CEN18LA392

NTSB accident investigation · Cirrus SR22 · Addison, TX · September 30, 2018

Accident · No injuriesLimited investigationFinal report
Date
September 30, 2018, 11:21 local (16:21 UTC)
Place
Addison, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N818GMCirrus SR22
Defining event
Enroute-climb to cruise: Sys/Comp malf/fail (non-power)
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Flight Standards DIstrict Office, Cirrus Aircraft
FAA report
20180930016519A
Case key
98376

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

Maintenance personnel’s improper installation of the muffler attachment hardware, which resulted in the muffler separating in flight, thermal damage that interrupted the magnetos’ function, and the subsequent total loss of engine power.

Findings · 2

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.

Maintenance: repairPersonnel issues › Task performance · Maintenance personnelCirrus Design SR22: 2 casesAll aircraft: 99 casesProbable cause
Engine exhaustAircraft › Aircraft power plant · Incorrect service/maintenanceCirrus Design SR22: 1 caseAll aircraft: 56 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 and flight instructor were conducting a cross-country instructional flight. During departure and while climbing through 2,800 ft mean sea level, the pilot and instructor noticed multiple avionics malfunctions and initiated a turn back toward the airport. While the airplane was turning, the engine lost all power, and the pilots noted indications of a fire. Because they were unable to find a suitable area for a forced landing, the pilot activated the airplane's parachute system. The airplane descended under the parachute into a parking lot, and the main wing spar sustained substantial damage. Examination of the engine revealed that the engine exhaust muffler attachment hardware was not secured correctly, which allowed the exhaust collector to freely rotate. A hole near the lower right engine cowling was consistent with escaping hot exhaust gas. Several components in the right forward side of the firewall were thermally damaged, and both magneto p-leads were shorted against the engine's metal mount frame. The thermal damage interrupted both magnetos' function, which resulted in the loss of engine power. During a pre-buy inspection of the airplane, the No. 1 cylinder base O-ring was replaced. The work order, dated 3 days before the accident, required removal of the muffler. During the muffler reinstallation, maintenance personnel likely did not correctly install the attachment hardware, which resulted in the muffler separating in flight, thermal damage that interrupted the magnetos' function, and the subsequent loss of engine power.

Factual narrative

On September 30, 2018, about 1121 central daylight time, a Cirrus SR22 airplane, N818GM, impacted terrain following a total loss of engine power near Addison Airport (ADS), Dallas, Texas. The pilot and flight instructor were not injured, and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed for the flight, which departed ADS about 1115, with a destination of Waco Regional Airport (ACT), Waco, Texas. While on departure climbing through 2,800 ft mean sea level, the pilot and flight instructor noticed multiple avionics malfunctions and turned back toward ADS. During this turn, the engine lost total power and indications of a fire were noticed. When the flight instructor and pilot recognized the airplane was not within gliding distance of ADS or a suitable forced landing area, the pilot initiated the Cirrus Airframe Parachute System (CAPS). The airplane descended under parachute into a parking lot and the main spar was damaged. Accident site examination revealed a hole near the lower right engine cowling from a burn through. Examination at the recovery facility revealed two of the three sets of hardware were missing from the muffler attach point. The remaining bolt, washers, spring and castellated nut remained attached, but no cotter pin was installed. Without the muffler attachment hardware, the exhaust collector was free to rotate. The hole in the lower right engine cowling was consistent with escaping hot exhaust gas. Various components in the right forward side of the firewall were thermally damaged. Numerous white areas consistent with electrical arcing were present, including both magneto p-leads shorted against the metal engine mount frame. Although both magneto p-leads were shorted, the two magnetos were not damaged. After the magneto p-leads were disconnected, the magnetos produced sparks at all ignition leads when the engine was manually rotated. During a pre-buy inspection of the airplane, a report prepared by the maintenance provider listed issues discovered and corrective actions performed. Two of the entries were "#1-cylinder base o-ring is seeping" and "replaced #1-cylinder base o-ring P/N 641066 IAW TCM IO-550-N MN CH17-3". The work order to replace the cylinder o-ring, dated three days prior to the accident, required removal and reinstallation of the muffler.

Aircraft

Registration
N818GM
Reported as
Cirrus SR22
Category
Airplane
Serial number
0256
Built
2002
Airframe hours
1,334
Engine
Continental IO-550N, 310 horsepower, reciprocating
Damage
Substantial damage
Fire
In-Flight
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · May 23, 2018 · 13 hours before
Departed
ADS · Dallas, TX
Destination
ACT · Waco, TX
Flight plan
IFR
Equipment
Airframe parachute, ADS-B, Stall warning system, Onboard weather, Handheld GPS, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Auto-pilot

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
44
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Last flight review
April 19, 2018
Seat
Left
Restraint
4-point
Flight hours
509 total · 2 in this make and model · 494 as pilot in command · 38 in the last 90 days · 14 in the last 30 days · 2 in the last 24 hours
Role
Flight instructor
Age
27
Injuries
None
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 15, 2017
Seat
Right
Restraint
4-point
Flight hours
1,514 total · 113 in this make and model · 1,289 as pilot in command · 78 in the last 90 days · 53 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 7 knots
Visibility
10 statute miles
Lowest ceiling
3,500 ft broken
Temperature
79 °F, dew point 70 °F
Altimeter
30.15 inHg
Observed at
KDAL, 3 nm away

Docket · 6

The files NTSB released with the investigation on September 14, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.1 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.