ERA12LA473

NTSB accident investigation · Cirrus Design SR-22 · Pickens, SC · July 22, 2012

Accident · No injuriesLimited investigationFinal report
Date
July 22, 2012, 17:05 local (21:05 UTC)
Place
Pickens, SC
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N138CKCirrus Design SR-22
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 23, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Cirrus Aircraft, Continental Engines, FAA/FSDO
FAA report
20120722016959A
Case key
84417

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

A total loss of engine power due to the failure of the crankshaft, which resulted from the application of insufficient torque on the cylinder through-bolts by maintenance personnel.

Findings · 3

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.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Incorrect service/maintenanceCirrus Design SR22: 6 casesAll aircraft: 373 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelCirrus Design SR22: 5 casesAll aircraft: 371 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

A few minutes after leveling the airplane at a cruise altitude of 9,000 feet mean sea level, the pilot felt the engine slightly vibrate or "wiggle." The propeller rpm then began to rise rapidly, and the pilot noted an engine oil pressure warning on the primary flight display. After unsuccessfully troubleshooting the engine problems, the pilot secured the engine and declared an emergency. An air traffic controller informed the pilot of an airport 4 miles from his location, and he turned the airplane toward that airport and prepared for an emergency landing. The pilot again unsuccessfully attempted to restart the engine and then resecured it while on the downwind leg of the airport traffic pattern. When the pilot turned the airplane toward the base leg of the traffic pattern at 1,200 feet, he added one notch of flaps, at which point, he felt the handling characteristics of the airplane change, and it began to feel "mushy." He then retracted the flaps, and the condition worsened. As the airplane descended through 1,000 feet, the pilot thought that he had "lost control of the airplane" and decided to activate the airframe emergency parachute. The parachute deployed, and, within seconds, the airplane settled into trees about 2 miles from the airport. The airplane remained suspended in the trees until emergency personnel arrived on scene and rescued the occupants. After the accident, the presence of oil was noted on the underside of the airplane. After the airplane was recovered from the trees, examination of the oil dipstick revealed small pieces of metal in the engine oil. Examination of the engine revealed that the crankshaft was fractured and that the crankcase exhibited varying degrees of fretting and lock-slot elongation on the main bearing supports, which is consistent with the application of insufficient torque on the cylinder through-bolts by maintenance personnel. New cylinders had been installed on the engine 113 hours before the accident. Because the cylinders were loose, the oil supply at the No. 2 main journal was shut off and the crankshaft broke, which resulted in the subsequent loss of oil pressure to the engine.

