an approached the golf course fairways
from an easterly to westerly direction. It appeared that the aircraft was
going to overfly the point of intended landing, but the CFI did not slip the
aircraft to lose altitude. The flight crossed trees at the easterly end of
the golf course fairways, and was too high. The CFI maneuvered the aircraft
in an attempt to find a suitable location to land, and the left-wing
collided with wires causing the airplane to rotate approximately 90 degrees
to the right. He did not see the wires prior to the collision, and does not
remember the collision with the power pole.
PERSONNEL INFORMATION
The left seat occupant is the holder of a commercial pilot certificate with
airplane multiengine land, and instrument airplane ratings. He also holds a
single-engine land rating at the private level. He was issued a first-class
medical certificate on May 27, 2003, with no limitations. He listed on the
NTSB "Pilot/Operator Aircraft Accident Report" that he had a total flight
time of 654 hours, of which 175 were in the accident make and model
airplane.
The right seat occupant was the holder of a commercial pilot certificate
with airplane single-engine land, airplane multiengine land, and instrument
airplane ratings. He was also the holder of a flight instructor certificate
with airplane single-engine, and instrument airplane ratings. He was issued
a first-class medical certificate on September 2, 2004, with a restriction
"must wear corrective lenses." He listed a total time of 1,620 hours on the
last medical certificate application.
AIRCRAFT INFORMATION
The airplane was manufactured by Cessna Aircraft Company in 1975, as a 172M,
and designated serial number 17266094. It was certificated in the normal and
utility categories, and was equipped with a 150 horsepower Lycoming
O-320-E2D engine, and a McCauley 1C160/DTM7553 fixed pitch propeller.
The airplane and engine were last inspected on November 4, 2004, when they
received a 100-hour inspection. At the time the accident, the airplane had
accumulated approximately 91 hours since the last inspection, and 6, 620
total flight hours.
METEOROLOGICAL INFORMATION
A METAR weather observation taken at the Orlando Executive Airport, Orlando,
Florida, at 1653, or approximately 6 minutes after the accident, indicates
the wind was from 190 degrees at 3 knots, the visibility was 10 statute
miles, scattered clouds existed at 6,000 feet, the temperature and dewpoint
were 26 and 15 degrees Celsius, respectively, and altimeter setting was
30.18 inHg.
COMMUNICATIONS
There were no reported communication difficulties.
WRECKAGE AND IMPACT INFORMATION
Examination of the accident site and wreckage by an FAA Aviation Safety
Inspector revealed the airplane came to rest at the base of a concrete power
pole located at 28 degrees 34.94 minutes North latitude and 081 degrees
22.96 minutes West longitude. The airplane was recovered for further
examination.
Examination of the airplane and engine following recovery was performed by
representatives of the airframe and engine manufacturer with NTSB and FAA
oversight. The examination of the airplane revealed no evidence of flight
control preimpact failure or malfunction; the flaps were fully extended. The
right side of the cabin, and the airplane forward of the instrument panel
was crushed. Both front seats remained attached to the seat rails but were
impact damaged. The right seat was noted to be positioned aft of the left
front seat.
The exterior surface of the fuselage bottom skin was noted to have a thin
film of oil, and the engine cowling was noted to have a fresh oil stain in
the vicinity of the oil dipstick opening. The upper portion of the oil
dipstick tube remained secured to the engine by safety wire; the threads of
the tube that screw in the lower tube were damaged. A crack was noted in the
threaded area of the lower tube. The engine oil dipstick was bent
approximately 90 degrees. Oil was also noted on the right rear interior
surfaces of the engine cowling, on the back of the engine, and on the
firewall; however, very little oil was noted on the engine forward of the
pressure of baffling.
The oil cooler, both flexible hoses connected to it, and the flexible oil
pressure hose were removed and checked for leaks using compressed air. The
oil pressure indicator hose, oil cooler, and the "Hose Assy Cooler To
Engine" did not leak when checked using compressed air; the flexible oil
pressure hose was noted to have a data tag indicating "3Q79." The flexible
hose "Hose Assy Engine To Cooler", Cessna P/N S1167-6-0260, was noted to
have a leak near the oil cooler end when tested for leaks using compressed
air; the hose was retained for further examination. The engine was removed
from the airplane for further examination.
Examination of the engine revealed 10 ounces of oil were drained from the
oil sump; ferrous material was noted in the bottom of the sump. The engine
could only be rotated through approximately 25 degrees before resistance was
encountered; continuity to the accessory case was noted during the partial
rotation of the engine. The oil suction screen was noted to have
contamination that was consistent with silicon rubber. Ferrous material was
noted in the oil filter canister.
