CEN11FA202

NTSB accident investigation · Cessna T210M · Independence, MO · February 24, 2011

Accident · Minor injuriesField investigationFinal report
Date
February 24, 2011, 01:45 local (07:45 UTC)
Place
Independence, MO
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6149BCessna T210M
Defining event
Enroute: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Night
Status
Completed · report January 15, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA -- Kansas City FSDO, Flight Express, Inc., Continental Motors Inc.
FAA report
20110224002289A
Case key
78422

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

Latent dimensional discrepancies related to the engine crankcase main bearing saddle bores, which precipitated the fatigue failure of the crankshaft and a complete loss of engine power. Contributing to the accident was the engine manufacturer's failure to properly identify and address the crankcase discrepancies when the engine was rebuilt.

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 · Inadequate inspectionCessna T210M: 3 casesAll aircraft: 233 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionCessna T210M: 3 casesAll aircraft: 233 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 reported that he was in cruise flight when the engine began to run rough and lose power. Smoke began to enter the cockpit, and engine oil covered the windshield. The engine ultimately lost all power. The pilot executed a forced landing to a roadway, and the left wing struck a bridge guardrail. Examination of the engine revealed a fatigue failure of the crankshaft initiating at the No. 6 connecting rod journal. Further examination determined that several crankcase main bearing saddles were oversized compared to the required specifications. As a result, the crankshaft was not adequately supported within the crankcase during operation, which precipitated the fatigue failure of the crankshaft. Records indicated that the engine was initially manufactured with one oversized saddle bore. The manufacturer subsequently rebuilt the engine, which was installed on the accident airplane. At the time of the accident, the engine had accumulated 1,303.5 hours since it was rebuilt.

Factual narrative

HISTORY OF FLIGHT On February 24, 2011, about 0145 central standard time, a Cessna T210M, N6149B, was substantially damaged during a forced landing following a loss of engine power in cruise flight near Independence, Missouri. The pilot made a forced landing to a roadway. The airplane was registered to and operated by Flight Express Inc. under the provisions of 14 Code of Federal Regulations Part 135 as an on-demand cargo flight. Night visual meteorological conditions prevailed and no flight plan was filed. The pilot sustained minor injuries. The flight originated from St. Louis Downtown Airport, Cahokia, Illinois, about 0030. The intended destination was Charles B. Wheeler Downtown Airport (MKC), Kansas City, Missouri. The pilot reported that he was in cruise flight at 4,000 feet mean sea level, about 18 miles from the intended destination, when the engine began to run rough and lose power. Smoke began to enter the cockpit and engine oil covered the windshield. The engine ultimately lost all power. The pilot executed a forced landing to a roadway. The left wing struck a roadway bridge guard railing during the landing. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate with single and multi-engine land airplane ratings. He also held a flight instructor certificate with single and multi-engine airplane and instrument airplane ratings. He was issued a first class airman medical certificate on March 1, 2010. The pilot reported that at the time of the accident, he had accumulated about 5,800 hours total flight time, with approximately 900 hours in Cessna 210 airplanes. His most recent flight review was completed on December 4, 2010. AIRCRAFT INFORMATION The accident airplane was a 1978 Cessna T210M, serial number 21062694. It was configured with one pilot seat to facilitate cargo operations. The airplane was powered by a 300-horsepower Continental Motors IO-550-P8B engine, serial number 821115-R. The operator reported a total airframe time of 12,103.0 hours at the time of the accident, with 88.3 hours since the most recent inspection. The engine had accumulated 1,303.5 hours at the time of the accident. The most recent inspection was completed on January 3, 2011, at 12,014.7 hours total airframe time. An engine oil change was completed on January 31, 2011. Maintenance records indicated that the engine was rebuilt by Continental Motors and installed on the accident airplane in March 2009. METEOROLOGICAL INFORMATION Weather conditions recorded at the Charles B. Wheeler Downtown Airport (MKC), located about 14 miles west of the accident site, at 0154, were: wind from 030 degrees at 7 knots; 10 miles visibility; overcast clouds at 6,000 feet above ground level; temperature 5 degrees Celsius; dew point 1 degree Celsius; altimeter 30.01 inches of mercury. Weather conditions recorded at the Lee’s Summit Municipal Airport (LXT), located about 10 miles south-southwest of the accident site, at 0153, were: wind from 040 degrees at 7knots; 10 miles visibility; overcast clouds at 5,000 feet above ground level; temperature 4 degrees Celsius; dew point 2 degrees Celsius; altimeter 30.01 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest on a roadway after the forced landing. The left wing struck a guard railing, resulting in substantial damage. Specifically, the lower left wing skin was cut across approximately the entire chord of the wing. Two of the impact cuts were located near the wingtip; the third was near mid-span outboard of the pitot tube. The contact with the guard rail also caused associated damage to the wing substructure in the area of the wing skin damage. TESTS AND RESEARCH A teardown engine examination was conducted under the direct oversight of the NTSB. The crankcase exhibited an approximate 4 inch by 8 inch opening forward of the No. 5 cylinder bore and extending above the No. 6 cylinder bore. The crankshaft was fractured between the No. 6 connecting rod journal and the No. 4 crankshaft main journal. The No.4 main bearing was observed to be shifted within the crankcase saddle. The No. 3 main bearing was fractured into multiple pieces, most of which were recovered from the oil sump. The camshaft was fractured at two locations; between the No. 6 intake and exhaust lobes, and common to the No. 3 main journal. The No. 6 connecting rod bolts were fractured. The No. 6 connecting rod was deformed and exhibited gouges consistent with secondary mechanical damage. The No. 5 and No. 6 pistons exhibited damage consistent with secondary mechanical impact. Specifically, portions of the skirt areas on both pistons were separated from the remainder of the associated piston. Piston fragments were recovered from the oil sump. This damage was also consistent with secondary mechanical impact. The crankshaft fracture surfaces exhibited features consistent with fatigue initiating at the forward radius of the No. 6 connecting rod journal. Three additional cracks were also observed initiating at the forward flank of the No. 3 main journal, the forward flank of the No. 4 connecting rod journal, and the aft flank of the No. 5 connecting rod journal. The camshaft fracture surface features were consistent with fatigue caused by reverse bending. Failure of the No. 6 connecting rod bolts was consistent with overstress. Records indicated that the No. 3 crankcase main saddle bearing diameter was oversize by 0.0017 inch when it was originally manufactured. The crankcase was subsequently reconditioned by the manufacturer for use in the rebuilt engine. The manufacturer’s engineering documentation related to reconditioned crankcase saddle bores noted that the diameter may exceed the specified limit by 0.002 inch within a 40-degree arc centered on the splint line of the crankcase. Outside of that area the diameter must conform to the dimensional requirements. Measurements of the crankcase saddle bores revealed oversize diameters at multiple locations. At a pointoriented 90 degrees to the crankcase split line, all saddle bore diameters measured within specifications. At saddle bores No. 1, No. 4, and No. 5, one of the diameter measurements taken at either the plus or minus 20-degree limit from the split line was oversized. At the No. 2 and No. 3 saddle bores, the diameter was oversized at both the plus and minus 20-degree limit. The maximum dimension, located on the No. 3 bore diameter, measured 2.8185 inch and was 0.0015 inch over the dimensional limit.

Aircraft

Registration
N6149B
Reported as
Cessna T210M
Category
Airplane
Serial number
21062694
Airframe hours
12,103
Engine
Cont Motor IO-550-P8B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Flight Express Inc.
Registered owner
Flight Express Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · January 4, 2011 · 88 hours before
Departed
CPS · Cahokia, IL
Destination
MKC · Kansas City, MO
Flight plan
Company VFR
Airport
MKC · Charles B. Wheeler Downtown

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
38
Injuries
Minor
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 4, 2010
Seat
Left
Flight hours
5,800 total · 900 in this make and model · 5,670 as pilot in command · 150 in the last 90 days · 80 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
40° at 7 knots
Visibility
10 statute miles
Lowest ceiling
5,000 ft overcast
Temperature
39 °F, dew point 36 °F
Altimeter
30.01 inHg
Observed at
LXT, 10 nm away

Docket · 6

The files NTSB released with the investigation on November 2, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.2 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.