ERA09LA523

NTSB accident investigation · Cessna 208 · Sheffield, MA · September 15, 2009

Accident · No injuriesLimited investigationFinal report
Date
September 15, 2009, 14:35 local (18:35 UTC)
Place
Sheffield, MA
Injuries
6 uninjured
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N336DNCessna 208
Defining event
Enroute-climb to cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report January 7, 2011
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Pratt & Whitney Canada, Cessna Aircraft Company, North American Flight Services, Transportation Safety Board of Canada, FAA/FSDO
FAA report
20090915049469A
Case key
74743

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

A total loss of engine power due to a failure of the 1st stage sun gear output splines for unknown reasons, which resulted in a power turbine overspeed condition, with subsequent blade distress/release.

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.

Not determinedNot determined › Not determined · Unknown/Not determinedCessna 208: 2 casesAll aircraft: 2,247 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 pilot and the five passengers, who were employees of an industrial services company, were returning from a job site with hazardous materials used for blasting operations. The airplane was in a climb, at an altitude of 8,500 feet, when it experienced a catastrophic engine failure. The pilot declared an emergency and subsequently performed a forced landing to a field. During the landing, the airplane's right wing struck a tree and separated. All occupants exited the airplane without injury; however, the airplane became fully engulfed in fire, which consumed the majority of the airplane. The airplane was equipped with a turbine engine that, at the time of the accident, had been operated for about 7,620 hours since new and 65 hours since it was overhauled about 19 months prior to the accident. Impact damage was observed to the interior of the engine exhaust duct. In addition, the exhaust duct contained portions of a fractured power turbine blade. Additional examination of the engine revealed damage consistent with a distressed 1st stage sun gear, and associated compressor turbine and power turbine damage. Examination of the sun gear teeth output splines revealed that they were too damaged to determine the cause of their deterioration. It was noted that the sun gear found on the accident engine was previously removed from another engine due to "spalled gear teeth" about 7 years prior to the accident. The condition of the sun gear when installed on the accident engine could not be determined.

