CEN13LA562

NTSB accident investigation · Cirrus Design SR22 · Mack, CO · September 23, 2013

Accident · Minor injuriesLimited investigationFinal report
Date
September 23, 2013, 17:35 local (23:35 UTC)
Place
Mack, CO
Injuries
1 minor, 2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N426TFCirrus Design SR22
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 25, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA - Salt Lake City FSDO
FAA report
20130923025669A
Case key
88133

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

A total loss of engine power due to the failure of the engine crankshaft, which resulted from maintenance personnel’s application of insufficient torque on the engine case through bolts.

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 · Incorrect service/maintenanceAll aircraft: 233 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · FailureAll aircraft: 233 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelAll aircraft: 143 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, while the airplane was in cruise flight, the engine suddenly lost power and then seized. During the subsequent forced landing, the airplane sustained substantial damage. Examination of the engine revealed that the crankshaft was fractured through the cheek extending from the No. 2 main bearing journal to the No. 3 connecting rod journal. The No. 2 main bearings had extruded from their crankcase positions and exhibited mechanical damage. The No. 2 main bearing support displayed signatures consistent with bearing shift. The No. 2 main bearing saddle support and several other bearing saddle supports exhibited fretting, consistent with movement between the engine case halves due to insufficient torque on the case through bolts. Maintenance logbook records showed that the Nos. 1, 2, 3, and 4 cylinders were replaced about 1 1/2 years before the accident. When maintenance personnel replaced those cylinders, they would have had to remove the nuts on the case through bolts because they also serve as hold-down bolts for the cylinders. Based on the evidence, it is likely that maintenance personnel applied insufficient torque on the case through bolts after replacing the cylinders, which led to case movement and ultimately to the No. 2 main bearings shifting and extruding, the crankshaft fracturing, and the engine seizing.

Factual narrative

On September 23, 2013, about 1735 mountain daylight time, a Cirrus Design Corp SR22 airplane, N426TF, sustained substantial damage during a forced landing to runway 25 at the Mack Mesa Airport (C07), Mack, Colorado. The pilot reported that the engine seized during cruise flight. The pilot executed a forced landing to the airport but landed long, and ran off the end. The airplane became airborne again due to a drop off in the terrain. The pilot then attempted landing on a road and struck a ditch. The private pilot sustained minor injuries and his two passengers were not injured. The business flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a Federal Aviation Administration (FAA) flight plan had been filed for the flight. The flight originated from the San Luis Valley Regional Airport, Alamosa, Colorado, about 1617, and was en route to the Ogden-Hinckley Airport, Ogden, Utah, when the accident occurred. The pilot reported that when the airplane was about 7 to 8 miles northeast of C07, at an altitude of 12,500 feet, the engine suddenly lost power and fuel flow reduced. The pilot reached to increase fuel flow, but the engine seized. He attempted to restart the engine, but it would not rotate. The pilot diverted the airplane to C07 and attempted a landing on runway 25. During the engine out landing, the airplane overran the runway. At the departure end of the runway was a large drop off and the airplane went over the drop off, becoming airborne again. The pilot continued to fly the airplane, maneuvering to avoid power lines and attempted a landing on a road. The airplane sustained damage during the landing. The airplane was equipped with a Heads Up Technologies Recoverable Data Module (RDM) that recorded flight and engine data at a 1 Hertz rate. Review of the recorded data confirmed the pilot's description of events. At 1723:39 (hhmm:ss), the airplane was at 12,190 feet pressure altitude and 82 percent engine power at 2,522 rpm. By 1727:29, the engine power had reduced to 49 percent at 2,524 rpm. Engine power was restored briefly and at 1727:41, was at 89 percent at 2,206 rpm, but then rapidly dropped to 0 percent power and 0 rpm at 17:30:00. The data further showed that the airplane came to rest at 1735:44. Subsequent to the accident, the engine was removed from the airplane for a teardown examination. The examination revealed that the crankshaft was fractured through at the cheek going from the No. 2 main bearing journal to the No. 3 connecting rod journal. The No. 2 main bearings had extruded from their crankcase positions and exhibited mechanical damage. The No. 2 main bearing support displayed signatures consistent with bearing shift. The No. 2 main bearing saddle supports and several other bearing saddle supports exhibited fretting. A review of the airplane's maintenance records showed that on April 13, 2012, the Nos. 1, 2, 3, and 4 cylinders were removed andreplaced due to cracking in the injector boss area. The cylinders were replaced with new units at that time. The through case bolts adjacent to the No. 2 main bearing journal also serve as hold down bolts for cylinders 2 and 3. In order to remove the cylinders it was necessary to remove the nuts from the through bolts.

Aircraft

Registration
N426TF
Reported as
Cirrus Design SR22 (NO SERIES)
Category
Airplane
Serial number
3586
Built
2009
Airframe hours
1,491
Engine
Cont Motor IO-550-N60B, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Trans Med LLC
Registered owner
Trans Med LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 26, 2013 · 190 hours before
Departed
ALS · Alamosa, CO
Destination
OGD · Ogden, UT
Flight plan
Company VFR
Airport
10CO · Mack Mesa Airport, runway 25, 2,600 × 60 ft, asphalt
Equipment
Electronic multifunction display, Data recorder, Auto-pilot, Airframe parachute, Stall warning system, Electronic primary flight display

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
2,888 total · 1,390 in this make and model · 2,838 as pilot in command · 94 in the last 90 days · 34 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 52 °F
Altimeter
29.96 inHg
Observed at
GJT, 19 nm away

Docket · 4

The files NTSB released with the investigation on July 1, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.8 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.