LAX91LA255
1991-06-08 · THERMAL, California, United States · Minor · 1 aircraft · Status: Completed
Airport TRM
Current FAA registration · N6230D
- Make / Model
- CESSNA 172N
- Year of manufacture
- 1979 · 12 years old at event
- Engine
- LYCOMING 0-320 SERIES (180 hp)
- Seats / Engines
- 4 seats · 1 engine
- Last airworthiness date
- 19790423
- ADS-B equipped
- Yes — Mode-S A823BE
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
THE PARTIAL FAILURE OF THE ENGINE/POWERPLANT FROM A WORN INTAKE VALVE AND THE FAILURE OF COMPANY/OPERATOR MANAGEMENT TO PERFORM AN OVERHAUL ON THE ENGINE WITHIN THE TIME FRAME RECOMMENDED BY THE ENGINE MANUFACTURER.
Factual narrative
A CESSNA 172N NOSED OVER IN SOFT SOIL DURING LANDING ROLL AFTER A FORCED LANDING. THE PILOT INDICATED THAT THE ENGINE WAS RUNNING ROUGH AND LOSING POWER. THE PILOT LANDED THE AIRPLANE ON AN AIRPORT, BUT WAS UNABLE TO MANEUVER THE AIRPLANE TO A RUNWAY. THE AIRPLANE DECELERATED TO ABOUT 20 MPH DURING THE GROUND ROLL ON DIRT. THE AIRPLANE NOSED OVER AFTER THE NOSE GEAR STRUCK A 15 TO 18 INCH HIGH DIRT BANK. THE ENGINE WAS EXAMINED BY AN A&P MECHANIC. THE A&P FOUND THE NUMBER THREE CYLINDER INTAKE VALVE WAS 'TULIPED.' ACCORDING TO THE AIRPLANE'S MAINTENANCE RECORDS, THE ENGINE HAD ACCRUED 2,850 HOURS OF OPERATION WITHOUT OVERHAUL. FORTY FOUR HOURS OF OPERATION BEFORE THE ACCIDENT, THE ENGINE'S CYLINDER COMPRESSION CHECKED 'OK' DURING A LEAK TEST. THE ENGINE MANUFACTURER RECOMMENDED TIME BETWEEN OVERHAULS IS 1,500 HOURS. DURING OVERHAUL THE VALVES ARE REMOVED AND VISUALLY CHECKED FOR WEAR. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_LAX91LA255.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
Matched on aircraft type or causal vocabulary (maintenance). All research papers
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA) From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2026 · Article (Reliability Engineering & System Safety) Understanding human error in military aviation maintenance: The role of Performance shaping factors, cognitive workload and error orientation
- Semantic Scholar 2025 · Article (Applied Sciences) Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Semantic Scholar 2024 · Article (Defence Science Journal) Modelling of Human Factors in Aviation Maintenance Using HFACS ME Human Factors Analysis and Classification System Maintenance Extension and Bayesian Network
Aircraft maintenance is a complex task involving a skilled human workforce, spare parts, and various other resources. Human factors are an inherent element of the human workforce.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER) Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…