Middlesboro-Bell County Airport
Aircraft Accident/Incident Report

Middlesboro, Kentucky 40965
Thursday, March 13, 2008 15:20 EDT

NTSB Narrative Summary Released at Completion of Accident

During a period of 6 months, a major engine overhaul and annual inspection was being performed on the pilot's airplane. The work was being performed by the pilot's friend, who was an airframe and powerplant mechanic with an inspector authorization. The accident flight was the first flight after the work was completed. About 10 minutes after departure, the engine began vibrating and lost all power during cruise flight. The major overhaul had included the installation of new cylinders. Proper installation of the new cylinders required that the exhaust valve rocker arms have a small orifice to allow oil to pass and lubricate the valves. The intake valve rocker arms did not have an orifice. Examination of the accident engine revealed that the No. 1 cylinder intake valve was stuck open, and exhibited features consistent with oil starvation. Further examination revealed that the No. 1 cylinder had an intake rocker arm (no orifices) on both the intake and exhaust valves. The No. 3 cylinder had an exhaust valve rocker arm (with orifice) on both the intake and exhaust valves. Review of a make and model engine overhaul manual revealed a caution, noting that the exhaust valve rocker arms have an orifice. Further examination of the cylinder did not reveal any additional mechanical anomalies.

NTSB Probable Cause Narrative

The mechanic's improper maintenance installation of the No. 1 cylinder rocker arms which led to oil starvation and a loss of engine power.

Event Information

Type of Event Accident
Event Date 3/13/2008
Event Day of the Week Thursday
Time of Event 1520
Event Time Zone Eastern Daylight Time
Event City Middlesboro
Event State KENTUCKY
Event Country --
Zipcode of the event site 40965
Event Date Year 2008
Event Date Month 3
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 363638N
Event Location Longitude 0834414W
Event Location Airport Middlesboro-Bell County
Event Location Nearest Airport ID 1A6
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation 1154
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1515 Eastern Daylight Time
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID 1A6
Elevation of weather observation facility 1154
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 9000
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 22
Dew Point at event time (in degress fahrenheit) 4
Wind Direction (degrees magnetic) 180
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 15
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 19
Altimeter Setting at event time (in. Hg) 29.86
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 24433
NTSB Notification Source SROC
NTSB Notification Date Mar 13 2008 12:00AM
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Nov 25 2008 12:31PM
User who most recently changed record lema
Basic weather conditions Visual Meteorological Cond
FAA District Office Louisville, KY

Aircraft Involved

Aircraft #1

Aircraft Registration Number N6651F
NTSB Number NYC08LA137
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 150F
Aircraft Series Identifier --
Aircraft Serial Number 15063251
Certified Max Gross Weight 1600
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Mar 1 2008 12:00AM
Airframe hours since last inspection --
Airframe Hours 4029
ELT Installed Yes
ELT Activated Unknown
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name Emory C Hurley
Aircraft Owner Street Address --
Aircraft Owner City Pikesville
Aircraft Owner State KY
Aircraft Owner Country USA
Aircraft Owner Zipcode 41501
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country USA
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code 1A6
Departure City Middlesboro
Departure State KY
Departure Country USA
Departure Time 1510
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code PBX
Destination City Pikeville
Destination State KY
Destination Country USA
Specific Phase of Flight Maneuvering
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Oct 17 2008 12:22PM
User who most recently changed record kenj
Since inspection or accident Time of Accident
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --