Sunday, April 28, 2019

Cessna 172M Skyhawk, registered to a corporation and operated by the pilot as a 14 Code of Federal Regulations Part 91 flight, N13306: Accident occurred June 12, 2017 in Suffolk, New York

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Farmingdale, New York

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket - National Transportation Safety Board:

Location: Suffolk, NY
Accident Number: ERA17LA203
Date & Time: 06/12/2017, 0615 EDT
Registration: N13306
Aircraft: CESSNA 172
Aircraft Damage: Substantial
Defining Event: Collision during takeoff/land
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 12, 2017, about 0615 eastern daylight time, a Cessna 172M, N13306, was substantially damaged during a forced landing to a golf course near Suffolk, New York. The private pilot was not injured. The airplane was registered to a corporation and operated by the pilot as a 14 Code of Federal Regulations Part 91 flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan was filed for the personal flight. The flight originated from Brookhaven Airport (HWV), Shirley, New York, and was destined for Bayport Aerodrome (23N), Bayport, New York.

According to the pilot, the purpose of the flight was to purchase fuel at HWV and then return to 23N. While en route to 23N, he heard a "loud pop" and the engine experienced a total loss of power. The pilot checked the fuel selector and mixture, and then searched for a place to perform a forced landing. He declared an emergency, unsuccessfully attempted to restart the engine, and turned toward a golf course. During the landing, the airplane struck a tree, which resulted in substantial damage to the right wing.

According to Federal Aviation Administration (FAA) airworthiness records, the airplane was manufactured in 1973 and was originally equipped with a Lycoming O-320 engine. According to the maintenance records, the engine's most recent overhaul was completed on April 9, 2011. The maintenance log entry detailing the overhaul of the engine stated in-part, "Engine assembled and overhauled per Lycoming maintenance manual." The entry noted that several individual engine components were "overhauled" including the crankshaft and crankshaft gear. Airworthiness approval tags (FAA Form 8130-3) that documented the overhaul of the crankshaft and crankshaft gear noted in the remarks section, "Inspected and/or repaired per Lycoming SB 475 C excluding paragraph 6." The entry also noted the installation of several new parts to the engine, though the installation of a new crankshaft gear bolt and lockplate were not specifically called out. The entry further noted, "All ADs and SBs have been complied with thru 2011-6m." The entry did not explicitly state the final crankshaft gear bolt torque, note and verify the installation and bending of the lockplate against the bolt head, or that the inspections and rework required by Lycoming Service Bulletin Number 475C had been accomplished. At the time the engine was installed on the airplane it accumulated 4,337 hours of total time.

The most engine's recent 100-hour inspection was performed on June 15, 2016. At that time, the engine had accumulated 4,520.5 hours of total time, and 183.5 hours since major overhaul. There was a note in the engine maintenance log dated June 5, 2017, that indicated the engine had 216.5 hours since major overhaul. No other remarks were made next to that date.

Following the accident, the airplane was recovered from the accident site to a local maintenance facility. Fuel was plumbed to the engine and three unsuccessful attempts were made to start the engine. The left magneto was removed from the accessory drive section of the engine and the propeller was turned by hand. No rotation of the left magneto drive gear was noted. Then, the right magneto was removed and the propeller was again rotated by hand with no movement on the right magneto drive gear. Additional inspection revealed that the crankshaft drive gear was displaced from the aft end of the crankshaft. Further disassembly revealed that the crankshaft drive gear retention bolt had backed out about 0.25 inch but had some threads engaged in the crankshaft. The crankshaft gear bolt was removed, and the lockplate was in place and bent around the bolt, as stated in the manufacturer's service bulletin.

The dowel pin was confirmed to be part number STD-1065. Measurement of the remaining portions of the dowel pin found in the drive gear were measured at 0.245-inch, 0.241-inch, 0.240-inch, and 0.234-inch, which were all below the minimum diameter per the manufacturer's service bulletin of 0.3095-inch to 0.3100-inch diameter. In addition, no thread damage was noted on the bolt or the threaded portion of the aft crankshaft counterbore.

The crankshaft drive gear retention bolt was only marked with an "SL GR 8." According to the manufacturer's mandatory service bulletin, the crankshaft gear bolt "must be identified with 4 digit part number on head of bolt," which should have been 2246 for the accident airplane installation.

The crankshaft gear and its attaching hardware were forwarded to the NTSB Materials Laboratory for detailed examination.

