# NTSB CEN12LA076: Cirrus Design SR20, N211CD, New Orleans, LA, November 20, 2011 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 20, 2011, 10:30 local (16:30 UTC) - Place: New Orleans, LA - Coordinates: 30.036388, -90.020835 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.0364&lon=-90.0208&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report December 11, 2012 - Report: Approved by Office Director - NTSB office: Central Region - NTSB case key (mKey): 82366 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82366/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82366 - Page: https://openairdocs.org/ntsb/CEN12LA076 ## Probable cause A loss of engine power due to detonation of the No.2 cylinder from a clogged fuel injector nozzle. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel injector nozzle](https://openairdocs.org/ntsb-findings/01057313): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Cirrus Design SR20, 1 case](https://openairdocs.org/ntsb-findings/01057313/cases.md?model=2130000), [All aircraft, 20 cases](https://openairdocs.org/ntsb-findings/01057313/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cirrus Design SR20, 2 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2130000), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cirrus Design SR20, 8 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2130000), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) ## Analysis Shortly after takeoff in instrument meteorological conditions over water, the pilot observed the No. 2 cylinder head temperature (CHT) rapidly increase followed by a drop in oil pressure. He declared an emergency and attempted to return to the airport, but the engine failed and the propeller seized. The pilot landed safely on the water and was rescued by a local fisherman. Examination of the engine revealed the No. 2 fuel injector nozzle was clogged resulting in detonation of the No. 2 cylinder. A review of maintenance records revealed that each of the fuel injector nozzles was removed and cleaned 5 days before the accident. The pilot said he had the nozzles cleaned because he noticed a high CHT on the No. 2 cylinder during a cross-country flight. After the nozzles were cleaned, they were placed back on the engine and two separate engine runs were conducted. No anomalies were noted. The pilot then flew a 2.5 hour cross-country flight without incident. However, on the pilot's next flight, which was the accident flight, the engine failed due to detonation. ## Factual narrative On November 20, 2011, at 1030 central standard time, N211CD, a Cirrus SR20, a single-engine airplane, sustained substantial damage when it ditched in Lake Ponchartrain, about four miles north of Lakefront Airport (NEW), New Orleans, Louisiana, after a total loss of engine power shortly after takeoff. The airline transport rated pilot sustained minor injuries. The airplane was registered to and operated by the pilot. An instrument flight rules flight plan was filed for the flight that departed NEW about 1015 and destined for Dalton Municipal Airport (DNN), Dalton, Georgia. Instrument meteorological conditions prevailed for the personal flight conducted under 14 Code of Federal Regulations Part 91. The pilot reported that shortly after takeoff from NEW, he observed the No. 2 cylinder head temperature (CHT) rapidly increase followed by a drop in oil pressure. He immediately turned back to the airport and requested short vectors for an instrument approach into NEW. The pilot said that when the airplane was about four miles from the runway, the engine "blew" and the propeller seized. He immediately declared an emergency; slowed the airplane to 80 knots and prepared for a landing in the water. The pilot said he broke through the low cloud layer at 300-feet at which point, he extended the flaps to 15 degrees, reduced airspeed until he heard the stall horn, and deployed the ballistic parachute system. The pilot made a wings-level landing on the water and remained upright. He then contacted air traffic control to inform them he was in the water. The pilot donned a life jacket and safely exited the airplane. When he exited the airplane, he noted oil streaks on the bottom side of the engine cowling. The pilot rested on the tail of the partially submerged airplane for approximately forty-five minutes until a local fisherman arrived and picked him up. The only damage to the airplane was a wrinkle in the firewall. The engine was examined at Continental Motors Incorporated, Mobile, Alabama, under the supervision of the Investigator-in-Charge (IIC). An external examination of the engine revealed no obvious impact damage; breaches to the engine case, or leaking oil. The only damage was from exposure to water. When the crankshaft flange was manually rotated, it stopped at approximately 300 degrees of travel before it locked up. Disassembly of the engine revealed the No. 2 piston exhibited damage consistent with detonation. The No. 1 and No. 6 piston rods were broken and were dark in color from exposure to heat. The other piston rods were also damaged and exhibited damage consistent with exposure to heat. The crankshaft was fractured in two sections and pieces of the No.6 piston cap were found in the oil sump. The fuel pump and throttle body were flushed to remove any water and debris before flushing the metering unit. The fuel metering unit was removed and flushed. A clean glass jar was placed under each nozzle to capture any water and debris. No visible debriswas noted and each jar appeared to fill uniformly. The fuel injector nozzles were removed and bench-tested. The No. 2 nozzle tested about two pounds below the minimum value. Shop air was then blown through the nozzle with a paper filter placed on the other end to catch any debris. The nozzle was re-tested and it produced a better value, but was slightly below the minimum value. Shop air was again blown through the nozzle and a paper filter was used to capture any debris. More debris was visually noted on the second forced air attempt than the first attempt. The nozzle was re-tested and its performance was not improved. The filters were examined using an electron microscope and several specs of black dirt were noted. The other nozzles tested slightly below minimum values indicating they were operating lean. A review of maintenance records revealed that the fuel injector nozzles were removed and cleaned five days before the accident on November 13, 2011. The pilot said he had them cleaned because he noticed a high CHT on the No. 2 cylinder during a cross country flight from Louisiana to Arkansas. After the nozzles were cleaned, they were placed back on the engine and two separate engine runs were conducted. No anomalies were noted. The pilot then flew back to Louisiana (a 2.5 hour flight) and everything was "normal." However, on his next flight, which was the accident flight, the subsequent engine failure occurred. ## Aircraft - Registration: [N211CD](https://openairdocs.org/deregistered/N211CD-2014-10-17), registration cancelled 2014-10-17, S/N 1049, built 2000 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR20 - Registry model: [Cirrus Design SR20](https://openairdocs.org/model/cirrus-design-sr20) (registry code 2130000) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 1049 - Engines: LYCOMING IO360 SER A&C 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Glass Thomas Brooks - Registered owner: Glass Thomas Brooks - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 18, 2011 - Departed: NEW, New Orleans, LA - Destination: Dalton, GA - Flight plan: IFR ## Weather - Conditions: Instrument (IMC), Day - Wind: 200° at 4 knots - Visibility: 3 statute miles - Temperature: 163 °F, dew point 162 °F - Observed at: NEW, 5 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20111120027849A](https://openairdocs.org/incident/20111120027849A), Nov 20, 2011: Cirrus Design Corp SR20, New Orleans, LA, Substantial damage. Aircraft departed Lakefront Airport (new) and on climb out started having engine problems. Contacted New Orleans departure (msy) turned back to lake front and… ## Docket (5 files) The files NTSB released with the investigation on October 15, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82366. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377661&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Maintenance Write-Up on Fuel Injector Nozzles (item 2, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377655&FileExtension=.PDF&FileName=Maintenance%20Write-Up%20on%20Fuel%20Injector%20Nozzles-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377818&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 4, .PDF, 255 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378588&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40378032&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.