Factual narrative

HISTORY OF FLIGHT On September 15, 2009, about 1435 eastern daylight time, a Cessna 208, N336DN, operated by North American Flight Services Inc., experienced a loss of engine power while climbing, and performed a forced landing in Sheffield, Massachusetts. The airplane was destroyed by a postcrash fire and the certificated commercial pilot and five passengers were not injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed Republic Airport (FRG), Farmingdale, New York, destined for the Saratoga County Airport (5B2), Saratoga Springs, New York. The on-demand air taxi flight was conducted under the provisions of 14 Code of Federal Regulations Part 135. The airplane was based at 5B2. The pilot and the five passengers were employees of an industrial services company. At the time of the accident, the occupants were returning from a job site, and the airplane was transporting electric detonators, ammonium nitrate and nitromethane used for blasting operations. The pilot reported that the airplane departed FRG at 1405, and he initiated a climb to 9,000 feet without any abnormalities. As the airplane was climbing, at an altitude of about 8,500 feet, the pilot heard two "whooshing" sounds, about 5 seconds apart. The engine then began to experience torque fluctuations. Shortly thereafter, the engine torque dropped to idle, and the pilot heard a "loud bang" and felt a "burst vibration." The pilot declared an emergency to air traffic control and was told that the closest airport was located about 10 miles north, in Great Barrington, Massachusetts. The pilot informed air traffic control that the airplane would not be able to reach Great Barrington, and he subsequently performed a forced landing to a field. During the landing, the airplane's right wing struck a tree and separated. All occupants exited the airplane without injury; however, the airplane became fully engulfed in fire, which consumed the majority of the airplane. PERSONNEL INFORMATION The pilot, age 30, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate, with ratings for airplane single-engine, airplane multiengine, and instrument airplane. The pilot reported 3,100 hours of total flight experience, which included about 25 hours in the same make and model as the accident airplane, all accumulated within the 90 days prior to the accident. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on March 26, 2009. AIRCRAFT INFORMATION The eight-seat, all-metal, high-wing, fixed-gear airplane, serial number 20800001, was manufactured in 1984. It was powered by a Pratt & Whitney Canada PT6A-114A, 675-horsepower engine, equipped with a McCauley three-bladed propeller assembly. The airplane was purchased by the owner, without an engine, from an operator locatedin Switzerland, on June 19, 2008. It was maintained under a continuous airworthiness maintenance program. At the time of the accident, the airplane had been operated for 10,182 hours. The engine, serial number 17310, was purchased by the operator through Northstar Aerospace, Stroud, Oklahoma, during March 2008. According to an engine logbook entry, it was overhauled by Northstar Aerospace on October 21, 2008. The overhaul was also documented on an FAA airworthiness approval tag, dated February 22, 2007. No previous logbooks or engine history was provided to the current owner. A maintenance record dated September 3, 2002, revealed that the sun gear found on the accident engine was previously removed from another engine due to "spalled gear teeth planetary gear." Mint Turbines LLC purchased the Northstar Aerospace Turbine Engine Service Group business on May 27, 2009. The engine was installed on the accident airplane on May 1, 2009. At the time of the accident, the engine had been operated for about 7,620 hours since new, and 65 hours since overhaul. METEOROLOGICAL INFORMATION The reported weather at airport located about 20 miles, north-northeast of the accident site, was: wind from 330 degrees at 7 knots; visibility 10 statute miles; few clouds at 4,700 feet, broken clouds at 6,000 feet; temperature 22 degrees Celsius (C); dew point 11 degrees C; altimeter 29.94 inches of mercury. COMMUNICATIONS According to air traffic control summaries and communication transcripts obtained from the FAA, the airplane was cleared for takeoff from runway 32, at FRG, at 1403. The airplane was subsequently cleared to climb to an altitude of 9,000 feet, at 1429. At 1434, the pilot reported to air traffic control that he needed to make an emergency landing due to an engine failure. FLIGHT RECORDERS The airplane was not equipped; nor was it required to be equipped with a cockpit voice recorder (CVR), or flight data recorder (FDR). WRECKAGE AND IMPACT INFORMATION The wreckage was examined by representatives from the airframe manufacturer, engine manufacturer, operator, and an FAA inspector at a storage facility located in Biddeford, Maine, on September 21, 2009. The fuselage aft of the engine firewall, with exception of charred portions of the floor, was consumed by the postcrash fire. The inboard portions of both wings were impact damaged, and partially consumed by fire. The right wing leading edge displayed an impact signature consistent with a tree strike. The disposition of the wreckage precluded a check of flight control continuity; however, the pilot did not report any problems with the primary flight controls during the accident. Burnt and impact damaged portions of the flap control system appeared to be consistent with a flaps retracted position. Examination of the engine revealed impact damage to the interior of the exhaust duct. In addition, the exhaust duct contained portions of a fractured power turbine blade. The engine was retained for furtherexamination. MEDICAL AND PATHOLOGICAL INFORMATION Toxicological testing performed on the pilot by an independent laboratory, was negative for drugs and alcohol. TESTS AND RESEARCH The engine was examined at Pratt & Whitney Canada, Bridgeport, West Virginia, on December 2, 2010, under the supervision of an NTSB investigator. The examination revealed that the compressor blades tips were all burnt and melted to a uniform height. The downstream face of the disk was blackened with soot, and the upstream face exhibited light bluish discoloration. The majority of the power turbine blades had released at their rivet slots. Several of the blades were fractured above and below the platform and one blade was fractured at midspan of the airfoil. Examination of the 1st stage sun gear revealed that the gear teeth that mated with the 1st stage carrier planet gears were obliterated and the shaft was discolored. All of the gear teeth on the 1st stage planet gears were damaged. The "Y" and "Z" gears rotated freely, and the "X" gear was seized. The compressor turbine disk assembly, power turbine disk assembly, and the 1st stage sun gear were further examined at Pratt & Whitney Canada's Material's laboratory, under the supervision of a Transportation Safety Board of Canada metallurgist. The examinations revealed that the compressor turbine blade distress was consistent with the blade temperature reaching the material fusion point of the blade material. The fracture surfaces of power turbine blades were essentially featureless as a result of partially melted material due to elevated temperature. Fractographic features suggested the airfoils released due to tensile overload. Examination of the sun gear teeth output splines revealed that they were too damaged to determine the cause of their deterioration. ADDITIONAL INFORMATION Hazardous Material According to first responders, one of the passengers was an explosives specialist who reported that the airplane contained a binary explosive, which consisted of individual containers of ammonium nitrate and nitromethane. In addition, explosive electric detonators were stored in a metal box, strapped to the floor of the airplane, behind the last seat. The containers of ammonium nitrate and nitromethane were completely consumed in the postcrash fire. The metal box containing the electric detonators was found in the center of the wreckage, in-tact, with its padlock burned off. Some of the detonators were charred due to heat, and were therefore determined to be unstable. Once cooled, the Sheffield Police Department Explosives Unit removed the electric detonators to a makeshift bunker that was constructed of sand, where they were destroyed using a small amount of initiating explosive. The pilot contacted the operator, who faxed material safety data sheets (MSDS) to the Sheffield Police Department station. All shipment documentation was destroyed in the fire. Neither copy of the hazardous material shipping paper nor theNotification of Pilot-in-Command (NOTOC) was available to first responders. The incident commander reported that hazardous materials communications were facilitated by the immediate availability of company representatives at the accident site. Additionally, a company explosives control officer arrived at the accident site by about 1545, and provided technical advice to the unified command. According to the chief pilot of North American Flight Services (NAFS), an NOTOC and dangerous goods declaration was completed prior all flights departing from 5B2, and when the airplane returns to 5B2, the paperwork is removed and filed. The chief pilot explained that since NAFS operated under 14 CFR Part 135, rather than 14 CFR Part 121, he believed that an exemption applied to NAFS concerning the retention and distribution of hazardous materials shipping papers and NOTOCs. In addition, since NAFS did not have a station a FRG, he was concerned about leaving hazardous materials security sensitive paperwork with unaffiliated third parties. Title 49 CFR Part 175.33 indicated the required items to be contained in a hazardous materials shipping paper, commonly referred to as a declaration of dangerous good. A NOTOC may be combined with the hazardous materials shipping paper into a single document. Hazardous materials regulation 49 CFR 175.33(c) required that the aircraft operator must retain a copy of the shipping paper at or through its principle place of business and must make the shipping paper available upon request, to an authorized official of a federal, state or local government agency at reasonable times and locations. The regulation also required that the hazardous material information be readily accessible at the airport of departure and intended airport of arrival for the duration of the flight leg. Title 49 CFR Part 175 did not contain any exemptions to compliance with hazardous materials shipping paper and notification of pilot-in-command requirements.

