# NTSB CEN20LA256: Cessna 320, N19AS, Round Rock, TX, July 1, 2020

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Limited · Final report
- Date: July 1, 2020, 13:00 local (18:00 UTC)
- Place: Round Rock, TX · Field with trees and cactus.
- Coordinates: 30.558606, -97.70443 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=30.5586&lon=-97.7044&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: McCauley Propeller, Continental Motors, FAA San Antonio FSDO, Textron Aviation
- ADs cited in the narratives: AD 2001-01-16, [AD 75-23-08 R5](https://openairdocs.org/ad/75-23-08-R5) (OpenAirDocs)
- NTSB case key (mKey): 101521
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA256
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101521/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101521
- Page: https://openairdocs.org/ntsb/CEN20LA256

## Probable cause

Improper maintenance that led to a loss of engine power due to a failed left engine magneto, the pilot’s improper application of single engine emergency procedures, and his failure to maintain control of the airplane which resulted in a collision with trees.

## Findings

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

- [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Fatigue/wear/corrosion; cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=2074502), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md)
- [Engine exhaust](https://openairdocs.org/ntsb-findings/01057800): Aircraft › Aircraft power plant · Damaged/degraded; cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/01057800/cases.md?model=2074502), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/01057800/cases.md)
- [Ignition system: magneto/distributor](https://openairdocs.org/ntsb-findings/01057414): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/01057414/cases.md?model=2074502), [All aircraft, 101 cases](https://openairdocs.org/ntsb-findings/01057414/cases.md)
- [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on equipment (probable cause); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=2074502), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2074502), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters: engine out control](https://openairdocs.org/ntsb-findings/01062025): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-findings/01062025/cases.md?model=2074502), [All aircraft, 35 cases](https://openairdocs.org/ntsb-findings/01062025/cases.md)

## Sequence of events

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

- [Maneuvering: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-events/150/sequence.md?model=2074502), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md)
- [Landing: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=2074502), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md)
- [Landing: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=2074502), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=2074502), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490); cases with it: [Cessna 320, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=2074502), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md)

## Analysis

The pilot departed in the multi-engine airplane and proceeded east. The airplane turned north and impacted trees about 30 nm west of the last flight track data. A postimpact fire ensued and the wreckage was destroyed. According to a witness driving near the accident site, the airplane flew low, and she thought the airplane was going to land. Another witness driving near the accident site, observed the airplane flying “erratically” with flames emitting from the left engine, but did not remember seeing smoke in the sky or smoke emitting from the airplane. Another witness near the accident site, reported that the airplane was "sputtering" and "popping" as it flew over his home. Postaccident examination showed that the airplane descended through trees and was highly fragmented and mostly consumed by fire. Both propellers had indications consistent with low amounts of rotational energy. The right engine propeller blades were at a blade angle near feather pitch at impact and the left engine propeller blades appeared to be fully feathered. All engine control levers were found full forward except the left engine propeller lever, which was full aft. Additional examination revealed the right magneto installed on the left engine would not rotate due to a failed bearing. The failure signatures were indicative of a loss of lubrication in the bearing. It is likely the airplane experienced at least a partial loss of engine power in the left engine as a result. The evidence is consistent with the pilot attempting to shut down the left engine due to the failed magneto and failing to maintain single-engine flight resulting in an impact with trees and terrain. Both engine exhaust systems were in an unairworthy condition due to very thin metal, holes, cracks, and signs of oxidative degradation. Exhaust leaks can result in an inflight fire. However, the post-impact fire prevented determination if an inflight fire occurred and the witness testimony of flames coming from the engine could not be verified.

## Factual narrative

In February 2009, Cessna released Service Newsletter 09-3 Engine Exhaust System Inspections. This document discusses the importance of performing inspections on the engine exhaust systems for the Cessna 300 and 400 series airplanes. This document has published a warning that states: Lack of diligence in accomplishing the required inspections and subsequent necessary replacement of life limited and/or discrepant exhaust components may lead to exhaust system failure and potentially cause a fire. This document also provides a reminder of compliance with FAA AD 2001-01-16 and that Cessna considers compliance with SB MEB99-9 to be mandatory. The Cessna 320 Service Manual discusses the engine exhaust system, and provides the following warning: A thorough inspection of the engine exhaust system is required to detect any breaks or cracks causing leaks which might result in the loss of optimum turbocharger efficiency and engine power. A leaking exhaust system may also promote deterioration of engine compartment structure and components or could result in a fire. Textron Aviation has published the Pilot Safety and Warning Supplements. This document provides guidance for pilots on how to handle inflight fires and states in part: A preflight checklist is provided to aid the pilot in detecting conditions which could contribute to an airplane fire. Flight should not be attempted with known fuel, oil, or exhaust leaks since they can lead to a fire. An engine compartment fire is usually caused by fuel contacting a hot surface, an electrical short, bleed air leak, or exhaust leak. According to Continental Motors, the engine exhaust gas temperatures for flight operations is dependent on the mixture setting. For cruise flight, the temperature can range from 1,450°F to 1,600°F at the optimal power setting. The maximum gas temperature for the engine exhaust system is 1,750°F. 14 CFR Part 43.3 discuses persons authorized to perform maintenance, preventive maintenance, rebuilding, and alterations. This regulation states in part: The holder of a mechanic certificate may perform maintenance, preventive maintenance, and alterations as provided in Part 65 of this chapter. A person working under the supervision of a holder of a mechanic or repairman certificate may perform the maintenance, preventive maintenance, and alterations that his supervisor is authorized to perform, if the supervisor personally observes the work being done to the extent necessary to ensure that it is being done properly and if the supervisor is readily available, in person, for consultation. However, this paragraph does not authorize the performance of any inspection required by Part 91 or Part 125 of this chapter or any inspection performed after a major repair or alteration. Except for holders of a sport pilot certificate, the holder of a pilot certificate issued under part 61 may perform preventive maintenance on any aircraft owned or operated by that pilot, which is not used under Part 121,129, or 135 of this chapter. The pilot had purchased the airplane about one year prior to the accident and the pilot kept the airplane at RYW. The mechanic based at RYW stated the pilot worked on the airplane himself and reported that the airplane looked “very rough to me.” Based on the pilot’s flight log, the pilot first flew the airplane in July 2019 and the most recent flight before the accident flight was in February 2020. Prior to the flight, the pilot sent a text message to a friend stating that airplane had been “down” due to “leaking fuel selectors” and that he “fixed a bunch of wiring” in the airplane. A review of the airplane’s maintenance records showed that the airplane had received an annual inspection in January 1999, April 2001, June 2002, April 2008, and then in February 2014. The most recent annual inspection occurred in July 2019. During the July 2019 annual inspection, it was noted that FAA Airworthiness Directive (AD) 2oo1-01-16 (effective February 15, 2000), concerning the exhaust system of the Cessna 300 and 400 series airplanes, was complied with. During the February 2014 annual inspection, AD 75-23-08 R5 (which was replaced by AD 2001-01-16) was noted that it was complied with. In August 1999, Cessna released Service Bulletin (SB) MEB99-9 Engine Exhaust Access Panels Installation. The purpose of this SB states: To add access panels to the lower nacelle which are designed to provide additional access for inspection and replacement of exhaust system components and non-destructive inspection of the engine support beams. While Cessna considers compliance with the SB to be mandatory, the FAA does not mandate compliance with the SB for 14 CFR Part 91 operations. A review of the airplane’s maintenance records did not show compliance with the SB. The airplane was not equipped with engine fire compartment extinguishers, nor was it required to be. According to Continental Motors, the engine exhaust gas temperatures for flight operations is dependent on the mixture setting. For cruise flight, the temperature can range from 1,450°F to 1,600°F at the optimal power setting. The maximum gas temperature for the engine exhaust system is 1,750°F. On July 1, 2020, about 1300 central daylight time, a Cessna 320 airplane, N19AS, was destroyed when it was involved in an accident near Round Rock, Texas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A mechanic based at the Rusty Allen Airport (RYW), Lago Vista, Texas, who knew the pilot, reported that on the day of the accident, the pilot asked the mechanic for assistance with moving the airplane. The pilot reported that when he went to taxi for departure, he “lost a brake on one side.” The mechanic helped the pilot reposition the airplane and assisted the pilot with bleeding the brake. The pilot reported to the mechanic that he might fly to the Burnet, Texas, area. The mechanic was not present when the pilotdeparted but was told from a witness that the pilot ran the airplane for a “long time” on the ramp before departing. Flight track data showed that the airplane departed from RYW, about 1220, and proceeded east. About 1243, the airplane turned left to the north and then to the west. The last flight track data at 1244 showed the airplane at 2,725 ft above msl, heading 240°, at 132 knots. One witness who was driving observed the airplane flying low and she thought the airplane was going to land. Another witness who was driving, observed the airplane flying “erratically” and she observed flames emitting from the left engine, but did not remember seeing smoke in the sky or smoke emitting from the airplane. Another witness reported that the airplane was "sputtering" and "popping" as it flew over his home. The airplane came to rest on a northeast heading in an area of trees and cactus, near a rock quarry, about 30 nm west of the last flight track data. The airplane was fragmented from the impact sequence and a postimpact fire ensued. The estimated density altitude for the accident site was 3,023 ft above msl. The pilot worked as a first officer for a regional airline and held a type rating for the Embraer EMB-145 series. According to Federal Aviation Administration (FAA) records, the pilot did not hold a mechanic certificate. Onsite documentation of the accident site showed that the airplane descended through various trees and was highly fragmented. The wreckage was mostly consumed by a postimpact fire. Postaccident examination of the airframe revealed flight control continuity. The landing gear actuator was found in the extended position and the flap actuator was found in the up position. Both engine exhaust systems were in a poor and unairworthy condition. The exhaust systems on the Cessna 320 are either manufactured out of stainless steel or Inconel (an austenitic nickel-chromium-based super alloy). Both exhaust systems had wall areas with very thin metal, holes, cracks, impact fractures, and signs of oxidative degradation. The loss of wall thickness in exhaust systems is the result of oxidative degradation, which can eventually result in holes over time at operating temperature. Based on the available evidence, it could not be determined when the oxidative degradation process started and how long it occurred for. There were no indications of any preimpact mechanical malfunctions or failures with the propellers. The propellers had indications consistent with low amounts of rotational energy and a blade angle near feather pitch at impact.

