CEN14LA226

NTSB accident investigation · Flight Design Ctls · Greenville, TX · April 25, 2014

Accident · Minor injuriesLimited investigationFinal report
Date
April 25, 2014, 17:42 local (22:42 UTC)
Place
Greenville, TX
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N106SFFlight Design Ctls
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report July 11, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA -- North Texas Flight Standards, Rotech Research Canada Ltd
FAA report
20140425017129A
Case key
89149

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

The fatigue failure of the No. 4 cylinder exhaust valve due to excessive wear of the corresponding train tappet, which resulted in a total loss of engine power.

Findings · 1

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 eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionFlight Design CTLS: 2 casesAll aircraft: 373 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 private pilot reported that a routine maintenance inspection had been completed earlier on the day of the accident. During the initial personal flight after the inspection, the engine exhaust gas temperatures (EGT) differed by up to 150 degrees, although they remained within the specified operating limitations. The pilot chose to divert to an intermediate airport to investigate any mechanical issue with the engine. The pilot reported that a mechanic informed him that the EGT difference was not unusual for that particular engine. No significant engine issues were identified, and two subsequent run-ups were normal. A third run-up and subsequent takeoff were also normal. As the flight progressed, the EGT indications were within limitations, and, after 25 minutes, they had equalized. About 5 minutes later, the engine and propeller "stopped abruptly." The pilot's attempts to restore engine power were unsuccessful. He subsequently executed a forced landing to an athletic field. During the landing, the nose landing gear separated, and the airplane nosed over. A postaccident engine examination revealed that the No. 4 cylinder exhaust valve had failed near the valve head due to bending fatigue. The No. 4 cylinder, piston, and exhaust valve head exhibited extensive gouging, scraping, and deformation consistent with secondary damage due to the failed exhaust valve. Further examination revealed that the No. 4 cylinder exhaust train tappet exhibited severe wear, which had significantly reduced the height of the exhaust tappet compared to the height of the intake tappet. The resulting gap in the exhaust valve train due to the shortened tappet likely caused excessive impact loads between the exhaust valve and the cylinder valve seat during engine operation, which resulted in the valve's failure. The subsequent secondary damage due to the separated valve head ultimately caused the catastrophic engine failure.

Factual narrative

On April 25, 2014, about 1742 central daylight time, a Flight Design GMBH CTLS light sport airplane, N106SF, was substantially damaged during a forced landing following a loss of engine power near Greenville, Texas. The pilot and passenger sustained minor injuries. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from the Fox Stephens Field – Gilmer Municipal Airport (JXI), Gilmer, Texas, about 1635. The intended destination was the Denton Enterprise Airport (DTO), Denton, Texas. The pilot reported that a routine maintenance inspection was completed earlier on the day of the accident. During the initial flight after the inspection, the engine exhaust gas temperatures differed by up to 150 degrees, although they remained within the specified operating limitations. He elected to divert to the Gilmer Municipal Airport (JXI), Gilmer, Texas. A mechanic reportedly informed the pilot that the EGT difference was not unusual for that particular engine. However, the spark plugs were removed and examined. Minor debris was removed from one of the upper, right spark plugs. Otherwise, the spark plugs exhibited normal wear signatures. The engine oil did not appear to contain any contamination. The spark plugs were re-installed and two subsequent engine run-ups were normal. A third run-up was completed before takeoff from JXI; both the run-up and the takeoff were normal. As the flight progressed, the EGT indications were within limitations and, after 25 minutes, had equalized. About 5 minutes later, the engine and propeller "stopped abruptly." The pilot's attempts to restore engine power were unsuccessful. He initially planned to divert to the Majors Airport (GVT), Greenville, Texas; however, the airplane did not have sufficient altitude to reach the runway. He subsequently elected to execute a forced landing to an athletic field located about 3 miles north of the airport. During the landing, the nose landing gear separated and the airplane nosed over. A postaccident engine examination was conducted under the supervision of a Federal Aviation Administration airworthiness inspector. The examination revealed that the no. 4 cylinder exhaust valve had failed near the valve head. Subsequent metallurgical examination determined that the failure resulted from bending fatigue. The no. 4 cylinder, piston, and exhaust valve head exhibited extensive gouging, scraping, and deformation consistent with secondary damage due to the failed exhaust valve. The damage also included a hole in the top of the piston with extensive secondary impact damage as noted. The tappets exhibited light to moderate spalling, with the exception of the no. 4 cylinder exhaust tappet, which exhibited severe wear. The wear had reduced the height of the exhaust tappet by more than 5 mm ascompared to the intake tappet. In addition, the no. 4 cylinder exhaust valve cam lobe was severely damaged with large spalls visible on both the opening and closing sides. At the time of the accident, the airplane, a Flight Design CTLS (s/n F-09-10-13), had accumulated 1,613 hours total time in service. It was powered by a 100-horsepower Rotax 912 ULS 2, 4-cylinder, reciprocating engine (s/n 6775304), with an identical service time. Maintenance records indicated that the engine complied with the requirements for an extended time-between-overhaul (TBO) of 2,000 hours. The most recent inspection was completed on the day of the accident at 1,608 hours time in service. The maintenance records noted that engine oil was changed at that time. The magnetic plug was noted as "dirty, but OK." In addition, the entry noted that an exhaust pipe leak on the no.2 cylinder was repaired and that two exhaust springs were replaced. There was no specific mention of any maintenance work to the no. 4 cylinder.

Aircraft

Registration
N106SF
Reported as
Flight Design Ctls
Category
Airplane
Serial number
F-09-10-13
Built
2009
Airframe hours
1,613
Engine
Rotax 912ULS, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Annual · April 25, 2014 · 5 hours before
Departed
JXI · Gilmer, TX
Destination
DTO · Denton, TX
Airport
GVT · Majors Airport

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
43
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
September 17, 2013
Seat
Left
Restraint
3-point
Flight hours
320 total · 194 in this make and model · 320 as pilot in command · 74 in the last 90 days · 15 in the last 30 days · 6 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 34 °F
Altimeter
29.93 inHg
Observed at
GVT, 3 nm away

Docket · 9

The files NTSB released with the investigation on May 31, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.4 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.