St. Johns, AZ, USA
N3487T
CESSNA 177
The certified flight instructor (CFI), pilot undergoing instruction (PUI), and one passenger were departing from an airport with a density altitude of 8,690 feet mean sea level. The fuel tanks were filled to maximum capacity, and the estimated gross weight was about 130 pounds less than the maximum gross weight. During the takeoff, a witness at the airport observed that as the airplane traveled down the runway there was no change in engine sound. The witness further stated that as the airplane lifted out of ground effect , it did not climb any higher. It continued down the runway and at its end, the witness saw the airplane stall and turn to the left, prior to ground impact. The PUI reported that during the takeoff, “We used virtually the entire runway for takeoff.” The PUI was focused on obstacles ahead of the runway and notified the CFI that they had cleared the obstacles. The PUI indicated that the CFI then assumed control of the airplane and entered the airplane into a climb to clear additional obstacles. The PUI stated that as the flight controls were pulled back it felt like they had less available power, most likely due to the attitude of the airplane. The airplane then collided with obstacles. Post accident engine examination showed that the intake lifter for the Number 4 cylinder camshaft lobe was worn and the follower was heavily pitted. Both the intake and exhaust lifter for the Number 3 cylinder were heavily scored and the corresponding camshaft lobes were heavily worn. While the exact amount of degradation to the engine's power output could not be established, the alteration of the cam lobe profile will alter the amount and duration of the valve opening, thus affecting power output. The engine was overhauled 10 years prior to the accident and had accrued about 330 hours during this time. Although the engine's storage history for the last 10 years could not be determined, the amount of corrosion and pitting found make it highly likely that the internal engine components corroded due to inadequate lubrication resulting from lack of consistent operation. Lycoming Service Letter L180B states that, "Engines in aircraft that are flown only occasionally may not achieve normal service life because of corrosion." A Lycoming publication states that, “Corrosion is a known cause of tappet and cam lobe wear. The engines of aircraft that are not flown regularly may be extremely vulnerable to corrosion...Once started, the process is not likely to stop until it reaches a point where these parts are doing an unacceptable job.”
HISTORY OF FLIGHT On August 16, 2008, at 1545 mountain standard time, N3487T, a Cessna 177, collided with terrain during takeoff from St. Johns Industrial Airpark, St. Johns, Arizona. The pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91. The certified flight instructor (CFI) survived the accident but later died, succumbing to his injuries. The private pilot undergoing instruction (PUI) and one passenger were seriously injured. The airplane sustained substantial damage. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed. The pilot departed from Grants-Milan Municipal Airport, Grants, New Mexico, and was destined for Falcon Field, Mesa, Arizona. Prior to the flight, flight service was contacted and the caller requested activation of a previously filed flight plan and an “update briefing.” The CFI’s name was listed as the pilot on the flight plan. The flight plan was then activated from Grants, New Mexico, to Falcon Field, with a fuel stop in St. Johns. St. Johns is located about 80 miles from Grants. The briefer advised the caller that there were thunderstorms developing near his route of flight. The caller then said, "We should load up and go." During the later portion of the briefing, the caller was overheard talking to another person as the briefer gave the briefing, and the briefer also queried the caller multiple times to confirm if he was still on the line and received the information that the briefer was providing. According to fueling personnel at the St. Johns Industrial Airpark who witnessed the accident, the airplane landed about 1520. During the landing, the airplane bounced on the runway and the engine lost power. The pilot could not restart the engine so the airplane was towed to the fueling area. The fuel tanks were filled to capacity (36.2 gallons were added), the engine started without difficulty, and the pilot then departed at 1545. The witness saw the airplane go down runway 14 and there was no change in the sound of engine power. The airplane lifted out of ground effect and did not climb any higher. It continued down the runway and at its end, the