Cessna 172R accident near Oceanside, California, March 8, 2009
On March 8, 2009 at about 1:50 am local time, a Cessna 172R, registered N2478B, was substantially damaged in an accident during enroute (cruise) near Oceanside, California. It was a personal flight under general aviation rules (Part 91). 2 people were seriously injured and 1 person had minor injuries. The weather was visual conditions (good weather).
The NTSB's probable cause their words, unchanged
A total loss of engine power in flight due to the fatigue failure of the No. 4 cylinder.
Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.
What the record shows
- Date
- March 8, 2009 · about 1:50 am local time
- Place
- Oceanside, California · map
- Type
- Accident
- Injuries
- 2 people were seriously injured and 1 person had minor injuries.
- Weather
- visual conditions (good weather)
- Aircraft
- Cessna 172R · all 172Rs on the register
- Registration
- N2478B · no longer on the register · serial 17281027
- Damage
- Substantial damage
- Flight
- Personal flight · general aviation rules (Part 91)
The NTSB's narrative final · quoted from the NTSB record
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.
The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.
The factual record from the NTSB's investigation tables, in plain English
What happened, in order
- Powerplant sys/comp malf/fail during enroute (cruise) defining event
- Loss of engine power (total) during enroute (cruise)
- Off-field or emergency landing during landing (landing roll)
- Collision with terrain or object (not controlled flight into terrain) during landing (landing roll)
The NTSB's findings
- cause Aircraft › Aircraft power plant › Engine (reciprocating) › Recip eng cyl section › Failure
- Environmental issues › Physical environment › Terrain › Rough terrain › Contributed to outcome
Pilot
- Certificate: private
- Ratings: single-engine land; instrument: airplane
- Flight time: 370 hours in all; 245 in this make and model
- Medical certificate: Class 3 (with waivers/limitations)
- Seat: left
- Injury: serious injuries
The aircraft
- Airframe total time: 3,124 hours
- Last inspection: annual inspection, January 14, 2009; 3,170 hours since
- Maximum gross weight: 2,457 lb
- Seats: 4
- Landing gear: fixed
- Engine: Lycoming IO-360-L2A (piston); 0 hours total
The flight
- Departed from: SNA Santa Ana CA at 1:15 am
- Destination: MYF San Diego CA
- Flight plan: not recorded
Weather at the time
- Light: daylight
- Visibility: 9 statute miles
- Sky: clear
- Temperature: 54°F (12°C), dew point 46°F (8°C)
- Altimeter: 30.02 inHg
- Observation at 1:52 am from KOKB
Injuries
| Fatal | Serious | Minor | None | |
|---|---|---|---|---|
| Flight crew | 1 | |||
| Passengers | 1 | 1 |
Documents from the investigation the NTSB's docket: the evidence folder behind the report
The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.
Other NTSB records under N2478B the same tail number, which may have belonged to a different aircraft at the time
Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.