According to the Materials Laboratory Factual Report, typically the crankshaft gear was mounted inside a counterbored pilot hole in the aft end of the crankshaft. The gear was pressed against the face of the recess by a bolt that engaged a threaded hole in the end of the crankshaft. A lockplate was installed between the bolt and the gear with ears that fold down against the side of the gear and up against the head of the bolt. The gear was rotationally aligned to the crankshaft by an alignment dowel. The alignment dowel from the accident engine was fractured, one end of the dowel retained inside the alignment hole in the gear, while the other end remained press-fit and retained in the end of the crankshaft.

The piece of the alignment dowel was extracted from the crankshaft gear hole with a punch and the fracture surface cleaned using standard laboratory procedures. The fracture surface, exhibited a flat appearance with multiple curved crack arrest marks progressing across the fracture. Multiple crack origin areas were observed on approximately opposite sides of the fracture. One crack from the origin area on the right covered about 80% of the fracture surface while the crack from the other origin area on the left side covered about 20% of the fracture. The dowel surface exhibited wear marks. On one side of the dowel, the wear had removed approximately 0.015 inch of material while the wear mark on the other side was comparatively superficial. Taken together, the features were consistent with a fatigue fracture of the alignment dowel that initially progressed under unidirectional bending and transitioned to reverse bending.

The pilot flange outer diameter exhibited rubbing damage along its interface with the crankshaft counterbore recess. Rub marks were also seen on the counterbore face of the pilot flange segments and at the interface between the lockplate and the gear. The tab on the locking plate was bent, but the bend was not aligned with the locking tab's plastic hinge.

Lycoming Engines provided guidance in the form of Service Bulletin No. 475C, which detailed procedure for attaching the crankshaft gear to the crankshaft during overhaul, following a propeller strike, or any other time when removal of the crankshaft gear was required. According to the bulletin, "Damage to the crankshaft gear and the counter-bored recess in the rear of the crankshaft, as well as badly worn or broken gear alignment dowels are the result of improper assembly techniques or the reuse of worn or damaged parts during reassembly. Since a failure of the gear or the gear attaching parts would result in complete engine stoppage, the proper inspection and reassembly of these parts is very important. The procedures described in the following steps are mandatory."

After aligning the crankshaft gear with the crankshaft utilizing the alignment dowel, paragraph 6 of the bulletin directed technicians to utilize a new bolt and lockplate, then tighten the bolt to 125 in.-lbs. of torque. The next step ensured proper seating of the gear by directing, "…with a hammer and brass drift, tap lightly around the pilot flange of the gear and listen for sharp solid sounds from the hammer blows that would indicate that the gear is seated against the crankshaft. As a check on the seating against the crankshaft, attempt to insert a pointed .001 inch thick feeler gage or shim stock between the gear and crankshaft at each of the three scallops. The .001 feeler gage, or any smaller feeler gage, must NOT fit between the two surfaces at any location (.001 feeler gage is used as an indicator, however, there must be no clearance between crankshaft and gear.)" Finally, the 5/16-inch bolt would be tightened to 204 in.-lbs. of torque, and the clearance between the outer diameter of the gear flange and the counter-bored pilot (inner diameter) of the crankshaft should measure no greater than 0.0005-inch at any point.

Upon completion of the installation the bulletin specified, "A logbook entry, specifying the final bolt torque, verifying that the lockplate was properly bent in place against the bolt head and that the inspections and rework required by Lycoming Service Bulletin No. 475C were accomplished, should be made and signed by an authorized inspection representative."

Pilot Information

Certificate: Private
Age: 37, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used: Unknown
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 3
Last FAA Medical Exam: 08/01/2012
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:

Aircraft and Owner/Operator Information

Aircraft Make: CESSNA
Registration: N13306
Model/Series: 172 M
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17262654
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 06/05/2017, 100 Hour
Certified Max Gross Wt.: 2299 lbs
Time Since Last Inspection:
Engines:  1 Reciprocating
Airframe Total Time: 4746.2 Hours at time of accident
Engine Manufacturer: LYCOMING
Engine Model/Series: O-320 SERIES
Registered Owner: YWP AIR INC
Rated Power: hp
Operator: YWP AIR INC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: ISP, 84 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 0556 EDT
Direction from Accident Site: 291°
Lowest Cloud Condition: Few / 25000 ft agl
Visibility:  8 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 240°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 30.02 inches Hg
Temperature/Dew Point: 20°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SHIRLEY, NY (HWV)
Type of Flight Plan Filed: None
Destination: BAYPORT, NY (23N)
Type of Clearance: None
Departure Time:
Type of Airspace:

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 40.750556, -72.948333 (est)

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