ANC98LA078

NTSB accident investigation · Cessna 207 · Holy Cross, AK · June 20, 1998

Accident · No injuriesLimited investigationFinal report
Date
June 19, 1998, 19:25 local (Jun 20, 1998, 03:25 UTC)
Place
Holy Cross, AK
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1673UCessna 207
Weather
Visual (VMC) · Day
Status
Completed · report July 2, 1999
Report
Approved by Office Director
NTSB office
Alaska Regional Office
FAA report
19980619019709A
Case key
3163

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 improper installation/undertorquing of the engine crankcase bolts by company maintenance personnel, and a subsequent fracture of the engine crankshaft. A factor in the accident was unsuitable terrain for a forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,crankshaft - fracturedCause
Engine assembly,crankcase - undertorquedCause
Maintenance,installation - improperCompany maintenance personnelCause
Forced landingEmergency descent/landing
Terrain condition - none suitableFactor
In flight collision with objectEmergency descent/landing
Object - tree(s)

Analysis

The pilot and three passengers, departed on an air taxi flight over remote terrain. While in cruise flight about 2,200 feet, the engine oil pressure began to drop, and the engine oil temperature began to rise. The pilot decided to divert to the nearest airport. The engine quit running, and the pilot selected an emergency landing area on a sand bar along a river that contained several willow trees. During the landing, the airplane received damage to the wings and fuselage. The engine had accrued 1,491 hours since an overhaul. During that time, seven engine cylinder changes were performed by company maintenance personnel. An examination of the engine revealed the crankshaft was broken along the aft, lower edge of the number two cheek journal, at the forward radius of the number two main bearing journal. The fracture line was straight and flat, through the full dimension of the number two cheek journal, and was oriented perpendicular to the longitudinal axis of the crankshaft. The number two main bearing was broken and flattened. The number two main bearing saddle was flattened and distorted. The left and right engine case halves mating surface exhibited galling/fretting at the number two main journal bolt holes.

Factual narrative

On June 19, 1998, about 1925 Alaska daylight time, a wheel equipped Cessna 207 airplane, N1673U, sustained substantial damage during a forced landing, about 3 miles north of Holy Cross, Alaska. The airplane was being operated as a visual flight rules (VFR) on-demand passenger flight to Bethel, Alaska, under Title 14 CFR Part 135, when the accident occurred. The airplane was operated by Inland Aviation Services Inc., Aniak, Alaska. The certificated airline transport pilot, and the three passengers, were not injured. Visual meteorological conditions prevailed. VFR company flight following procedures were in effect. The flight originated at the Grayling Airport, Grayling, Alaska, about 1840.

During a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), on June 19, 1998, at 2030, the pilot reported he was in cruise flight about 2,200 feet mean sea level (msl). About 25 miles from Holy Cross, the pilot noticed the engine oil pressure began to drop below the normal operating range, and the engine oil temperature began to rise. The pilot decided to divert to Holy Cross. About 10 miles from Holy Cross, the oil temperature continued to rise, and the engine propeller rpm increased to maximum. The engine began losing power, and then quit running. The pilot selected an emergency landing area on a sand bar along the Yukon River. The sand bar contained several willow trees. During the landing, the airplane's nose gear was sheared off, and the wings received damage from the trees. The pilot reported he did not notice any external signs of damage to the engine.

The engine accrued 1,491.1 hours since being overhauled on April 15, 1991. Since the overhaul, the number three, and number five engine cylinders were changed after the engine accrued 808.9 hours. At 1,132.1 hours since overhaul, the number one cylinder was changed. At 1,241.5 hours, the number three cylinder was again changed. At 1,273.5 hours, the number two cylinder was changed. At 1,340.1 hours, the number four, and number six cylinders were changed. During the most recent 100 hour inspection of the engine on May 25, 1998, 50.8 hours before the accident, no metal was found in the engine oil.

On July 27, 1998, a Federal Aviation Administration (FAA) airworthiness inspector, Anchorage Flight Standards District Office, examined the engine during a tear down inspection. The inspection revealed the crankshaft was broken along the aft, lower edge of the number two cheek journal, at the forward radius of the number two main bearing journal. The number two main bearing was broken and flattened. The number two main bearing saddle was flattened and distorted. The left and right engine case halves mating surface exhibited galling/fretting at the number two main journal bolt holes. The surface of the number two main bearing journal exhibited circumferential discoloration and scoring.

On August 21, 1998, the NTSB IIC examined the accident engine crankshaft. The fracture line was straight and flat, through the full dimension of the number two cheek journal, and was oriented perpendicular to the longitudinal axis of the crankshaft. The forward edge of the fracture surface adjacent to the number two main bearing was curled aft and inward. The fracture surface of the number two cheek journal exhibited gouging and distortion in the center of the cheek, corresponding to about the dimension of the main journal diameter.

The number two rod bearing journal exhibited blue discoloration along the aft edge of the bearing surface, at the aft radius of the cheek. The number two rod bearing exhibited spalling of the inner surface. The number two rod bearing oil galley was plugged with metal.

Aircraft

Registration
N1673U
Reported as
Cessna 207
Category
Airplane
Serial number
20700273
Airframe hours
11,877
Engine
Continental IO-520-F, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Inland Aviation Services Inc.
Registered owner
Inland Holdings Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 25, 1998 · 51 hours before
Departed
KGX · Grayling, AK
Destination
BET · Bethel, AK
Flight plan
Company VFR

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
35
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
12,000 total · 4,000 in this make and model · 12,000 as pilot in command · 110 in the last 90 days · 61 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 5 knots
Visibility
50 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 50 °F
Altimeter
29.00 inHg

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 N1673U · 1

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