Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Oceanside, California 92054
Saturday, March 7, 2009 17:50 PST
NTSB Narrative Summary Released at Completion of Accident
The pilot made an off-airport forced landing following an in-flight loss of engine power. The No. 4 cylinder (left rear) fractured and separated circumferentially in the area where the head joins the barrel. Metallurgical examination identified a fatigue fracture primarily on the exhaust side of the cylinder head, perpendicular to the axis of the barrel. Its inner edge abutted the crest of the first thread on the barrel. Engine Components, Inc. (ECi), manufactured the cylinder. ECi issued Mandatory Service Bulletin (MSB) No.08-1, Revision 3, dated August 19, 2008. It stated that the purpose of the MSB was to alert their customers about possible fatigue cracking and head separations on a specified group of replacement cylinders for Lycoming parallel valve engines. Cylinders identified by specific serial number ranges were to be inspected and pressure tested or inspected and replaced at specified reduced life limits. On October 20, 2008, Federal Aviation Administration (FAA) Airworthiness Directive (AD) 2008-19-05 became effective and mirrored ECi's MSB serial number range and corrective actions. The AD stated that the intent was to prevent loss of engine power due to cracks at the head-to-barrel interface in the cylinder assemblies and possible engine failure caused by separation of a cylinder head. The cylinders from the accident airplane had serial numbers that were outside of the range listed in the MSB and AD. The FAA has issued a Notice of Proposed Rule Making (NPRM) that would revise the serial numbers covered by the AD to encompass an expanded population of affected cylinders. ECi has a design change that is pending FAA approval.
NTSB Probable Cause Narrative
A total loss of engine power in flight due to the fatigue failure of the No. 4 cylinder.
Event Information
| Type of Event | Accident |
| Event Date | 3/7/2009 |
| Event Day of the Week | Saturday |
| Time of Event | 1750 |
| Event Time Zone | Pacific Standard Time |
| Event City | Oceanside |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 92054 |
| Event Date Year | 2009 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 331757N |
| Event Location Longitude | 1172803W |
| Event Location Airport | -- |
| Event Location Nearest Airport ID | -- |
| 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 | -- |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1752 Pacific Standard Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | KOKB |
| Elevation of weather observation facility | 28 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | PST |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 9 |
| Air Temperature at event time (in degrees celsius) | 12 |
| Dew Point at event time (in degress fahrenheit) | 8 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | -- |
| Wind Speed (knots) | -- |
| Wind Velocity Indicator | Calm |
| Wind Gust Indicator | -- |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.02 |
| 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 | 1 |
| Injury Total None | -- |
| Injury Total Serious | 2 |
| Injury Total All | 3 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 26595 |
| NTSB Notification Source | FAA Western Pacific Operations |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Feb 11 2010 4:55PM |
| User who most recently changed record | coos |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N2478B |
| NTSB Number | WPR09LA145 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | Unknown |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | CESSNA |
| Aircraft Model | 172R |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 17281027 |
| Certified Max Gross Weight | 2457 |
| 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 | 4 |
| Number of Engines | 1 |
| Fixed gear or retractable gear | Fixed |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Jan 14 2009 12:00AM |
| Airframe hours since last inspection | 3170 |
| Airframe Hours | 3124 |
| ELT Installed | Yes |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | No |
| ELT Type | C91-A |
| Aircraft Owner Name | Alan Jacobson |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | Costa Mesa |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 92627 |
| Operator is an individual? | No |
| Operator Name | Alan Jacobson |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | Costa Mesa |
| Operator State | CA |
| Operator Country | USA |
| Operator Zip code | 92627 |
| 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 | No |
| Departure Airport Code | SNA |
| Departure City | Santa Ana |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 1715 |
| Departure Time Zone | PST |
| Destination Same as Local Flt | -- |
| Destination Airport Code | MYF |
| Destination City | San Diego |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Feb 11 2010 5:01PM |
| User who most recently changed record | coos |
| Since inspection or accident | Last Inspection |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |