15 Jul 2024: CESSNA 150M

15 Jul 2024: CESSNA 150M (N714PW) — Unknown operator

No fatalities • Ritzville, WA, United States

Probable cause

Maintenance personnel’s improper installation of the No. 2 cylinder exhaust valve, which allowed the valve to drop into the cylinder and resulted in a total loss of engine power.

— NTSB Determination

Accident narrative

On July 15, 2024, about 1145 Pacific daylight time, a Cessna 150M, N714PW, was substantially damaged when it was involved in an accident near Ritzville, Washington. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot reported that, while en route from Spokane, Washington, to Yakima, Washington, he heard a loud metal sound followed by an immediate reduction in engine rpm and a rough-running engine. While troubleshooting the rough-running engine, he diverted to the Pru Field Airport (33S), Ritzville, Washington. While en route a loss of engine oil pressure occurred followed by a total loss of engine power. The pilot initiated an off-airport landing to an open field. During the landing roll, the nose landing gear collapsed and the airplane impacted terrain.

Postaccident examination of the airplane revealed that the left wing and forward fuselage were substantially damaged. Subsequent lighted borescope examination of the airplane’s engine revealed mechanical damage to the No. 2 cylinder’s combustion dome and piston face. The No. 2 cylinder was removed and the exhaust valve stem had exited the cylinder valve guide and was impaled into the cylinder head. The exhaust valve was fracture-separated from the valve stem and not observed within the cylinder or engine. Metallic debris was observed within the No. 2 cylinder. Remnants of the piston were observed within the cylinder and oil sump.

The No. 2 cylinder, piston, and remnants of the No. 2 exhaust valve were sent to the NTSB Materials Laboratory, Washington, DC, for examination. Examination revealed the cylinder head damage was consistent with impact with the exhaust valve tip after it had been displaced out of the exhaust valve guide. The exhaust rocker arm exhibited grinding marks on the rocker pad. Marks corresponding to contact with the spring seat were also observed on the arm adjacent to the rocker pad. Wear marks corresponding to contact with the exhaust valve keeper halves were also observed on the center hole bore. The exhaust valve stem was fractured near the valve head, and the stem was bent into an “S” shape. The outside diameter of the valve stem measured .4343 inch near the tip end of the valve stem, which was slightly above the maximum outside diameter of a new exhaust valve stem. Fretting damage from contact with the keeper halves was observed at the shoulder near the valve tip. The fracture surfaces of the valve stem exhibited features consistent with overstress fracture.

According to engine maintenance logs, the engine was last overhauled on June 11, 1981. All 4 cylinders were subsequently removed, repaired, and reinstalled on July 24, 1988. The maintenance record entry documenting this work included the statement, “ground and laped [sic] valves and seats,” which was the most recent entry that would require disassembly of the valves to complete. In the last maintenance entry, dated July 10, 2024, the engine was reported to have 1,232.45 hours since major overhaul and 320.25 hours since repair of the cylinders.

Continental Aerospace Technologies, Publication M-0, Standard Practice Maintenance Manual, dated August 2024, states: “Replace or overhaul the engine upon accumulating the operating hours specified in Table 6-1, or twelve (12) years after being placed in service, whichever occurs first.”

Contributing factors

  • Incorrect service/maintenance
  • Maintenance personnel

Conditions

Weather
VMC, wind 210/09kt, vis 10sm

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