# NTSB CEN18LA392: Cirrus SR22, N818GM, Addison, TX, September 30, 2018

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: September 30, 2018, 11:21 local (16:21 UTC)
- Place: Addison, TX
- Coordinates: 32.896945, -96.834167 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.8969&lon=-96.8342&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-climb to cruise: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report April 13, 2020
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: Continental Motors, Flight Standards DIstrict Office, Cirrus Aircraft
- NTSB case key (mKey): 98376
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA392
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98376/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98376
- Page: https://openairdocs.org/ntsb/CEN18LA392

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cirrus Design SR22, 2 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=2130001), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md)
- [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cirrus Design SR22, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=2130001), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-climb to cruise: Sys/Comp malf/fail (non-power)](https://openairdocs.org/ntsb-events/330) (defining event); cases with it: [Cirrus Design SR22, 6 cases](https://openairdocs.org/ntsb-events/330/sequence.md?model=2130001), [All aircraft, 994 cases](https://openairdocs.org/ntsb-events/330/sequence.md)
- [Enroute-climb to cruise: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Cirrus Design SR22, 10 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=2130001), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md)
- [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Cirrus Design SR22, 50 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2130001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)

## 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](https://openairdocs.org/aircraft/N818GM), registered now, S/N 0256, built 2002 (OpenAirDocs)
- Reported make and model: Cirrus SR22
- Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs)
- Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 0256
- Year built: 2002
- Airframe hours: 1334
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 44; injuries: none; 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
- Flight instructor; age 27; injuries: none; 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

## 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 20180930016519A](https://openairdocs.org/incident/20180930016519A), Sep 30, 2018: Cirrus Design Corp SR22, Farmersbranch, TX, Destroyed. Shortly after takeoff from addison Texas inroute to waco Texas (IFR)pilot noticed circut breakes poping and then aircraft lost electrical power. Instructor…

## Docket (6 files)

The files NTSB released with the investigation on September 14, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98376. 8.1 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 8 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8704543&FileExtension=pdf&FileName=Pilot%206120_Redacted-Rel.pdf
- Excerpt of engine examination report (item 2, PDF, 1 page, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8704475&FileExtension=pdf&FileName=Excerpt%20of%20Engine%20Examination%20Report-Rel.pdf
- Excerpt of airframe examination report (item 3, PDF, 2 pages, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8712723&FileExtension=pdf&FileName=Excerpt%20of%20Airframe%20Examination%20Report_Redacted-Rel.pdf
- Information from FAA inspector (item 4, PDF, 1 page, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8705802&FileExtension=pdf&FileName=Information%20from%20FAA%20Inspector-Rel.pdf
- Maintenance discrepancy action report (item 5, PDF, 3 pages, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8703782&FileExtension=pdf&FileName=Discrepancy_Action_Report%20-%20Redacted-Rel.pdf
- Statement of party representatives to NTSB investigation (item 6, PDF, 3 pages, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8702874&FileExtension=pdf&FileName=.Party%20Member%20Statements_Redacted-Rel.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.