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NTSB Report

July 28, 2011 · Cessna 172M · N1443U

Pahokee, FL

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
July 28, 2011
Injury Outcomes
1 injury (1 minor injury), 1 uninjured
Location
Pahokee, FL
Aircraft
Cessna 172M
Tail Number
N1443U
Operator
Atp Aircraft 2
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
ERA11LA429

The flight instructor stated that, as the airplane climbed through about 500 feet above the ground after takeoff on the intended dual instructional cross-country flight, the engine started shaking, sputtering, and making “alarming” noises. The flight instructor took control of the airplane, noted nothing abnormal with the mixture, fuel selectors, engine instruments, or fuel quantity, and decided to return to the departure airport to land. The flight instructor noted that there was not a total loss of engine power, but it was not possible to maintain the airplane’s altitude. When the flight instructor realized that the airplane was too high and too fast to land on the intended runway, she moved the throttle to idle; however, she did not use flaps or slip the airplane to reach the runway. The airplane overflew the entire length of the runway, and the flight instructor elected to land the airplane in a lake on the left to avoid obstacles straight ahead and on the right. Postaccident examination of the engine revealed that the No. 3 cylinder exhaust valve head had sheared off at the stem. The stem, spring, and rocker arm were still intact, and the No. 3 piston exhibited signs of mechanical damage from the sheared head inside the combustion chamber. At the time of the accident, the engine had 2,229.5 hours of operation since major overhaul. The engine manufacturer's recommended time between overhauls was 2,000 hours.

NTSB Probable Cause

The flight instructor's misjudgment of the airplane's position and airspeed relative to the runway while returning to the airport after a partial loss of engine power. Contributing to the accident was the separation of the engine's No. 3 cylinder exhaust valve head from the stem, and the operator’s exceedence of the engine manufacturer's recommended time between overhauls.

Full Narrative

On July 28, 2011, about 1200 eastern daylight time, a Cessna 172M, N1443U, was substantially damaged during a forced landing in Lake Okeechobee, near Pahokee, Florida. The certificated flight instructor was not injured and the certificated student pilot incurred minor injuries. Visual meteorological conditions prevailed. No flight plan had been filed for the flight, between Palm Beach County Glades Airport (PHK), Pahokee, Florida, and Fort Lauderdale Executive Airport (FXE), Fort Lauderdale, Florida. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the flight instructor, the accident flight was part of a series of cross country and student solo flights that day. Upon arrival at PHK, three practice landings were completed before a full stop landing. During a subsequent takeoff for FXE from runway 17, with winds from 100 degrees magnetic at 10 knots, the student pilot was at the controls. All of the gauges were "in the green," and the fuel tanks were half full. After the takeoff and a straight-out departure, as the airplane reached 500 feet, the engine started shaking, sputtering, and making "alarming" noises. The flight instructor immediately took control of the airplane, and quickly glanced at the mixture, fuel selectors, engine instruments, and fuel, without noting anything abnormal. The flight instructor then turned the airplane back toward runway 35, and transmitted via radio an engine failure, but saw that the engine did not completely quit. Instead, it was not producing any thrust, and the airplane could not maintain altitude. The flight instructor also stated that after turning the airplane back toward runway 35, she realized that it was too high and too fast. She pulled out the throttle; however, she did not use flaps or attempt to slip the airplane. The airplane then overflew the entire length of the runway, and the flight instructor had to consider other options. In front of her was a house, to the right was a road lined with power lines, and to the left was the lake. The flight instructor then turned the airplane over the lake, and "floated" it as long as possible before it touched down and nosed over. The flight instructor and student pilot exited the airplane and waited on its belly until rescue. After its removal from the lake, Federal Aviation Administration (FAA) inspectors and flight school maintenance personnel examined the airplane and the Lycoming 0-320-E2D engine, and found that the No. 3 cylinder exhaust valve head had sheared off the stem. The stem, spring and rocker arm were still intact, and the No. 3 piston exhibited signs of mechanical damage from the sheared head inside the combustion chamber. The airplane's engine was last inspected during a 100-hour inspection on July 21, 2011. According to the logbook entry, at that time, the engine had accrued 2,211.8 hours of operation since major overhaul. At the time of the accident, hours of engine operation since major overhaul were 2,229.5. According to Lycoming Service Instruction 1009AU, dated November 18, 2009, recommended time between overhauls of the O-320-E engine is 2,000 hours.

Flight

Event TypeAccident
Event Time12:00 EDT
Nearest AirportPalm Beach County Glades (1nm)
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCessna 172M
Tail NumberN1443U
Aircraft CategoryAir
DamageSubstantial
OperatorAtp Aircraft 2
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsLycoming · 0-320 SERIES · Reciprocating · 180
Seats4

People & Injuries

Injury Summary1 injury (1 minor injury), 1 uninjured
Fatal0
Serious0
Minor1
Uninjured1
Total2
Crew 1Age 21 · First Class · None
Crew 2Age 23 · First Class · Minor

Conditions

ConditionsVMC
LightDaylight
Wind100° @ 10 kt, gusting 19 kt
Visibility10 sm
CeilingNone
Altimeter29.97 inHg
Observation Time16:00
Weather SourcePILO

Appendix: Source Data