# NTSB CEN16LA201: Cessna 402B, N76MD, Sioux Falls, SD, May 27, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: May 27, 2016, 09:15 local (14:15 UTC) - Place: Sioux Falls, SD - Coordinates: 43.582778, -96.742774 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.5828&lon=-96.7428&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 93282 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16LA201 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93282/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93282 - Page: https://openairdocs.org/ntsb/CEN16LA201 ## Probable cause The failure of the No. 4 cylinder head, which resulted in an engine fire and subsequent damage to the wing structure. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=207590P), [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. - [Approach: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Cessna 402B, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=207590P), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## 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](https://openairdocs.org/aircraft/N76MD), registered now, S/N 402B1055, built 1977 (OpenAirDocs) - Reported make and model: CESSNA 402B (B) - Registry model: [Cessna 402B](https://openairdocs.org/model/cessna-402b) (registry code 207590P) (OpenAirDocs) - Registry engine: [Continental GTSI0-520-F-K](https://openairdocs.org/engine/continental-gtsi0-520-f-k) (registry code 17031, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 402B1055 - Year built: 1977 - Airframe hours: 13479 - Engines: CONT MOTOR TSIO-520-E 300 horsepower reciprocating; CONT 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 33; injuries: none; 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 - Pilot; age 28; injuries: none; 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 ## 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 20160527007999A](https://openairdocs.org/incident/20160527007999A), May 27, 2016: Cessna 402B, Sioux Falls, SD, Substantial damage. On may 27, 2016, the company chief pilot was conducting initial new hire flight training with a new hire pilot in a Cessna 402B. They were doing practice… ## Other investigations on N76MD (1) 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. - [NTSB GAA24WA039](https://openairdocs.org/ntsb/GAA24WA039), Nov 24, 2023: Cessna 402B (N76MD), Panama City, Panama, destroyed, 1 fatal ## Docket (4 files) The files NTSB released with the investigation on November 9, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93282. 4.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446272&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - SDR Report (item 2, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446273&FileExtension=.PDF&FileName=SDR%20Report-Master.PDF - Cylinder Examination - NTSB (item 3, .PDF, 4 photos, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446274&FileExtension=.PDF&FileName=Cylinder%20Examination%20-%20NTSB-Master.PDF - Photo Array (item 4, .PDF, 3 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446275&FileExtension=.PDF&FileName=Photo%20Array-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.