CEN21LA057

NTSB accident investigation · Cirrus SR22 · Tishomingo, OK · October 24, 2020

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
October 24, 2020, 12:00 local (17:00 UTC)
Place
Tishomingo, OK
Injuries
4 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N183VCirrus SR22
Defining event
Enroute-descent: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Continental Aerospace Technologies, Cirrus Owners and Pilots Association, Federal Aviation Administration, Cirrus Aircraft
FAA report
20201024021649A
Case key
102279

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 pilot’s improper adjustment of the engine mixture control, which resulted in a total loss of engine power. Contributing to the accident was a disconnected oil temperature connector, which was likely damaged during maintenance before the accident flight and provided erratic indications during the flight.

Findings · 4

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.

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 three passengers departed on a personal flight in visual conditions. As the airplane approached its destination while at an altitude of about 900 ft above ground level, the pilot received cockpit indications of erratic high engine oil temperature. About 5 seconds after the indications began, the pilot moved the throttle to idle power and likely adjusted the fuel-air mixture. About 3 seconds after moving the throttle to idle power, the pilot advanced the throttle to a cruise power setting, but the fuel flow and engine power did not increase. The pilot made additional throttle movements, but the fuel flow and engine power did not correspond to throttle movements most likely because the pilot had adjusted the fuel-air mixture toward a lean setting. Thus, the pilot’s actions in response to the high engine oil indications led to the loss of engine power. Without engine power, the airplane’s airspeed decreased to about 85 knots, and the pilot successfully deployed the airplane’s parachute system. Postaccident examination revealed no anomalies that would have precluded normal engine power. The oil temperature connector and back shell were damaged, with the back shell disconnected from the oil temperature connector. The accident flight was the first after maintenance work during which a crush gasket adjacent to the damaged oil temperature connector was replaced. The oil temperature connector was most likely damaged during this maintenance and resulted in erratic indications of high engine oil temperature during the accident flight.

Factual narrative

On October 24, 2020, about 1200 central daylight time, a Cirrus SR22 airplane, N183V, was substantially damaged when it was involved in an accident near Tishomingo, Oklahoma. The pilot and the three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. During a postaccident interview, the pilot recalled that, while the airplane was descending toward its destination (Atoka Municipal Airport, Atoka, Oklahoma), he was alerted to high oil temperature indications and noted a loss of engine power. The pilot stated that he attempted to restore engine power by adjusting the air-fuel mixture and throttle but was unable to do so. Download of the airplane’s remote data module revealed that, while the airplane was approaching its destination at an altitude of about 900 ft above ground level, erratic high engine oil temperatures (from 314°C to 801°C) were recorded for 5 seconds. The engine oil temperature returned to normal for the next 7 seconds, which was followed by erratic high temperatures for the remainder of the flight. According to (source), engine oil temperatures greater than 240°C triggered a flashing red warning cockpit annunciator and an aural chime every 1.5 seconds. The downloaded data from the remote data module also showed that, about 5 seconds after high oil temperatures began, decreases in fuel flow, manifold pressure, and engine rpm were recorded, which were consistent with throttle movement to idle power. About 3 seconds later, manifold pressure increased, consistent with a throttle increase, but fuel flow indications remained near 3 to 5 gallons per hour. The manifold pressure subsequently decreased and increased twice with no corresponding change in fuel flow. The pilot then assessed the available locations for a forced landing and determined that the options were unsuitable. As a result, he activated the Cirrus Airframe Parachute System. The downloaded data showed that the parachute activation occurred about 45 seconds after the high oil temperatures began and that the airplane’s airspeed at the time of activation was about 85 knots. The airplane descended under the parachute and impacted terrain, resulting in substantial damage to an airframe engine mount. Postaccident examination of the engine revealed normal mechanical continuity. The fuel inlet filters were clear of debris, and no anomalies were noted with the ignition leads, spark plugs, magnetos, fuel servo, flow divider, or fuel injectors. The oil reservoir was empty, with the several holes in the oil pan due to impact damage. The oil temperature connector and back shell were damaged, and the back shell was disconnected from the connector. The accident flight was the first flight after maintenance was performed to address high engine oil consumption during previous flights. The logbook entry for this maintenance included replacement of crush gaskets on the oil cooler housing. One of the crush gasketsthat was replaced was adjacent to the damaged oil temperature connector. According to a Federal Aviation Administration Safety Team (FAAST) publication: General aviation accidents often result from inappropriate responses to unexpected events. Humans are subject to a “startle response” when they are faced with unexpected emergency situations and may delay action or initiate inappropriate action in response to the emergency. Training and preparation can reduce startle response time and promote more effective and timely responses.

Aircraft

Registration
N183V
Reported as
Cirrus SR22
Category
Airplane
Serial number
3125
Built
2008
Airframe hours
1,754
Engine
Continental Motors IO-550-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Leatherneck Oilfield Service Inc
Registered owner
Leatherneck Oilfield Service Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 25, 2020 · 65 hours before
Departed
KODO · Odessa, TX
Destination
KAQR · Atoka, OK
Equipment
Data recorder, Airframe parachute, 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
41
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3
Last flight review
November 1, 2018
Seat
Left
Restraint
4-point
Flight hours
379 total · 296 in this make and model · 368 as pilot in command · 19 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 36 °F
Altimeter
30.17 inHg
Observed at
KADM, 15 nm away

Docket · 9

The files NTSB released with the investigation on June 9, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.1 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.