# NTSB ERA12LA473: Cirrus Design SR-22, N138CK, Pickens, SC, July 22, 2012

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: July 22, 2012, 17:05 local (21:05 UTC)
- Place: Pickens, SC
- Coordinates: 34.810001, -82.702774 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=34.8100&lon=-82.7028&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: No injuries
- Injuries: 4 uninjured
- Status: Completed, report April 23, 2014
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: Cirrus Aircraft, Continental Engines, FAA/FSDO
- NTSB case key (mKey): 84417
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA473
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84417/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84417
- Page: https://openairdocs.org/ntsb/ERA12LA473

## 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

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

- [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cirrus Design SR22, 9 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2130001), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md)
- [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Cirrus Design SR22, 6 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2130001), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cirrus Design SR22, 5 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2130001), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)

## Sequence of events

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

- [Enroute: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cirrus Design SR22, 50 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2130001), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Cirrus Design SR22, 31 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2130001), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Emergency descent: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cirrus Design SR22, 23 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2130001), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cirrus Design SR22, 113 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2130001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/aircraft/N138CK), registered now, S/N 3492, built 2009 (OpenAirDocs)
- Reported make and model: CIRRUS DESIGN CORP SR-22
- Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs)
- Registry engine: [Continental IO-550-N](https://openairdocs.org/engine/continental-io-550-n) (registry code 17215, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 3492
- Airframe hours: 1365
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 38; injuries: none; 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

## 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 20120722016959A](https://openairdocs.org/incident/20120722016959A), Jul 22, 2012: Cirrus Design Corp SR22, Pickens, SC, Substantial damage. At approximately 9000 ft. enroute from mccullom field (ryy) Georgia to greensboro (gso) in north carolina the aircraft engine ran rough and quit. The pilot…

## Docket (17 files)

The files NTSB released with the investigation on February 21, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84417. 28.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404828&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Pilot Interview (item 2, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377500&FileExtension=.PDF&FileName=Pilot%20Interview-Master.PDF
- Pilot Statement (item 3, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377501&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF
- Photo 1: Aircraft in trees, view from underside of airplane (photo courtesy of FAA) (item 4, .PDF, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377782&FileExtension=.PDF&FileName=Photo%201%3A%20Aircraft%20in%20trees,%20view%20from%20underside%20of%20airplane%20(photo%20courtesy%20of%20FAA)-Master.PDF
- Photo 2: Aircraft in trees, view from left side (photo courtesy of FAA) (item 5, .PDF, 8.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377784&FileExtension=.PDF&FileName=Photo%202%3A%20Aircraft%20in%20trees,%20view%20from%20left%20side%20(photo%20courtesy%20of%20FAA)-Master.PDF
- Photo 3: Aircraft in trees, rescue of occupants (photo courtesy of FAA) (item 6, .PDF, 320 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377787&FileExtension=.PDF&FileName=Photo%203%3A%20Aircraft%20in%20trees,%20rescue%20of%20occupants%20(photo%20courtesy%20of%20FAA)-Master.PDF
- Photo 4: Metal found on oil dipstick (photo courtesy of FAA) (item 7, .PDF, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40377788&FileExtension=.PDF&FileName=Photo%204%3A%20Metal%20found%20on%20oil%20dipstick%20(photo%20courtesy%20of%20FAA)-Master.PDF
- Recorder Device - Attachment 1 - Tabular Data (CSV) (item 8, .CSV, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383930&FileExtension=.csv&FileName=Recorder%20Device%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)-Master.csv
- Recorder Device - Attachment 2 - Tabular Data (CSV) (item 9, .CSV, 998 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383931&FileExtension=.csv&FileName=Recorder%20Device%20-%20Attachment%202%20-%20Tabular%20Data%20(CSV)-Master.csv
- Aircraft and Engine Logbook (excerpt) (item 10, .PDF, 822 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389721&FileExtension=.PDF&FileName=Aircraft%20and%20Engine%20Logbook%20(excerpt)-Redacted.PDF
- FAA Engine Teardown Report (item 11, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389722&FileExtension=.PDF&FileName=FAA%20Engine%20Teardown%20Report-Redacted.PDF
- Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 392 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389715&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF
- Retention / Release of Wreckage Form (item 13, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389716&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF
- Recorder Device - Specialist's Factual Report (item 14, .PDF, 583 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389895&FileExtension=.PDF&FileName=Recorder%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF
- Continental Motors Engine Teardown Report (item 15, .PDF, 13.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407868&FileExtension=.PDF&FileName=Continental%20Motors%20Engine%20Teardown%20Report-Master.PDF
- Continental Engine Torque Values (item 16, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407869&FileExtension=.PDF&FileName=Continental%20Engine%20Torque%20Values-Master.PDF
- Continental Engine Service Bulletin (item 17, .PDF, 553 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407870&FileExtension=.PDF&FileName=Continental%20Engine%20Service%20Bulletin-Master.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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