Factual narrative

The airplane was manufactured in 2009 and equipped with a Continental IO-550 engine. The following entries were noted in the airplane and engine logbooks: On April 28, 2010, all six cylinders were removed from the engine and sent to a repair station. According to the work order, maintenance to the cylinders included, "checking the guides and resealing the valves." The cylinders were reinstalled on May 4, 2010, and an operational check revealed no leaks or other anomalies. The most recent annual inspection was completed on the airframe and engine on September 1, 2011 at a tachometer time of 963 hours. No anomalies were noted during the inspection. On April 4, 2012, a new crankshaft seal and new cylinders were installed on the engine at a tachometer time of 1,252 hours. According to the logbook entry, an operational check was performed after installation, with no anomalies noted. The next entry in the logbook was on May 3, 2012. This entry described compression checks on all 6 cylinders with the following values: "1. 78/80; 2. 74/80; 3. 76/80; 4. 77/80; 5. 75/80; 6. 75/80." According to the entry, another operational check was performed with "no leaks noted." An oil change was performed on July 18, 2012. According to the logbook entry, the oil filter was cut and no metal was noted. The tachometer time noted at the accident site was 1,365 hours. On July 22, 2012, at 1705 eastern daylight time, N138CK, a Cirrus SR-22, was substantially damaged during a forced landing in Pickens, South Carolina. The commercial pilot and three passengers were not injured. Visual meteorological conditions prevailed and an IFR flight plan was filed for the flight that departed Cobb County Airport-Mc Collum Field (RYY), Atlanta, Georgia, and was destined for Piedmont Triad International Airport (GSO), Greensboro, North Carolina. The business flight was conducted under the provisions of 14 CFR Part 91. According to the pilot, he began the day flying the airplane alone from Shelby County Airport (EET), Alabaster, Alabama to Gulfport-Biloxi International Airport (GPT), Gulfport, Mississippi, where he picked up 3 passengers. Prior to departure from GPT, the airplane was fueled "to the tabs" and 1 quart of oil was added to the engine. He and the 3 passengers then departed GPT, destined for RYY. As the airplane was descending enroute to RYY, the engine experienced a "brief misfire," which the pilot reported he had experienced in other airplanes before and was not concerned about. The airplane also experienced an ALT 2 failure enroute. The pilot attempted to troubleshoot the problem, without success, and then shed some of the electrical load. He continued to RYY and landed without incident. The landing at RYY was a planned fuel stop, enroute to the final destination of GSO, where the airplane was based. Prior to departure from RYY, the airplane was fueled with 60 gallons of 100LL aviation fuel, which again filled the tanks "to the tabs." The pilot checked the oil (about 6 1/2quarts) and examined the engine and underside of the airplane for any abnormal conditions which would have explained the earlier engine misfire. He found no anomalies and proceeded with the departure. The takeoff from RYY was normal, and as the airplane climbed through an altitude of 800 feet, the pilot noted the oil temperature was "in the green" (about 190 deg) and the airspeed was about 130 knots. The pilot leveled the airplane at 9,000 feet, at a cruise speed of 165 knots. A few minutes later, the pilot felt a "wiggle," or a slight vibration from the engine. The prop RPM began to rise rapidly and he noted an engine oil pressure warning on the primary flight display (PFD). The pilot disengaged the autopilot, applied full mixture, and turned the fuel pump on. He also assured the magnetos were in the "on" position. The pilot thought he may have had a propeller overspeed condition, so he reduced the throttle; however, the RPMs remained high. He then secured the engine and declared an emergency with Greer Approach Control, with whom he had been communicating. The air traffic controller informed the pilot that Pickens County Airport (LQK) was at his "10:00 and 4 miles," and the pilot turned toward the field and prepared for a forced landing. He noted the RPMs were not decreasing as he pitched the airplane down for the descent (the airspeed was about 110-120 knots). The pilot attempted unsuccessfully to restart the engine, and then re-secured it while on the downwind leg of the traffic pattern for runway 23 at LQK. He believed he had plenty of airspeed and altitude, when he turned base at 1,200 feet, and added one notch of flaps. As the pilot added the flaps, he felt the handling characteristics of the airplane change, and it began to feel "mushy." He then retracted the notch of flaps and the condition became worse. As the airplane descended through 1,000 feet, the pilot felt as if he had "lost control of the airplane" and decided to activate the airframe emergency parachute. The parachute deployed and within seconds the airplane settled into the trees. The airplane remained suspended in the trees until emergency personnel arrived on-scene and rescued the occupants. The pilot held a commercial pilot certificate and a flight instructor certificate with multiple ratings including: instrument airplane, airplane single-engine land, and multiengine land. His most recent first-class medical certificate was issued on May 1, 2012. The pilot reported 1,800 hours of total flight experience, 350 of which were in the make and model of the accident airplane. Recoverable Data Module (RDM) Examination The airplane was equipped with a Heads Up Technology Recoverable Data Module (RDM) mounted in the empennage, which was intended to record various flight and aircraft parameters. The device was retained after the accident, and forwarded to the NTSB Vehicle Recorders Laboratory, Washington, D.C., for data recovery. According to the RDM data, the engine lost power at1659, and the airplane began a descent immediately after. The CAPS handle was pulled at 1704:55, and the CAPS rocket deployed at the same time. The last data points were recorded at 1705:20 Engine Teardown Inspection The engine was sent to Teledyne Continental Motors in Mobile, Alabama for a teardown inspection. The inspection revealed the crankshaft was fractured through the number 3 cheek between the number 2 rod journal and the number 2 main journal. The camshaft exhibited mechanical damage and was fractured in two places; forward of the second lobe and at the center of the second main journal. The crankcase exhibited varying degrees of fretting and lock slot elongation on the main bearing supports. The number 2 main bearing support exhibited signs of bearing rotation. Additionally, low torque values were noted for the cylinder through-bolts. No indications of fatigue were noted on any of the fractured components (For additional information regarding the engine teardown, see the Continental Motors Teardown Report and the FAA Inspector Teardown Report in the public docket for this accident). Examination of the airplane by a Federal Aviation Administration inspector revealed the airplane impacted trees about 2 miles from LQK. The airplane remained suspended in the trees during the inspector's examination; however, he did note the presence of oil on the underside of the airplane. After the airplane was recovered from the trees, examination of the oil dipstick revealed approximately 4 quarts of oil in the engine. There were also small pieces of metal noted on the dipstick.

Aircraft

Registration
N138CK
Reported as
Cirrus Design SR-22
Category
Airplane
Serial number
3492
Airframe hours
1,365
Engine
Cont Motor IO-550-N, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Operator
Cair LLC
Registered owner
Cair LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 1, 2011 · 402 hours before
Departed
RYY · Atlanta, GA
Destination
GSO · Greensboro, NC
Flight plan
IFR
Airport
LQK · Pickens County Airport

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
38
Injuries
None
Certificate
Flight instructor
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
December 13, 2011
Seat
Left
Flight hours
1,800 total · 350 in this make and model · 1,700 as pilot in command · 250 in the last 90 days · 100 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
95 °F, dew point 72 °F
Altimeter
30.15 inHg
Observed at
LQK, 2 nm away

Docket · 17

The files NTSB released with the investigation on February 21, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 28.0 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.