witness saw the airplane stall and turn to the left, prior to ground impact. Following the accident, the PUI’s father stated that due to their injuries, the PUI and passenger were unable to provide statements about the accident circumstances. The PUI’s father did speak with his son about the accident and stated that the PUI had obtained his pilot certificate a couple of weeks prior to the accident, and the CFI was flying with him due to the PUI’s inexperience and flying in mountainous terrain. The PUI was seated in the left front seat, and the CFI was seated in the right front seat. The PUI’s wife was seated in the back seat. Additionally, the PUI told his father that during the takeoff, the airplane was not gaining altitude and as it started to descend, the PUI gave the controls to the CFI and they were attempting to land on a nearby street. During the forced landing, they impacted a power line pole and then the right wing impacted a vehicle. The PUI felt that he must have lost consciousness momentarily and when he woke up, the cockpit was filled with smoke and flames and he was on fire. He got out of the airplane and rolled on the ground. He was unsure how the CFI and the passenger were able to get out of the airplane. Members of the Boeing Flight Club stated that the CFI and PUI had attended a pilot meeting with club members prior to the accident flight. During the meeting, they discussed the flight and how it would be conducted. The CFI had scheduled a flight with another student prior to the accident flight, and was also scheduled to fly with a student following the accident flight. According to one of the members, St. Johns was a popular fuel stop due to the low fuel prices. On September 29, 2009, the PUI submitted a written statement regarding the circumstances of the event. He reported that the purpose of the flight was instructional for the PUI to obtain proficiency in the Cessna 177 and become familiar with the route of flight from Mesa, Arizona, to Grants, New Mexico. During the flight to Grants, they landed at St. Johns for a short break, then departed runway 3 on their way to Grants. After spending the afternoon in Grants, they returned to St. Johns, and the CFI was performing a short-field landing. Approximately 30 feet above ground level (agl), the engine lost power and they landed without power. The engine would not restart. The PUI reported that as the airplane was refueled, the CFI did an inspection to see why the engine lost power and no anomalies were identified. The engine was restarted and the airplane went through normal run up procedures. The PUI further reported that the CFI checked the Cessna’s performance and determined that the flight was within the manufacturer’s designated take off parameters. Additionally, the PUI reported that during the takeoff, the CFI made the standard radio announcements and the PUI was flying the airplane. The PUI stated, “We used virtually the entire runway for takeoff.” As the airplane reached the rotation speed, the airplane lifted off the runway. The PUI was focused on obstacles ahead of the runway and notified the CFI that they had cleared the obstacles. The CFI then assumed control of the airplane and stated that they had not cleared the obstacles. The PUI reported that the CFI then pulled back on the flight controls and the airplane entered a steep climb to clear an additional obstacle. The PUI stated that as the flight controls were pulled back “...it felt like our engine was failing, probably due to the steepened attitude of the airplane causing a greater demand on power.” The PUI noted to the CFI that their airspeed was decreasing, the CFI pushed forward on the flight controls, and the airplane was unable to climb. The PUI further stated that he saw an opening in the trees that led to a residential street. The CFI banked the airplane to the left, and lined up to land on the street. The PUI stated that "My last recollection was having the picture in my view of where we would touchdown, roll and stop. Apparently, we struck power poles in the flight path and crashed." PERSONNEL INFORMATION Certified Flight Instructor The CFI, age 48, held a commercial pilot certificate for airplane single-engine land and instrument. He also held a CFI certificate for single-engine land as well as an advanced ground instructor certificate. He held a second-class medical that was issued in July 18, 2007, with no limitations or waivers. Copies of the CFI’s logbook were obtained from his family and showed 1,081 hours total flight time, with 587 hours flight instruction. The logbook showed that the pilot had accrued about 60 hours in the accident airplane. The pilot had accumulated 22.4 hours in the accident airplane over the past 90 days, and other than one positioning flight, these hours were logged as instructional. Private Pilot Undergoing Instruction The PUI, age 29, held a private pilot certificate for single-engine land. He held a third-class medical certificate that was issued on April 15, 2008, with no limitations or waivers. The PUI’s logbook was recovered from the burned wreckage and reviewed by the FAA coordinator. It showed about 50 hours total flight time, and 5 hours pilot-in-command. The PUI had logged four flights since obtaining his private pilot certificate on July 19, 2008. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number 17700787, was manufactured in 1968. It was powered by a Textron Lycoming O-320-E2D engine equipped with a McCauley 1C172/TM7653 propeller. Review of copies of the maintenance records showed an annual inspection was completed on August 5, 2008, at a recorded tachometer reading of 2,626.29 hours, and a total airframe time of 2,626.29 hours. The engine’s time since major overhaul was 330.29 hours. The engine last underwent a field overhaul on December 8, 1998, at a tachometer time of 2,296 hours. During this field overhaul, the logbook entry stated “...new camshaft, new tappet bodies.” The logbook entry noted that the engine was returned to service with 0 hours since major overhaul. The airplane had been purchased by its current owner in April of 2008. A for sale listing of the airplane dated March 11, 2008, showed that the airframe had 2,590 hours and the engine had 296 hours. The current owner allowed the CFI to fly the airplane but he was not aware that it was being used for instruction. Weight and balance calculations based on the PUI’s statement submitted on September 29, 2009, showed that the estimated takeoff weight from St. Johns was 2,222 pounds with a center of gravity of 106.02 inches. The Cessna 177 POH lists the maximum gross weight of the airplane as 2,350 pounds with a center of gravity range between 105.5 and 114.5 inches. Performance calculations showed that at the maximum gross weight and 1/4 flaps, at 5,000 feet mean sea level and local temperatures and wind conditions, the distance would have been about 3,288 feet to clear a 50-foot obstacle and the climb rate would have been about 365 feet per minute. At 6,250 feet mean sea level, the distance would have been about 4,452 feet to clear a 50-foot obstacle and the climb rate would have been about 310 feet per minute. With the flaps fully retracted, the operating handbook indicates that the takeoff rolls are increased by 10 percent. AIRPORT INFORMATION The Airport Facility Directory Southwest (AFD/SW) stated that runway 14/32 at St. Johns airport is 5,322 feet in length at an elevation of 5,737 feet mean sea level. The AFD for Grants shows that runway 13/31 is 7,172 feet in length at an elevation of 6,537 mean sea level. The FAA completed a Runway Safety Action Plan report for St. Johns. The report noted, in part, that the power lines and poles in the cemetery adjacent to the runway 32 threshold, penetrated the airport’s imaginary surfaces as defined by 14 Code of Federal Regulations 77.25. According to an aviation analyst that participated in the review, although there were additional obstructions off of the departure end of runway 14, the runway contained a 92 foot displaced threshold that allowed for a 20:1 obstruction clearance. St. Johns airport is attempting to get instrument approach procedures into the airport. In order to do this, multiple obstructions identified in the report will have to be removed or lighted. METEOROLOGICAL INFORMATION Upon their departure from Grants around 1553 mountain standard time, Grants was reporting the following weather conditions; skies, clear; visibility, 10 statute miles; winds from 120 degrees at 16 knots, gusting to 21 knots, temperature 26 degrees Centigrade; dew point was 8 degrees Centigrade; and the altimeter was 30.14. The closest official aviation weather station to the accident was St. Johns. At 1554, the following weather conditions were reported: skies, clear; visibility, 10 statute miles, winds from 280 degrees magnetic at 8 knots, gusting to 14 knots; temperature 30 degrees Centigrade; dew point was 5 degrees Centigrade; and the altimeter was 30.04 inches of Mercury. A Safety Board computer program was used to calculate the density altitudes for Grants and St. Johns airports. When the airplane departed from Grants, the calculated density altitude was 9,163 feet mean sea level. When the airplane departed from St. Johns, the calculated density altitude from St. Johns was 8,690 feet mean sea level. TESTS AND RESEARCH The majority of the airframe had been consumed by