# NTSB DFW08LA223: Rockwell International S-2R, N8472V, Uvalde, TX, September 1, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 1, 2008, 14:00 local (19:00 UTC) - Place: Uvalde, TX - Coordinates: 29.341943, -99.705276 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.3419&lon=-99.7053&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report May 6, 2010 - Report: Approved by Office Director - Parties: FAA San Antonio FSDO, Honeywell Aerospace, FAA Scottsdale FSDO - NTSB case key (mKey): 68865 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW08LA223 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68865/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=68865 - Page: https://openairdocs.org/ntsb/DFW08LA223 ## Probable cause A total loss of engine power due to the improper use of unauthorized replacement parts in the engine and repeated operation of the engine in an over-temperature condition. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (turbine/turboprop): turbine section](https://openairdocs.org/ntsb-findings/01057250): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/01057250/cases.md?model=7630202), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01057250/cases.md) - [Engine (turbine/turboprop): turbine section](https://openairdocs.org/ntsb-findings/01057250): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/01057250/cases.md?model=7630202), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01057250/cases.md) - [Engine (turbine/turboprop)](https://openairdocs.org/ntsb-findings/01057200): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/01057200/cases.md?model=7630202), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01057200/cases.md) - [Maintenance/inspections: return to service](https://openairdocs.org/ntsb-findings/01010530): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/01010530/cases.md?model=7630202), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/01010530/cases.md) - [Maintenance: unauthorized maint/repair](https://openairdocs.org/ntsb-findings/02062040): Personnel issues › Task performance · Not specified (probable cause); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-findings/02062040/cases.md?model=7630202), [All aircraft, 14 cases](https://openairdocs.org/ntsb-findings/02062040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Rockwell International S-2R, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=7630202), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Maneuvering-low-alt flying: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Rockwell International S-2R, 8 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7630202), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Rockwell International S-2R, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7630202), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The engine of the agricultural airplane lost power while it was maneuvering at low altitude. The airplane impacted thick vegetation and terrain, causing substantial damage to the right wing, nose and tail. A subsequent teardown examination of the engine showed little evidence that the engine was operating at the time of impact, but the ingestion of vegetation into the combustor and the torsional failure of the torsion shaft suggests that there was some rotation of the engine at the time of impact. The engine examination also revealed that several turbine rotors had damage and missing blade material due to short term operation of the engine at an over temperature condition. There was evidence that the rotors had been operating for several hours after the over temperature event that caused the stress rupture of the blades. Further, the examination showed that the first stage turbine rotor and the prop pitch control cam did not conform to Honeywell specifications and were not authorized replacement parts, and a previous weld repair on the engine combustor plenum did not conform to standard practices for weld repairs on aerospace parts. ## Factual narrative On September 1, 2008, approximately 1500 central daylight time (CDT), a Rockwell International S-2R, N8472V, registered to Farm & Ranch Aerial Service Inc., and operated by Rusty’s Flying Service as a 14 Code of Federal Regulations Part 137 agricultural flight, crashed while maneuvering at low altitude. Visual meteorological conditions prevailed and flight plan had not been filed. The airplane was substantially damaged by the impact forces. The commercial pilot, who was the only occupant, was not injured. The airplane had departed the Glasscock Field Airport (4TS8) D’Hanis, Texas. The pilot reported he was half way through his third pass over a 200 acre cotton field and had 80 gallons of chemical and 180 gallons of fuel on board when the engine surged twice and then completely failed. The pilot was able to clear the bigger oak trees on the edge of the field and he stalled the airplane into a thick patch of brush. The Federal Aviation Administration (FAA) inspector that responded to the accident scene reported that the airplane appeared to have stalled tail first into thick vegetation, impacted terrain and came to rest upright. The right wing, nose and tail were crushed from the impact. One of the three blades on the propeller appeared to be undamaged. A second blade had a single bend and the third blade had a S- type bend. The wreckage was removed from the accident scene and transported to the facilities of Air Salvage