## Aircraft

- Registration: [N19AS](https://openairdocs.org/deregistered/N19AS-2022-07-30), registration cancelled 2022-07-30, S/N 320-0086, built 1961 (OpenAirDocs)
- Reported make and model: Cessna 320 (Undesignat)
- Registry model: [Cessna 320](https://openairdocs.org/model/cessna-320) (registry code 2074502) (OpenAirDocs)
- Registry engine: [Continental TSI0-470-B](https://openairdocs.org/engine/continental-tsi0-470-b) (registry code 17029, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 320-0086
- Year built: 1961
- Airframe hours: 7648.2
- Engines: Continental Motors TSIO-470-D 260 horsepower reciprocating; Continental Motors TSIO-470-D 260 horsepower reciprocating
- Damage: Destroyed
- Fire: In-Flight
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 10, 2019, 22.8 hours before
- Departed: RYW, Lago Vista, TX
- Destination: RYW, Lago Vista, TX
- Equipment: ADS-B

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 58; injuries: fatal; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review December 19, 2019; seat: left; toxicology performed; flight hours: 1,667.9 total, 56.1 in this make and model, 1,392.5 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 200° at 12 knots
- Visibility: 10 statute miles
- Lowest ceiling: 2,800 ft overcast
- Temperature: 86 °F, dew point 73 °F
- Altimeter: 29.94 inHg
- Observed at: KGTU, 7 nm away
- METAR: KGTU 011756Z 20012KT 10SM OVC028 30/23 A2994 RMK AO2 SLP131 T03000228 10300 20267 50001

## 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 20200701009029A](https://openairdocs.org/incident/20200701009029A), Jul 1, 2020: Cessna 320, Round Rock, TX, Destroyed, 1 fatal. N19AS a Cessna 320 skyknight serial number 320-0086, departed runway 15 at lago vista, rusty allen airport (kryw) under visual flight rules at approximately…

## Docket (19 files)

The files NTSB released with the investigation on April 19, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101521. 83.5 MB in all.