Aircraft

Registration
N336DN
Reported as
Cessna 208
Category
Airplane
Serial number
20800001
Airframe hours
10,182
Engine
Pratt and Whitney Canada PT6-114A, 675 lbs thrust, turbo prop
Damage
Destroyed
Fire
On-Ground
Flight
Part 135
Operator
North American Flight Services Inc
Registered owner
North American Flight Services Inc
Airworthiness certificate
Standard, Normal
Last inspection
Continuous airworthiness · May 1, 2009 · 65 hours before
Departed
FRG · Farmingdale, NY
Destination
5B2 · Saratoga Spgs, NY
Flight plan
IFR

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
30
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
September 2, 2009
Seat
Left
Flight hours
3,100 total · 25 in this make and model · 2,900 as pilot in command · 50 in the last 90 days · 30 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 7 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
72 °F, dew point 52 °F
Altimeter
29.94 inHg
Observed at
PSF, 20 nm away

Docket · 31

The files NTSB released with the investigation on November 1, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.5 MB in all.

Air Traffic Control SummariesItem 1 · .PDF · 151 KBAir Traffic Control TranscriptsItem 2 · .PDF · 384 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 3 · .PDF · 508 KBPilot StatementItem 4 · .PDF · 242 KBFAA Inspector StatementItem 5 · .PDF · 652 KBSheffield Police Department Statements and Interview SummariesItem 6 · .PDF · 701 KBMaintenance Records (excerpts)Item 7 · .PDF · 1.1 MBPratt & Whitney Canada Engine Report # 09-086Item 8 · .PDF · 1.3 MBWeather DataItem 9 · .PDF · 143 KBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 114 KBPhotograph # 1 – View of main wreckage 1 of 2 (Provided by FAA)Item 11 · .PDF · 69 KBPhotograph # 2 – View of main wreckage 2 of 2 (Provided by FAA)Item 12 · .PDF · 88 KBPhotograph # 3 – View of Empennage (Provided by FAA)Item 13 · .PDF · 48 KBPhotograph # 4 – View of Examined Engine Components (Provided by Pratt & Whitney Canada)Item 14 · .PDF · 418 KBHazardous Materials Factual ReportItem 15 · .PDF · 58 KBHazardous Materials Attachment 1: Massachusetts State Police shift logItem 16 · .PDF · 2.5 MBHazardous Materials Attachment 2: Record of Telephone Contact, Sheffield Chief of PoliceItem 17 · .PDF · 35 KBHazardous Materials Attachment 3: Record of Telephone Contact, Commander Massachusetts State Police Explosives UnitItem 18 · .PDF · 35 KBHazardous Materials Attachment 4: FAA Photograph of Portable Explosives MagazineItem 19 · .PDF · 585 KBHazardous Materials Attachment 5: SEC Investments Corp. Description of Kinepak Binary Explosives SystemItem 20 · .PDF · 1.7 MBHazardous Materials Attachment 6: MSDS Kinepak Solid, Ammonium NitrateItem 21 · .PDF · 38 KBHazardous Materials Attachment 7: MSDS Kinepak Liquid, NitromethaneItem 22 · .PDF · 46 KBHazardous Materials Attachment 8: MSDS Electric DetonatorsItem 23 · .PDF · 99 KBHazardous Materials Attachment 9: Record of Telephone Contact, NASF director of OperationsItem 24 · .PDF · 28 KBHazardous Materials Attachment 10: Record of Telephone Contact, NASF Chief PilotItem 25 · .PDF · 35 KBHazardous Materials Attachment 11: NAFS Description of Shipping Paper Operating ProcedureItem 26 · .PDF · 117 KBHazardous Materials Attachment 12: NAFS Example of Dangerous Goods Declaration, NOTOC, and Explosives Team Inventory Load ListItem 27 · .PDF · 1.1 MBHazardous Materials Attachment 13: Record of Telephone Contact, FAA Hazmat Special Agent New England RegionItem 28 · .PDF · 24 KBHazardous Materials Attachment 14: Republic Airport Prior Permission RequestItem 29 · .PDF · 70 KBHazardous Materials Attachment 15: September 22, 2009 Email From FAA hazmat Branch Manager Describing Results of FAA Air Carrier InspectionItem 30 · .PDF · 15 KBHazardous Materials Attachment 16: NAFS Corrected List of Hazardous Materials Present on the Aircraft During Flight FRG-5B2Item 31 · .PDF · 188 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.