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NTSB investigation record

SEA08LA179

Completed

Cessna 177· N3487T

Date
August 16, 2008
Location
St. Johns, AZ
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

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.

Investigator assessment

Analysis narrative

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.”

Source record

Factual narrative

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

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