of Dallas (ASOD), near Lancaster, Texas. On September 19, 2008 the Board investigator-in-charge examined the wreckage at ASOD and the engine was removed from the airplane and shipped to the Honeywell Product Integrity Investigation Laboratory in Phoenix, Arizona. On November 18, 2008 a teardown and examination of the engine was conducted at that facility under the oversight of an FAA inspector. The examination shows evidence of over temperature damage and missing material from turbine rotor blades. A metallurgical examination shows that the first stage turbine rotor and the prop pitch control cam do not conform to Honeywell specifications and are not authorized replacement parts. The configuration of the control system components on the engine do not meet the type certificate specifications and a previous weld repair on the engine combustor plenum does not conform to standard practices for weld repairs on aerospace parts. Airplane maintenance logbooks could not be located and were not available for inspection. The Hobbs meter reading at the accident site was 874.4. A few selected pages of maintenance records for the engine were located that covered the period from June 20, 2004 at 3369.5 engine time since overhaul (TSOH) until the last entry at 4763.4 TSOH on June 24, 2008. A maintenance record entry by a certified repair station on June 24, 2008, shows that a hot section inspection was performed; the engine was returned to service and reinstalled on N8472V at a Hobbs meter reading of 442.0. ## Aircraft - Registration: [N8472V](https://openairdocs.org/aircraft/N8472V), registered now, S/N 2232R (OpenAirDocs) - Reported make and model: ROCKWELL INTERNATIONAL S-2R - Registry model: [Rockwell International S-2R](https://openairdocs.org/model/rockwell-international-s-2r) (registry code 7630202) (OpenAirDocs) - Registry engine: [Pratt & Whitney R1340 series](https://openairdocs.org/engine/pratt-whitney-r1340-series) (registry code 52016, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2232R - Airframe hours: 7935 - Engines: Honeywell Garrett TPE 331-1-151 665 horsepower turbo prop - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Lindeman, Rusty, doing business as Rusty's Flying Service - Registered owner: Farm & Ranch Aerial Service Inc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, April 14, 2008, 432 hours before - Departed: 4TS8, D'Hanis, TX - Destination: 4TS8, D'Hanis, TX ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 28; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review December 18, 2006; seat: single; flight hours: 2,300 total, 400 in this make and model, 2,220 as pilot in command, 400 in the last 90 days, 150 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 93 °F, dew point 66 °F - Altimeter: 29.79 inHg - Observed at: KUVA, 10 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 20080901844709A](https://openairdocs.org/incident/20080901844709A), Sep 1, 2008: Ayres S2R, D'Hanis, TX, Destroyed. (-23) The aircraft lost engine power while making a third pass during aerial application. The pilot stated he put the aircraft into a high pitch attitude to… ## Other investigations on N8472V (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 FTW90DPA07](https://openairdocs.org/ntsb/FTW90DPA07), Jun 15, 1990: Ayres S2R (N8472V), Mcgregor, TX, substantial damage. Probable cause: THE FUEL EXHAUSTION INDUCED POWER LOSS, WHICH RESULTED FROM THE PILOT'S INACCURATE FUEL CONSUMPTION CALCULATIONS. ## Docket (11 files) The files NTSB released with the investigation on March 2, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=68865. 30.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 603 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325447&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Additional Statement from Pilot (item 2, .PDF, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325448&FileExtension=.PDF&FileName=Additional%20Statement%20from%20Pilot-Redacted.PDF - Maintenance Records - Engine logs, selected pages (item 3, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325446&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine%20logs,%20selected%20pages-Redacted.PDF - Powerplant - Preliminary Engine Exam (item 4, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325440&FileExtension=.PDF&FileName=Powerplant%20-%20Preliminary%20Engine%20Exam-Master.PDF - Powerplant - FAA Engine Teardown Field Notes (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325441&FileExtension=.PDF&FileName=Powerplant%20-%20FAA%20Engine%20Teardown%20Field%20Notes-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325442&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Map of accident site and surrounding area (item 7, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325443&FileExtension=.PDF&FileName=Map%20of%20accident%20site%20and%20surrounding%20area-Master.PDF - Photo 1 (item 8, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325444&FileExtension=.PDF&FileName=Photo%201-Master.PDF - Photo 2 (item 9, .PDF, 182 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325445&FileExtension=.PDF&FileName=Photo%202-Master.PDF - Reports from Parties - Engine Examination (item 10, .PDF, 28.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325846&FileExtension=.PDF&FileName=Reports%20from%20Parties%20-%20Engine%20Examination-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325845&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.