CEN10FA521

NTSB accident investigation · Cessna P210N · Caledonia, MI · September 6, 2010

Accident · No injuriesField investigationFinal report
Date
September 6, 2010, 08:45 local (12:45 UTC)
Place
Caledonia, MI
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N4632ACessna P210N
Defining event
Maneuvering: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 20, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Teledyne Continental Motors
FAA report
20100906045279A
Case key
77206

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 loss of engine power as a result of a fatigue failure of the crankshaft due to the loss of engine case through-bolt torque. Contributing to the accident was a mechanic's use of incorrect hardware.

Findings · 5

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 · Fatigue/wear/corrosionCessna P210N: 6 casesAll aircraft: 233 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Contributed to outcomeCessna P210N: 2 casesAll aircraft: 329 cases
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCessna P210N: 3 casesAll aircraft: 371 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Maintenance personnelCessna P210N: 6 casesAll aircraft: 1,386 casesProbable cause

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 and certified flight instructor were in a holding pattern during an instrument proficiency check when they heard a bang from the airplane's engine area. They initiated a forced landing and the airplane impacted terrain at the base of a hill. Fuel leaked and a ground fire ensued, resulting in substantial damage to the left wing. No airframe preimpact anomalies were observed on-scene. An engine teardown inspection revealed a separation of the crankshaft No. 3 short cheek consistent with fatigue. Additionally, the No. 2 lower through-bolt had the lowest torque value of all bolts and incorrect hardware was used on that through-bolt. Fretting was observed on the mating surfaces of the main bearing supports near the No. 2 through-bolt and its bearing had spun out of its support. Engine logbook entries indicated a mechanic replaced cylinders that would have required the removal and installation of hardware on the No. 2 through-bolt, approximately 19 months prior to the accident.

Factual narrative

On September 6, 2010, about 0845 eastern daylight time, a Cessna P210N, N4632A, operated by Centurion Aviation LLC and piloted by a commercial pilot with a certificated flight instructor (CFI) on board, sustained substantial damage when it impacted terrain during a forced landing following an in-flight loss of engine power while maneuvering near Caledonia, Michigan. A post-impact ground fire occurred. The instructional flight was operating under 14 Code of Federal Regulations Part 91 without a flight plan. Visual meteorological conditions prevailed at the time of the accident. Both the CFI and the commercial pilot reported no injuries. The local flight departed from the Gerald R. Ford International Airport (GRR), near Grand Rapids, Michigan, about 0800. The pilot reported that the purpose of the flight was to conduct an instrument proficiency check (IPC). The pilot stated that the airplane was fueled to full prior to departure. He indicated that during the IPC he was cleared by GRR air traffic controllers to climb to 4,000 feet above mean sea level and hold as published over a GRR navigational aid. The pilot said that while he was starting the hold’s outbound leg, he heard “a large bang from the engine area.” The pilot removed his view limiting devices and turned north toward GRR. The CFI advised GRR air traffic controllers that the flight had a problem and were returning to GRR. The pilot and CFI realized the airplane had no engine power and they agreed “to do an off field landing.” The pilot set up for an approach to an alfalfa field. The pilot stated that the terrain was rolling and the airplane impacted terrain at the base of a hill in the field where its nose gear separated. The airplane “careened sideways” into a corn field and came to rest in the corn field. Fuel leaked out of the left wing’s tip tanks and ignited. The pilot turned the airplane’s fuel selector to off. The CFI opened the emergency door and both pilots exited. The fire was extinguished by the local fire department. According to the pilot, the total elapsed time from the "engine loss to crashing was less than 2 minutes.” N4632A, a Cessna P210N, Centurion, serial number P21000810, was a six-place, single engine, full cantilever high-wing, all-metal airplane of semimonocoque construction. The wings were constructed with integral fuel tanks. The airplane was powered by a six-cylinder, horizontally opposed, turbocharged, air-cooled, fuel injected, Teledyne Continental TSIO-520-RCAF engine with serial number 517924. According to airplane logbook excerpts, the engine's number three and five cylinders were replaced on April 17, 2006, and its number one and two cylinders were replaced on February 18, 2007. According to the pilot's accident report, the airplane's last annual inspection was completed on September 3, 2009, and the airplane had accumulated 4,342 hours of total time at that inspection. At 0853, the recorded weather at GRR was: Wind 180 degrees at 11 knots, 10 statutemiles visibility, sky condition broken 12, 000 feet, temperature 18 degrees C, dew point 12 degrees C, altimeter 29.93 inches of mercury. Federal Aviation Administration inspectors examined the wreckage on-scene. No airframe pre-impact anomalies were observed. The airplane’s engine was shipped to the engine manufacturer for a teardown inspection. The crankshaft exhibited a separation of its number three short cheek. The number two lower through-bolt torque was the lowest of all through-bolts found during the engine disassembly. A nut, specified to be used on a cylinder stud, was found installed on that through-bolt. Fretting was observed on the mating surfaces of the main bearing supports near that through-bolt and its bearing had also spun out of its support. The crankshaft separation exhibited beach and ratchet marks. An engine manufacturer metallurgist confirmed that the separation was consistent with fatigue.

Aircraft

Registration
N4632A
Reported as
Cessna P210N
Category
Airplane
Serial number
P21000810
Airframe hours
4,342
Engine
Cont Motor TSIO-520-RCAF, 310 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Centurion Aviation LLC
Registered owner
Centurion Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 3, 2009
Departed
GRR · Grand Rapids, MI
Destination
GRR · Grand Rapids, MI
Airport
GRR · Gerald R. Ford IAP

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
42
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 10, 2010
Seat
Left
Flight hours
3,300 total · 42 in this make and model · 3,230 as pilot in command · 200 in the last 90 days · 59 in the last 30 days · 5 in the last 24 hours
Role
Flight instructor
Age
26
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
November 2, 2009
Seat
Right
Flight hours
1,800 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 11 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft broken
Temperature
64 °F, dew point 54 °F
Altimeter
29.93 inHg
Observed at
GRR, 5 nm away

Docket · 5

The files NTSB released with the investigation on May 9, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.3 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.