CEN16LA201

NTSB accident investigation · Cessna 402B · Sioux Falls, SD · May 27, 2016

Accident · No injuriesLimited investigationFinal report
Date
May 27, 2016, 09:15 local (14:15 UTC)
Place
Sioux Falls, SD
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N76MDCessna 402B
Defining event
Approach: Fire/smoke (non-impact)
Weather
Visual (VMC) · Day
Status
Completed · report January 18, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20160527007999A
Case key
93282

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

The failure of the No. 4 cylinder head, which resulted in an engine fire and subsequent damage to the wing structure.

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 · FailureCessna 402B: 1 caseAll 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 commercial pilot in the left seat and the airline transport pilot in the right seat were conducting new-hire training for the left-seat pilot. While maneuvering for a practice approach, the pilots noticed the left engine was running rough. The left-seat pilot activated the auxiliary fuel pump, and the roughness resolved temporarily. Shortly thereafter, the left engine tachometer went to zero, and the left-seat pilot noticed flames emitting from the left engine cowling. The pilots declared an emergency, secured the left engine, and landed the airplane uneventfully; the wing structure was damaged by the fire. Examination of the left engine revealed thermal damage to the No. 4 cylinder, consistent with a preexisting crack condition that allowed exhaust gas to erode the cylinder head and resulted in an engine fire.

Factual narrative

On May 27, 2016, at 0915 central daylight time, a Cessna 402B airplane, N76MD, experienced an in-flight left engine fire while maneuvering near the Joe Foss Field Airport (FSD), Sioux Falls, South Dakota. The airline transport pilot and commercial pilot were not injured, and the airplane sustained substantial damage to the left wing. The airplane was operated by Encore Air Cargo, Sioux Falls, South Dakota, as a 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed at the time of the accident and a company flight plan was filed. The local flight departed FSD at 0840. According to the airline transport pilot, while maneuvering for a practice approach, the flight crew noticed a rough running left engine. The commercial pilot activated the auxiliary fuel pump, and the engine then operated without issue. Shortly thereafter, the left engine tachometer went to zero and the commercial pilot, who was seated in the left seat, noticed flames emitting from the left engine cowling. The flight crew declared an emergency and secured the left engine. The airplane landed uneventfully and taxied to the company ramp. Postaccident examination of the airplane by a Federal Aviation Administration inspector and company mechanics revealed substantial damage to the left wing structure and firewall. In addition, the number 4 cylinder was burned through at the exhaust port. The number 6 cylinder valve cover displayed thermal damage consistent with the observed damage to the number 4 cylinder. The number 4 cylinder was removed and sent to Continental Motors Group, Mobile, Alabama, for further examination. On October 13, 2016, the number 4 cylinder was examined by the Continental Motors Group under the supervision of a National Transportation Safety Board investigator. Examination of the cylinder showed a burned through area at the cylinder head exhaust port, consistent with a preexisting crack that allowed exhaust gas to erode the cylinder head. A preexisting crack could not be determined due to the erosion of the burned through area. In addition to the burned through area, a crack was noted on the opposite side of the exhaust port. According to the maintenance records, the number 4 cylinder was overhauled 178.3 hours prior to the accident.

Aircraft

Registration
N76MD
Reported as
Cessna 402B (B)
Category
Airplane
Serial number
402B1055
Built
1977
Airframe hours
13,479
Engines
Cont Motor TSIO-520-E, 300 horsepower, reciprocatingCont Motor TSIO-520-E, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 4, 2016
Departed
FSD · Sioux Falls, SD
Destination
FSD · Sioux Falls, SD
Flight plan
Company VFR
Airport
FSD · Joe Foss Field Airport, runway 15, 8,000 × 150 ft, concrete
Equipment
Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
March 9, 2016
Seat
Right
Restraint
3-point
Flight hours
3,997 total · 1,849 in this make and model · 2,945 as pilot in command · 54 in the last 90 days · 14 in the last 30 days · 3 in the last 24 hours
Role
Pilot
Age
28
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
June 30, 2014
Seat
Left
Restraint
3-point
Flight hours
1,248 total · 10 in this make and model · 975 as pilot in command · 90 in the last 90 days · 13 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 8 knots
Visibility
10 statute miles
Lowest ceiling
12,000 ft overcast
Temperature
63 °F, dew point 55 °F
Altimeter
29.78 inHg
Observed at
FSD

Docket · 4

The files NTSB released with the investigation on November 9, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.8 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.

Other investigations on N76MD · 1

Matched to the same aircraft by N-number and date.