# NTSB CEN15LA015: Cessna P210N, N731QV, West Memphis, AR, October 15, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 15, 2014, 17:25 local (22:25 UTC) - Place: West Memphis, AR - Coordinates: 35.134998, -90.234443 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1350&lon=-90.2344&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report March 5, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Continental Motors, Inc., FAA FSDO - NTSB case key (mKey): 90268 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA015 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90268/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90268 - Page: https://openairdocs.org/ntsb/CEN15LA015 ## Probable cause A catastrophic engine failure due to an oil starvation event for reasons that could not be determined based on the available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=2073454), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna P210N, 1 case](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=2073454), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna P210N, 20 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073454), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna P210N, 31 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073454), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Shortly after takeoff, the manifold pressure dropped. The private pilot then turned the airplane back to the airport. He saw smoke coming from under the engine cowl, and the engine stopped producing power while the airplane was on short final and about 800 ft above ground level. The airplane impacted power lines before landing in a grassy area short of the runway. Holes were observed in the top of the engine crankcase. Disassembly of the engine revealed all the crankshaft's connecting rod journals and connecting rods displayed signs of thermal distress and discoloration associated with engine operation without sufficient oil. All six cylinder bays exhibited mechanical damage consistent with an oil starvation event. The engine and component examinations did not identify any anomalies that would have precipitated an oil starvation event and subsequent engine failure. The No. 2 piston was fractured into numerous pieces. The area adjacent to the broken connecting rod displayed surface coloration and oxide formation consistent with exposure to very high temperatures. The engine had experienced a previous "hydraulic lock" event about 1 1/2 years before the accident, but it could not be determined if damage sustained during that event caused the catastrophic failure of the No. 2 piston. ## Factual narrative On October 15, 2014, about 1725 central daylight time, a Cessna P210N airplane, N731QV, sustained substantial damage following a forced landing and impact with terrain after a reported loss of engine power during initial climb out from West Memphis Municipal Airport (AWM), West Memphis, Arkansas. The pilot, who was the registered owner and sole occupant of the airplane, was not injured. Visual meteorological conditions prevailed for the local flight, which was being operated as a personal flight in accordance with 14 Code of Federal Regulations Part 91, and no flight plan had been filed. The pilot reported he was departing for a local training flight. After takeoff, about 10 minutes into the flight while climbing through 4,500 feet MSL, the manifold pressure dropped and the pilot made a turn to return to AWM. Smoke was observed coming from under the engine cowl and the engine stopped while on short final about 800 feet AGL. The airplane impacted power lines before landing in a grassy area short of the runway and on airport property. A JPI EDM-830 engine data module was recovered and subsequently downloaded by a recorder specialist and the NTSB's Vehicle Recorder Laboratory. Data indicated the flight took off about 1714 and about six minutes after takeoff engine RPM began to fluctuate and one minute later the exhaust gas temperatures increased. By 1723, engine RPM decreased, voltage decreased, and manifold pressure increased. The airplane was powered by a six-cylinder Continental Motors IO-550-P6B, serial number 1006549, that was assembled at the Continental Motors factory on May 9, 2012, as a new IO-550-P6B. The engine was shipped to Vitatoe Industries, Inc. on May 14, 2012, where the engine was modified utilizing Vitatoe Supplemental Type Certificate (STC) SA02918CH, converting the engine to a turbo-normalized induction system. According to the maintenance records, the modified engine was installed on the accident airplane on August 7, 2012 (the tachometer time was not reported). The electric boost pump was removed and replaced on April 5, 2014. After the fuel boost pump was replaced, the operator reported he attempted to start the engine after running the boost pump. The crankshaft/propeller rotated but came to an abrupt stop and could not be rotated through (a condition consistent with hydraulic lock). The operator reported that the starter could not rotate the propeller through on consecutive attempts. The operator left the aircraft and returned a couple days later with a battery charger. The engine started on the first attempt without need for battery charging. The operator continued to operate the airplane with no anomalies up until the time of the accident. Hydraulic lock is most common in reciprocating engines and occurs when the amount of liquid introduced into the cylinder is greater than the available volume when the piston head is at the top of its stroke. It typically results in breaking or bending of the connecting rod, but canalso damage the pistons and crankshaft. When an engine experiences hydraulic lock, damage to the engine connecting rods, crankshaft, piston heads, bearings, etc., might not be apparent without an engine inspection. The engine was removed and taken to the Continental Motors facility in Mobile, Alabama, for examination. Holes were observed in the top of the crankcase. Disassembly of the engine revealed all of the crankshaft's connecting rod journals and connecting rods displayed signs of thermal distress and discoloration associated with engine operation without sufficient lubricating oil. There were no signs of an oil leak on any of the engine's components; however, the remote oil filter lines were removed by maintenance personnel for crate shipment and were not observed as part of the examination. Disassembly of the engine revealed that all six cylinder bays sustained mechanical damage. The damage observed was consistent with an engine oil starvation event. However, all bearing saddles were in place and there was no sign of bearing slip or matting surface fretting. All the oil galleys were free from obstructions. In addition to the oil starvation event, the No. 2 piston was fractured into numerous pieces. The face of the piston was fractured into multiple pieces. The No. 2 connecting rod, piston pin, and fractured piston pieces were sent to the NTSB Materials Laboratory for further evaluation. The No. 2 piston pieces examined at the NTSB's Material Laboratory comprised the entire head and estimate 50% of the skirt. The majority of both pin bosses were also present. The entire upper compression ring was also received. Visual and magnified optical examinations revealed features and patterns indicative of overstress separation on all of the received piston fractures. Some of the pieces were darkly colored consistent with baked on oil deposit while other mating pieces were clean. The crown of the piston was clean and had small valve dents corresponding to the intake and exhaust valve locations. The No. 2 piston pin was intact, but the aluminum pin plugs were mechanically damaged. The No. 2 connecting rod was fractured through both main bearing straps. The fracture features were partially obscured by post fracture mechanical damage but the visible fracture features were consistent with bending overstress separations. The adjacent area of the rod displayed surface coloration and oxide formation consistent with exposure to very high temperatures. The bearing surface of the rod showed heavy flow and smearing of the material. The engine and component examinations did not identify any anomalies that would have precipitated an oil starvation event and the subsequent engine failure. ## Aircraft - Registration: [N731QV](https://openairdocs.org/deregistered/N731QV-2018-05-31), registration cancelled 2018-05-31, S/N P21000534, built 1980 (OpenAirDocs) - Reported make and model: CESSNA P210N (N) - Registry model: [Cessna P210N](https://openairdocs.org/model/cessna-p210n) (registry code 2073454) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P21000534 - Year built: 1980 - Airframe hours: 4196 - Engines: CONT MOTOR TSIO-520 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 5, 2014 - Departed: AWM, WEST MEMPHIS, AR - Destination: AWM, WEST MEMPHIS, AR - Airport: AWM, West Memphis Muni, runway 35, 6,003 × 100 ft, concrete - Equipment: Electronic primary flight display, Electronic flight bag or handheld device, Auto-pilot, Stall warning system, Onboard weather, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: none; private; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review August 18, 2013; seat: left; restraint: 3-point; flight hours: 4,000 total, 2,000 in this make and model, 4,000 as pilot in command, 36 in the last 90 days, 5 in the last 30 days, 0.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 50 °F - Altimeter: 29.87 inHg - Observed at: KAWM ## 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 20141015020469A](https://openairdocs.org/incident/20141015020469A), Oct 15, 2014: Cessna P210N, West Memphis, AR, Substantial damage. On October 15, 2014, at 1710 CDT, a Cessna P210N, N731Q, landed short of runway 35 at West Memphis Municipal Airport, West Memphis, Arkansas, after… ## Docket (9 files) The files NTSB released with the investigation on December 21, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90268. 3.5 MB in all. - Materials Laboratory Factual Report 15-055 (item 1, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459033&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2015-055-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 865 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459034&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459035&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 Engine (item 4, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459036&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20Engine-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459037&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Non-Volatile Memory Data- EDM Factual Report (item 6, .PDF, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459038&FileExtension=.PDF&FileName=Non-Volatile%20Memory%20Data-%20EDM%20Factual%20Report-Master.PDF - Non-Volatile Memory Data - EDM Data (item 7, .CSV, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459039&FileExtension=.csv&FileName=Non-Volatile%20Memory%20Data%20-%20EDM%20Data-Master.csv - Record of Conversation with Pilot/Owner (item 8, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459040&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20Pilot%2FOwner-Master.PDF - Photographs of Accident Site and Airplane Logbook Excerpt (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459041&FileExtension=.PDF&FileName=Photographs%20of%20Accident%20Site%20and%20Airplane%20Logbook%20Excerpt-Master.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.