ANC14LA085

NTSB accident investigation · Cessna TU206 · Deadhorse, AK · September 22, 2014

Accident · No injuriesLimited investigationFinal report
Date
September 22, 2014, 10:18 local (18:18 UTC)
Place
Deadhorse, AK
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N206JCessna TU206
Defining event
Enroute: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2016
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Parties
Federal Aviation Administration, Continental Motors Inc.
FAA report
20140922018149A
Case key
90124

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The application of insufficient torque to the engine cylinder through bolts during the replacement of the No. 1 cylinder, which resulted in the displacement of the No. 2 bearing, oil starvation, and a catastrophic engine failure.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Incorrect service/maintenanceCessna U206C: 1 caseAll aircraft: 233 casesProbable cause
Maintenance: replacementPersonnel issues › Task performance · Maintenance personnelCessna U206C: 1 caseAll aircraft: 70 casesProbable cause
Terrain: wet/muddy terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna U206C: 1 caseAll aircraft: 110 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The commercial pilot was conducting an on-demand air taxi commuter flight. The pilot reported that, during cruise flight, the engine began vibrating violently and lost power and that the throttle and propeller controls were unresponsive. The cockpit subsequently filled with smoke. The pilot conducted a forced landing to the nearest and driest tundra patch, during which the airplane nosed over. Examination of the engine revealed a large hole on the top left side of the crankcase near the No. 2 cylinder. The No. 2 connecting rod had separated from the crankshaft connecting rod journal. The No. 2 main bearing support mating surfaces exhibited fretting damage. The No. 2 main bearing had shed material from its forward side and had shifted. Measurements of the breakaway torque on the cylinder through bolts indicated that the torque on the Nos. 2 and 3 cylinder through bolts was below the engine manufacturer's specification. It is likely that the insufficient torque on the Nos. 2 and 3 cylinder through bolts resulted in the fretting damage and the No. 2 main bearing shifting and interrupted the oil flow to the No. 2 connecting rod bearing. The interruption of oil flow resulted in the bearing becoming starved of oil and overheating and the subsequent separation of the connecting rod from the crankshaft. A review of maintenance records revealed that the No. 1 cylinder was replaced about 403 flight hours before the accident, which would have required the removal and installation of hardware on the Nos. 1, 2, and 3 cylinder through bolts. It is likely that insufficient torque was applied to the through bolts during the replacement of the No. 1 cylinder.

Factual narrative

***This report was modified on April 12, 2016. Please see the docket for this accident to view the original report.*** On September 22, 2014 at 1018 Alaska daylight time, a Cessna TU206, N206J, sustained substantial damage following a loss of engine power and subsequent emergency landing, near Deadhorse, Alaska. The airplane was registered to and operated by 70 North LLC, under the provisions of Title 14 Code of Federal Regulations Part 135 as an on-demand air taxi flight. The commercial pilot and the three passengers were not injured. Visual meteorological conditions prevailed and a company flight plan was filed. The cross-country flight originated from Badami Airport, Alaska at 1006 with a destination of Deadhorse, Alaska. According to the pilot, about 12 minutes after departure, the engine began vibrating violently during a loss of power, and the throttle and propeller controls were unresponsive. Smoke soon filled the cockpit. The pilot executed a forced landing onto the nearest and driest area of tundra. During touchdown onto an area of tundra-covered terrain, the airplane nosed over, sustaining substantial damage to the fuselage, wings, and empennage. Passengers reported that during cruise flight about 800 feet above ground level they heard a loud bang followed by smoke in the cabin area. The engine began to run rough and then suddenly quit. The pilot called out a mayday and initiated a forced landing. One passenger stated that during the landing sequence the airplane's tail touched down first and shortly after the airplane nosed over. Examination of the airplane by a local mechanic revealed that the wings and fuselage were buckled and the vertical stabilizer and rudder were crushed near the top. Oil was observed on the lower side of the fuselage. The wreckage was recovered to a secure location for further examination. The engine was removed from the airframe and sent to the facilities of Continental Motors, Inc. (CMI), Mobile, Alabama, for further examination. The engine was examined on January 14, 2015, by representatives from CMI under the supervision of the NTSB investigator-in-charge (IIC). The examination revealed a large hole on the top left side of the crankcase near the number 2 cylinder. Visual inspection through the hole revealed that the number 2 connecting rod separated from the crankshaft connecting rod journal. The engine was subsequently disassembled and examined. The cylinders were removed from the engine during the examination. The break-away through bolt torque during disassembly indicated that cylinder number 2 and 3 through bolt torque was below CMI specification. The crankcase halves remained secured. The main bearing support mating surfaces for the number 2 bearing revealed fretting signatures. The number 1, 2, 3, and 4 cylinder bays had mechanical damage. The oil galleys on both crankcase halves were free of debris. The number 2 main bearing displayed contamination imbedded in the surface layer and also lubricationdistress and displaced babbit material. The number 2 bearing had shed material from its forward side and had shifted on the bearing support such that it covered the oil port that fed the number 2 connecting rod bearing. The bearing lock tab showed lateral movement on the bearing support. The remaining main bearings displayed similar contamination; however there was no sign of lock tab movement or lock slot elongation. The crankshaft remained intact but displayed thermal distress at the number 2 connecting rod journal. The rear set of counterweights were mechanically damaged and were free to move on their hanger blades. The connecting rods were intact and revealed normal operation, with exception to the number 2 connecting rod which sustained thermal and mechanical damage and was separated through the base of the I-beam, separating both yoke sections of the bearing support. The connecting rod cap was bent and had thermal and mechanical damage. The number 1 connecting rod bearing revealed normal operating signatures. The number 3, 4, 5 and 6 connecting rod bearings revealed contamination and hard particle damage. Only fragments of the number 2 connecting rod bearing were found and displayed evidence of thermal discoloration and heat distress associated with a lack of lubrication. According to CMI, the engine was remanufactured on August 3, 2000. Review of the engine maintenance logbooks revealed that the engine was then overhauled and tested on June 9, 2005, and installed on the accident airplane on August 11, 2009. The number 2 cylinder was removed and replaced on August 28, 2012, at 423.3 hours since overhaul. The number 1 cylinder was removed and replaced on September 4, 2013, at 764.1 hours since major overhaul. The most recent maintenance performed on the engine was a 100-hour inspection and an oil and oil filter change, which was conducted on August 19, 2014 at an engine time of 1,071.8 hours since major overhaul. According to the tachometer reading, from the time of the accident to the last recorded oil change was 95.5 hours. The time between the last recorded oil changes were 105.7 and 95.8 hours.

Aircraft

Registration
N206J
Reported as
Cessna TU206
Category
Airplane
Serial number
U2060965
Built
1967
Airframe hours
6,987.6
Engine
Continental Motors IO-520-F48B, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
70 North LLC, doing business as 70 North
Registered owner
70 North LLC
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · August 19, 2014 · 96 hours before
Departed
AK78 · Deadhorse, AK
Destination
SCC · Deadhorse, AK
Flight plan
Company VFR
Airport
AK78 · Badami
Equipment
Stall warning system, Handheld GPS, Satellite tracking device

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
58
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
9,000 total · 1,500 in this make and model · 9,000 as pilot in command · 290 in the last 90 days · 88 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 8 knots
Visibility
10 statute miles
Lowest ceiling
2,400 ft overcast
Temperature
32 °F, dew point 28 °F
Altimeter
29.62 inHg
Observed at
PASC, 12 nm away

Docket · 8

The files NTSB released with the investigation on March 8, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N206J · 1

Matched to the same aircraft by N-number and date.