CEN09LA602

NTSB accident investigation · Air Tractor AT-301A · New Miner, WI · August 22, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
August 22, 2009, 16:15 local (21:15 UTC)
Place
New Miner, WI
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N3651RAir Tractor AT-301A
Defining event
Maneuvering-low-alt flying: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report May 28, 2010
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA-Milwaukee FSDO, Honeywell Aerospace
Case key
74794

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

On this page

Probable cause

A total loss of engine power due to the fatigue failure of the engine torsion shaft. Contributing to the accident was the chrome plating of the shaft by an undetermined maintenance/overhaul facility.

Findings · 4

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 (turbine/turboprop): reduction gear and shaftAircraft › Aircraft power plant · Fatigue/wear/corrosionAir Tractor AT-301: 1 caseAll aircraft: 8 casesProbable cause
Engine (turbine/turboprop): reduction gear and shaftAircraft › Aircraft power plant · Incorrect service/maintenanceAir Tractor AT-301: 1 caseAll aircraft: 8 casesProbable cause
MaintenancePersonnel issues › Task performance · Not specifiedAir Tractor AT-301: 1 caseAll aircraft: 143 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 pilot reported a complete loss of engine power about 15 minutes after takeoff during an agricultural application pass. He executed a forced landing into a tree plantation adjacent to the agricultural field. A postaccident inspection of the engine revealed that the torsion shaft had separated near the forward bushing journal. The fracture surfaces exhibited features consistent with fatigue failure. In addition, chromium plating was observed at all three bearing journals. Further examination by NTSB materials engineers determined that the torsion shaft fractured due to fatigue that was likely initiated by cracks in the chromium plate repair of the shaft. The plating itself was porous with radial cracks at all journal locations. Records indicated that the torsion shaft was newly overhauled when it was installed in the engine, about 3 1/2 years prior to the accident. However, detailed records related to the overhaul work were not available and the source of the chrome plating could not be determined. The engine manufacturer stated that chrome plating was not specified for production parts, nor was it permitted during component overhaul. A service bulletin recommending replacement of the torsion shaft had not been completed. The bulletin recommended replacement of the original (long) torsion shaft with a shorter shaft. The bulletin noted that the long torsion shafts were susceptible to bushing and bushing journal wear, which would be reduced by installation of the short torsion shafts.

Factual narrative

On August 22, 2009, about 1615 central daylight time, an Air Tractor AT-301A, N3651R, piloted by a commercial pilot, was substantially damaged during a forced landing following a loss of engine power near New Miner, Wisconsin. The agricultural application flight was being conducted under 14 Code of Federal Regulations Part 137 without a flight plan. Visual meteorological conditions prevailed. The pilot sustained minor injuries. The local flight departed a private airstrip located near Bancroft, Wisconsin, about 1600. The pilot reported the engine failure occurred about 15 minutes after takeoff during an agricultural application pass. He noted that the airplane was approximately 10 feet above ground level (agl) at the time. The pilot recalled that the engine torque indication was 80 psi, instead of a normal 42 – 45 psi. The other engine readings were normal. He stated, “Literally at that moment the engine suddenly lost power.” The pilot commented that the agricultural field he was spraying was completely surrounded by pine tree plantations. He attempted to stretch the glide to land on a narrow logging road; however, the airplane did not have enough "energy" to reach the road. He set-up for a landing into the trees. He noted that “just before impact [the] right wing and nose began dropping.” The right wing impacted the trees first, rotating the airplane from a northeast heading to a southeast heading as it came to rest. The pilot noted that the airplane was loaded with spray material and “topped off” with fuel prior to the flight. He commented that given the airplane’s flight and loading condition at the time of the engine failure, a 180-degree turn to return to the corn field would have been “impossible.” A post accident examination of the engine revealed that the torsion shaft (p/n 868605-5, s/n 5K091) was separated approximately 7 inches aft of the forward face. Metallurgical examination noted that the shaft fractured circumferentially at the forward end of the forward bushing journal. In addition, a longitudinal crack (0.25 inch long) and a spiral crack (0.40 inch long) were also present immediately aft of the circumferential crack. The circumferential fracture surface exhibited crack arrest marks consistent with fatigue emanating from the longitudinal crack. The remainder of the circumferential fracture surface exhibited characteristics consistent with overstress separation. The surface of the torsion shaft exhibited spalling in the area of the spiral crack. The longitudinal fracture surface exhibited arrest and ratchet marks consistent with fatigue progression initiating at multiple locations. Further examination determined that the forward journal was chrome plated with the fatigue origins in the shaft base metal at the interface with the chrome plating. The examination also noted chrome plating at the other two bearing journal diameters. The plating itself was porous with radial cracks at all journal locations. Maintenance recordsindicated that the engine (TPE331-1-151A, s/n P90094C) was disassembled for a hot section inspection, a compressor section inspection, and a gearbox repair in April 2005. At that time, the torsion shaft (p/n 868605-5, s/n 5K091) was installed in overhauled condition. According to a representative of the engine repair facility, the torsion shaft was in parts storage since initial receipt and it was installed in the accident engine as a newly overhauled part. Records indicated that the torsion shaft was overhauled in December 1997. However, the component overhaul facility has since ceased operations and additional information was not available. A review of the manufacturer’s engineering documentation and repair instructions (72-IR-10 / Dec. 1995) for the torsion shaft revealed that chrome plating was not specified for production parts, nor is it permitted during overhaul. The manufacturer reported that there was no record of the accident part serial number in their production records. In addition, the serial number etched on the fractured torsion shaft did not correspond to either of two serial number formats used by the manufacturer. Service Bulletin TPE331-72-0119, originally issued by the engine manufacturer in 1977, recommended replacement of the original (long) torsion shafts (p/n 868605-5) with short torsion shafts. The bulletin noted that the long torsion shafts were susceptible to bushing and bushing journal wear, which would be reduced by installation of the short torsion shafts. Compliance was recommended at the next scheduled inspection.

Aircraft

Registration
N3651R
Reported as
Air Tractor AT-301A
Category
Airplane
Serial number
301-0261
Airframe hours
7,209
Engine
Honeywell TPE331-5-151A, 600 horsepower, turbo prop
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
Jp'S Agricair Inc
Registered owner
Jp'S Agricair Inc
Airworthiness certificate
Special, Restricted (Special)
Last inspection
Annual · June 1, 2009
Departed
PVT · Bancroft, WI
Destination
PVT · Bancroft, WI
Airport
Private

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
41
Injuries
Minor
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
June 1, 2008
Seat
Single
Flight hours
5,500 total · 1,500 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 6 knots
Visibility
10 statute miles
Lowest ceiling
4,100 ft broken
Temperature
70 °F, dew point 52 °F
Altimeter
30.09 inHg
Observed at
ISW, 14 nm away

Docket · 9

The files NTSB released with the investigation on March 25, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.8 MB in all.