fire. The right wing was fire damaged, and the left wing was consumed by fire. The control cables were intact and traced throughout the wreckage. The right flap appeared to be in the retracted position but was heavily damaged. The restraint systems had burned. The majority of the fuel system had also been consumed by fire. The throttle quadrant settings could not be determined. The propeller remained attached to the engine at the crankshaft flange. Both propeller blades exhibited bending, leading edge gouging, and trailing edge “S” bending. The tips to both blades were missing. To facilitate the examination, the engine was partially disassembled. The engine was rotated by turning the crankshaft flange and continuity of the crankshaft to the rear gears and valve train was confirmed. Thumb compression was obtained on all cylinders and all valves produced the appropriate amount of lift. No damage was noted to the cylinder walls, piston domes, or valves. The carburetor bowl had separated from the upper portion of the carburetor and both pieces sustained fire damage. One carburetor float was located and the other was not. The fuel inlet screen was separated and not located. No fuel remained in the carburetor bowl. The engine driven fuel pump sustained fire damage and could not be tested. Both magnetos were fire damaged and would not rotate. The ignition harnesses sustained extensive fire damage. All of the spark plug electrodes were intact and exhibited light gray coloration consistent with normal operation when compared to the Champion Check-A-Plug chart. Oil remained in the oil sump and was observed throughout the engine. The oil suction screen was removed and found free of contaminants. The oil pressure screen housing sustained thermal damage. The oil pressure screen contained a small amount of black sooty material. The engine was further disassembled. No damage was noted to the crankcase, cylinders, pistons, valves, rods, crankshaft, rear gears, or oil pump. Both of the front main bearings exhibited areas of corrosion, pitting, and some radial scoring. The face of the intake tappet for the number 4 cylinder was heavily pitted and the corresponding camshaft lobe was worn. The intake and exhaust tappets for the number 3 cylinder were scored and the corresponding camshaft lobes were worn. MEDICAL AND PATHOLOGICAL INFORMATION The Maricopa County Office of the Medical Examiner completed an autopsy on the CFI. The cause of death was attributed to thermal injuries sustained during the accident. The Federal Aviation Administration’s Bioaeronautical Research Laboratory completed toxicological tests on samples that were taken after the CFI had been admitted to the hospital. ADDITIONAL INFORMATION Textron Lycoming Engine Operation Guidance According to the Textron Lycoming publication Lycoming Flyer, "We have firm evidence that engines not flown frequently may not achieve the normal expected overhaul life. Engines flown only occasionally deteriorate much more rapidly than those that fly consistently." When an aircraft engine is flown once or twice a month it, "...usually accumulates rust and corrosion internally. This rust and corrosion is often found when an engine is torn down." Additionally, the Textron Lycoming Key Reprints from the Lycoming Flyer state that “Corrosion is a known cause of tappet and cam lobe wear. The engines of aircraft that are not flown regularly may be extremely vulnerable to corrosion...Once started, the process is not likely to stop until it reaches a point where these parts are doing an unacceptable job.” According to Textron Lycoming Service Instruction No. 1009AS the recommended time between overhaul periods was 2,000 hours or every 12 years. Lycoming Service Letter L180B states that, "Engines in aircraft that are flown only occasionally may not achieve normal service life because of corrosion. The desired flight time for air cooled engines is at least one continuous hour at oil temperatures of 165 degrees Fahrenheit to 200 degrees Fahrenheit at intervals not to exceed 30 days, depending on location and storage conditions. This one hour does not include taxi, take-off, and landing time." Additionally it states that if an aircraft is to remain inactive for 30 days or more, a preservative should be installed, "...especially if the aircraft is located near salt water or similar humid environment."
The failure of both pilots to abort the takeoff when a suitable climb rate could not be attained. Contributing to the accident was the reduction of available power due to the camshaft lobe and lifter corrosion/wear, the high density altitude, and the CFI’s inadequate supervision.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
