# NTSB ERA15IA024: Cirrus Design SR22, N242MB, Lexington, NC, October 22, 2014 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: October 22, 2014, 06:25 local (10:25 UTC) - Place: Lexington, NC - Coordinates: 35.816665, -80.258613 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.8167&lon=-80.2586&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 26, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA, Continental Motors, Cirrus Aircraft - NTSB case key (mKey): 90288 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15IA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90288/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90288 - Page: https://openairdocs.org/ntsb/ERA15IA024 ## Probable cause Maintenance personnel's improper tightening of the crankcase through bolt nuts during reassembly of the engine at the last overhaul, which resulted in the failure of the crankshaft and the subsequent total loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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) - [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) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cirrus Design SR22, 6 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=2130001), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/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: [Cirrus Design SR22, 9 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2130001), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: 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) - [Enroute-cruise: 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: 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) ## Analysis The commercial pilot was conducting a personal cross-country flight. The pilot reported that, while en route to his destination at a cruise altitude of about 5,000 ft mean sea level, the engine "failed." He flew the airplane toward an open field and deployed the ballistic recovery parachute. He subsequently conducted a successful landing in the field. An examination of the engine revealed that the crankshaft had fractured between the No. 2 main journal and the No. 2 connecting rod journal. An examination of the crankshaft revealed that the fracture was due to fatigue that had initiated from multiple origins at the fillet radius between the No. 2 main journal and the cheek at the aft end of the journal. The fatigue initiated from surface damage that occurred due to the No. 2 main bearing shifting. The bearing likely shifted due to the improper tightening of the crankcase through bolt nuts and subsequent insufficient clamping force of the crankcase saddle surfaces. A review of the airplane's maintenance records revealed that the engine was last overhauled 775 total flight hours before the accident, and no records were found indicating that the through bolts had been removed since that time. It is likely that maintenance personnel improperly tightened the crankcase through bolts during the overhaul. ## Factual narrative On October 22, 2014, at 0625 eastern daylight time, a Cirrus SR22, N242MB, registered to and operated by a private individual, deployed the Cirrus Airframe Parachute System (CAPS) following a total loss of engine power. The commercial pilot was not injured and the airplane sustained minor damage. Visual meteorological conditions prevailed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91. The flight, operating under instrument flight rules, originated from Mc Gee Field Airport (24NC), Monroe, North Carolina, at 0600 central daylight time and was destined for Piedmont Triad International Airport (GSO), Greensboro, North Carolina. According to the pilot, while enroute to his destination, at a cruise altitude of 5,000 feet msl he contacted GSO approach and opened his flight plan. Shortly thereafter the engine "failed"; the pilot flew the airplane towards an open field and deployed the CAPS system. The airplane made a successful landing in the field. Examination of the engine revealed that the crankshaft had fractured between the number two main journal and the number two connecting rod journal. The number two bearing displayed bearing shift signatures and had completely extruded from the bearing support. The number one, two, three, and the number four bearing supports displayed fretting near the through bolt holes. There was no evidence of an oil starvation or lack of lubrication. Examination of the oil pump revealed that the drive gear was intact. The oil pump cavity contained light scratches. The oil pump gear teeth were intact and did not exhibited any anomalies. The oil pressure relief valve seat contained some metallic debris and the relief valve plate displayed signs of peened imprints around the seat area circumference. The oil filter was removed from the engine and the oil filter housing was cut open and the filter element was removed from the canister for examination. The oil filter element contained flakes and slivers from the damaged internal engine components. The oil sump drain plug was removed and the oil was drained from the sump; the amount was measured to be 8 quarts. The oil was dark in color and contained metallic debris. The oil sump was removed and sections of bearing were found in the sump along with metallic slivers and shavings. The oil pickup tube was bent and the screen was intact; metallic debris was noted on the screen. A review of maintenance records revealed that the Continental IO-550N7 engine was rebuilt by Teledyne Continental Motors on August 22, 2011. The engine accumulated 775 hours since factory rebuild and there is no record or evidence of the cylinders being removed since rebuild. The engine accumulated 200 hours since the last annual inspection dated November 8, 2013. Further review of records revealed that a 50 hour engine oil change was performed 69 hours prior to the accident on September 29, 2014. The crankshaft was removed sent to the NTSB materials laboratory forfracture analysis. An examination of the crankshaft revealed that the fracture was due to fatigue that initiated from multiple origins at the fillet radius between the second main journal and the cheek at the aft end of the journal. ## Aircraft - Registration: [N242MB](https://openairdocs.org/aircraft/N242MB), registered now, S/N 0911, built 2004 (OpenAirDocs) - Reported make and model: CIRRUS DESIGN CORP SR22 - Registry model: [Cirrus Design SR22](https://openairdocs.org/model/cirrus-design-sr22) (registry code 2130001) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0911 - Year built: 2004 - Airframe hours: 2512 - Engines: CONT MOTOR IO-550 SERIES 315 horsepower reciprocating - Damage: Minor damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 8, 2013, 200 hours before - Departed: 24NC, Monroe, NC - Destination: GSO, Greensboro, NC - Flight plan: IFR - Equipment: Electronic multifunction display, Auto-pilot, Data recorder, Airframe parachute, Stall warning system, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review January 23, 2014; seat: left; restraint: 4-point; flight hours: 3,354 total, 1,650 in this make and model, 3,254 as pilot in command, 59 in the last 90 days, 16 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Dawn - Wind: 310° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 41 °F, dew point 37 °F - Altimeter: 29.97 inHg - Observed at: GSO, 30 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 20141022019719A](https://openairdocs.org/incident/20141022019719A), Oct 22, 2014: Cirrus Design Corp SR22, Lexington, NC, Substantial damage. At 5000 ft. the engine sputtered then stopped running. The pilot was unable to reach the next available airport and deployed the caps parachute. The aircraft… ## Docket (9 files) The files NTSB released with the investigation on March 10, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90288. 18.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 964 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437534&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Materials Laboratory Factual Report 15-023 (item 2, .PDF, 1 photo, 244 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437532&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report%2015-023-Master.PDF - Airframe Logbook pages from rebuilt engine install (item 3, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437592&FileExtension=.PDF&FileName=Airframe%20Logbook%20pages%20from%20rebuilt%20engine%20install-Master.PDF - N242MB Engine Logbook (item 4, .PDF, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437536&FileExtension=.PDF&FileName=N242MB%20Engine%20Logbook-Master.PDF - Propeller Logbook Excerpts (item 5, .PDF, 326 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437537&FileExtension=.PDF&FileName=Propeller%20Logbook%20Excerpts-Master.PDF - Engine remove and replace documents (item 6, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437538&FileExtension=.PDF&FileName=Engine%20remove%20and%20replace%20documents-Master.PDF - Continental Engine Exam Report w/photos (item 7, .PDF, 13.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437539&FileExtension=.PDF&FileName=Continental%20Engine%20Exam%20Report%20w%2Fphotos-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437540&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Evidence Control Form (item 9, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437541&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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. --- 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.