NTSB Report on member's accident.

Scott Sherer

Hi everyone,
Some time ago we lost a Cessna member in a Cardinal 177B incident. Here is the NTSB report on that.

Our hearts go out to his family.

johnsouthworth

Scott, thank-you for sharing and my thoughts with the family also. Any reports the NTSB or any other agency, eg CASA, NZ or UK CAA etc, generates have some key intents, one of which is for other aviators/stakeholders to learn and use to modify practises to reduce risk of re-occurance where possible.

The oil spectrum analysis is good practise and it seems likely the cylinder change may have been prompted by the Sept 19 result Although it is hard to second guess I will use this assumption as the tests were conducted a number of times so they were being used and looked at.

For me the learning points would have been as follows. The results prior to the cylinder change were concerning. If the change-out was a response(and I would expect an oil change at that point) to that then a follow up test very soon after would be warranted. This would confirm whether a fix had occured or problems still existed.

The second point is that spectrum analysis can id issues and, for me, should be conducted at each annual. It is the cheapest safety tool in a pilot's tool box.

My final comment, based on some other experiences, troubleshooting is a process. You should never assume that something is rectified without confirmation. Your position should be the problem still exists until I know it doesn't.

Thanks for sharing this. These reports are always sobering but make the reader better equipped.

Scott Sherer

I have a similar conclusion as you do. It's tough to post these things but in the end, it's worthwhile to do so. Thanks for your comments.

Seneca38173

Thanks for posting this. On initial read it’s clearly a tragedy. And from what I read on the web, the pilot was both highly-competent and well-liked. But I have an additional take after having a discussion with my engine shop owner, yesterday.

The clue is the multiple statements from witnesses, who reported the engine was running audibly rough, and that ground roll acceleration was poor. Taken together, these are the telltale symptoms of one (or more) cylinder that’s not cycling the same as the other three. After doing all the easy stuff, like cleaning the nozzles on an injected engine, and verifying the plugs and mags are working right, engine shops have a method for pinpointing the root cause. They’ll check the compressions and borescope from the last annual, and potentially repeat them for confirmation. If that’s all good, they’ll take a closer look at the valves, springs, guides and seats. Finally, they may remove the cylinders and inspect the rings, but I understand a ring problem is rarely the cause. The cause most certainly won’t be lifter spalling or related to the crankshaft, because those have different symptoms.

When you read the preliminary report, you get the impression the NTSB supervised a full teardown and had access to the maintenance logbooks. So why didn’t they investigate and report on the obvious and usual suspects, especially those items they can just copy down from the logbooks? It’s common for rings to fracture in a crash. So why didn’t they send the fractured rings to a materials specialist who can determine how long they had been operating in that state?

I admit we’re all spring-loaded to expect pilot error to play a significant role in most accidents. But we should only reach that conclusion after a thorough investigation. I’m hoping the NTSB will once again demonstrate their reputation for being thorough and unbiased in their final report. They owe it to the pilot and his family.

jacobsja

Most importantly, completely agree that this is not the way any of us want to make the news and it is definitely tragic for the family.

Unless I am missing something, while mechanical failure looks like a contributing factor, it is not the lesson here. My take-away is an old adage: Fly The Plane First!

Engine not developing full power prior to rotation or after rotation with usable runway? Yank the throttle and try to stop / land without overrun. Based on NTSP's narrative, witness reported that the engine complained that it was not at its best from take-off roll to end.

Engine pukes after rotation and below ~800'-ish AGL with no usable runway? Pitch to best glide, look ~45* left / right, pick-yer-poison of a put-down location, pray there is an opportunity to avoid innocent people, and make the loosely defined 'good landing'. Based on NTSB's imagery, the plane got maybe 100' AGL where the narrative states that it might have gotten up to 150'. In any event, it hurts to see where it appears like somebody tried to turn back to the field with such little altitude. I have seen where somebody managed to successfully do a 180* turn from 500' when the engine hard-locked, but IIRC even that pilot stated that he was blessed and surprised. At my home airfield I am resigned that, depending on departure direction, this means I will either get wet (and possibly deal with the threat of hypothermia) or hope that the trees spirits will be kind.

In either of the above scenarios, I recognize that my beloved plane has the potential for turning into scrap.

Yes, I get-it that all of us are now analyzing the Quarterback's play long after the game. Sadly, we will never know the decision making process as this is way more valuable to me than any engine tear-down.

Truly hope that should this happen in my world, that I can push-aside the freak-out reaction and walk the walk.