- Accident photographs (item 1, PDF, 15 pages, 9.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13339812&FileExtension=pdf&FileName=Accident%20Photographs%20-Rel.pdf
- Various statements (item 2, PDF, 15 pages, 781 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349401&FileExtension=pdf&FileName=Various%20Statements%20Redacted-Rel.pdf
- Examination reports (item 3, PDF, 8 pages, 832 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349518&FileExtension=pdf&FileName=CEN20LA256%20Examination%20Reports%20Redacted-Rel.pdf
- Materials laboratory factual report 22-002 (item 4, PDF, 22 pages, 23 photos, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13316122&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2022-002-Rel.pdf
- Federal aviation administration and Textron aviation documents (item 5, PDF, 60 pages, 10.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347011&FileExtension=pdf&FileName=Federal%20Aviation%20Administration%20and%20Textron%20Aviation%20Documents%20Redacted-Rel.pdf
- Continental motors documents (item 6, PDF, 3 pages, 796 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13358245&FileExtension=pdf&FileName=Continental%20Motors%20Documents-Rel.pdf
- Continental motors tsio-470-D engine exhaust gas temperatures email (item 7, PDF, 2 pages, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13430010&FileExtension=pdf&FileName=Continental%20Motors%20TSIO-470-D%20Engine%20Exhaust%20Gas%20Temperatures%20Question%20Email%20Redacted-Rel.pdf
- Maintenance records (item 8, PDF, 35 pages, 34.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349288&FileExtension=pdf&FileName=Maintenance%20Records%20Redacted-Rel.pdf
- Most recent maintenance work - work order package (item 9, PDF, 15 pages, 14.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349842&FileExtension=pdf&FileName=Most%20Recent%20Maintenance%20Work%20-%20Work%20Order%20Package%20Redacted-Rel.pdf
- N19AS ADS-B data (.kmz file) (item 10, KMZ, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347873&FileExtension=kmz&FileName=N19AS%20ADS-B%20Data-Rel.kmz
- N19AS ADS-B data (.xlsx file) (item 11, XLSX, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347695&FileExtension=xlsx&FileName=N19AS%20ADS-B%20Data-Rel.xlsx
- Private N19AS ADS-B data (item 12, PDF, 86 pages, 295 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13348694&FileExtension=pdf&FileName=Private%20N19AS%20ADS-B%20Data%20Redacted-Rel.pdf
- N19AS opsvue data (.kmz file) (item 13, KMZ, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13348461&FileExtension=kmz&FileName=N19AS%20OPSVUE%20Data-Rel.kmz
- N19AS opsvue data (.csv file) (item 14, CSV, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13348471&FileExtension=csv&FileName=N19AS%20OPSVUE%20Data-Rel.csv
- Federal aviation administration - pilot information (item 15, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13361583&FileExtension=pdf&FileName=FAA%20Pilot%20Information%20Redacted-Rel.pdf
- Pilot's logbook (.xlsx file) (item 16, XLSX, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13348303&FileExtension=xlsx&FileName=Pilot%27s%20Logbook_01-01-2018%20to%2006-24-2020-Rel.xlsx
- Autopsy and toxicology information (item 17, PDF, 2 pages, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13338088&FileExtension=pdf&FileName=Autopsy%20and%20Toxicology%20Information%20Redacted-Rel.pdf
- Weather data (item 18, PDF, 3 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347345&FileExtension=pdf&FileName=Weather%20Data%20Redacted-Rel.pdf
- NTSB party member forms (item 19, PDF, 3 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13407926&FileExtension=pdf&FileName=NTSB%20Party%20Member%20Forms%20Redacted-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.

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