Disassembly of the engine revealed no damage to the camshaft, lifters,
pushrods, valve rockers, valve springs, valves, or oil pump. The No. 2
cylinder connecting rod was separated from the crankpin; the crankpin and
connecting rod exhibited evidence of high heat. The connecting rod cap was
fragmented and one of the connecting rod bolts was bent and fractured. The
remains of a separated connecting rod bolt and bearing shell material were
found in the crankcase. Examination of the remaining connecting rod bearings
revealed the surface conditions were, "...best described as 'wiped'." No
damage was noted to the main or camshaft bearings. No obstructions were
noted in the crankcase oil galleys, camshaft bearing oil passages, or the
passages to the hydraulic tappet bodies.
MEDICAL AND PATHOLOGICAL INFORMATION
A postmortem examination of the CFI was performed by the District Nine
Medical Examiner's Office, Orlando, Florida. The cause of death was listed
as blunt trauma to head and torso.
Toxicological analysis of specimens of the CFI was performed by the
Wuesthoff Reference Laboratory (Wuesthoff), Melbourne, Florida, and the FAA
Toxicology And Accident Research Laboratory (CAMI), Oklahoma City, Oklahoma.
The result of analysis by Wuesthoff was negative for the immunoassay screen,
and volatiles; caffeine was detected. The result of analysis by CAMI was
negative for carbon monoxide, cyanide, volatiles, and tested drugs.
TESTS AND RESEARCH
Following manufacture of the engine, it was shipped to Cessna Aircraft
Company on May 17, 1974, where it was installed in another airplane
(N1641V). The engine remained installed in that airplane until removed for
overhaul on an unspecified date after June 25, 1982. The engine was
overhauled on August 18, 1982, and installed in the accident airplane on
August 27, 1982. The entry in the engine logbook for that date indicates
"replaced all flammable fluid carrying hoses...." The engine remained
installed in the accident airplane until it was removed for overhaul again
on an unspecified date after February 1, 2001. The engine was signed off as
being overhauled on March 9, 2001, and installed in the accident airplane
the following day. The engine remained installed in the airplane from March
10, 2001, until postaccident removal. There was no entry in the airframe or
engine logbooks indicating the oil cooler hoses had been replaced since
1982; the airplane had accumulated approximately 4,652 hours since the
"flammable fluid carrying hoses" were changed.
According to the mechanic who had maintained the airplane since January
2000, and installed the engine following overhaul in 2001, he reportedly
manufactured and installed replacement oil cooler hoses when the overhauled
engine was installed. He also reported it was common practice for him to
replace all engine compartment rubber hoses when an engine is installed
following overhaul. He obtained the hose material from 11-foot sections of
hose he obtained from "API" or "Air Parts of Miami."
The Lycoming Engine Overhaul Manual, Section 3, "General Overhaul
Procedures", indicates all engine hoses are to be replaced at normal
overhaul regardless of their apparent condition, and references Service
Bulletin No. 240 for further information. A note in the airplane maintenance
manual indicates that rubber engine compartment hoses are to be replaced
every 5 years or at engine overhaul, whichever occurs first.
A marking on the failed "Hose Assy Engine to Cooler", Cessna P/N
S1167-6-0260, indicates "3Q81", or 3rd Quarter 1981. Review of the
engineering drawing for the hose revealed a requirement that hoses have the
"Cure Date of Hose Used In Hose Assembly" legibly marked.
Examination of the "Hose Assy Engine To Cooler", Cessna P/N S1167-6-0260,
which was noted to have a leak, was performed by the NTSB Materials
Laboratory, located in Washington, D.C. A crack approximately .7 inch in
length was located approximately 4.25 inches from the oil cooler adapter
end. The crack was oriented "slightly away from the longitudinal axis."
Bench binocular microscope (BBM) examination of the hose revealed the woven
fiber strands were missing in the cracked area. Scanning electron microscope
(SEM) and BBM examination of the face of the crack revealed the thickness of
the outer layer of rubber was reduced, and a portion of the reduced outer
layer of rubber that was located midspan of the crack was missing.
Additionally, the fiber strands that were located between the inner and
outer rubber layers were fractured. The inner layer of rubber was found to
contain fracture lines that emanated from the outer surface layer in an area
that contained an impression of fiber strands from the fibers between the 2
rubber layers. The lines on the surface crack indicated that cracking of the
inner layer propagated towards the inner diameter of the hose; cracking on a
flat plane was noted to within .01 inch of the inside surface of the hose.
Examination of other areas of the inside surface of the hose revealed
extensive longitudinal cracks. Additionally, the exterior surface contained
abrasion damage in three areas other than the cracked area of the hose; the
abrasion damage did not extend through the outer layer of rubber.
A review of the "Pilot's Operating Handbook" revealed an emergency procedure
dealing with "Low Oil Pressure." The amplied procedure indicates, "If a
total loss of oil pressure is accompanied by a rise in oil temperature,
there is good reason to suspect an engine failure is imminent. Reduce engine
power immediately and select a suitable forced landing field. Use only the
minimum power required to reach the desired touchdown spot."
ADDITIONAL INFORMATION
The wreckage minus the retained flexible hoses to and from the oil cooler
was released to Buck Williams of Sample International, Inc., on January 13,
2005. The retained hoses were also released to Buck Williams on October 4,
2005.
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