ERA15LA071

NTSB accident investigation · Cessna 210 5(205) · Sussex, NJ · December 4, 2014

Accident · Minor injuriesLimited investigationFinal report
Date
December 4, 2014, 11:00 local (16:00 UTC)
Place
Sussex, NJ
Injuries
1 minor, 5 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N8296ZCessna 210 5(205)
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report October 19, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Textron Aviation, FAA/FSDO, Continental Motors, Inc.
FAA report
20141204024039A
Case key
90461

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

Maintenance personnel’s inadequate inspection of the No. 2 cylinder valve area during the most recent annual inspection, which resulted in the in-flight failure of the intake valve springs due to rust on the spring surfaces and subsequent fatigue cracking.

Findings · 4

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 · Inadequate inspectionCessna 210-5(205): 1 caseAll aircraft: 373 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelCessna 210-5(205): 1 caseAll aircraft: 167 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionCessna 210-5(205): 1 caseAll aircraft: 373 casesProbable cause
Maintenance/inspections: scheduled maint checksAircraft › Aircraft handling/service · Inadequate inspectionCessna 210-5(205): 1 caseAll aircraft: 76 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 reported that, shortly after the skydiving flight departed, the engine experienced a "mechanical failure" and that he then executed a forced landing in a farm field south of the airport. The airplane nosed over in the mud, which resulted in structural damage to the airframe. During a postaccident test run of the engine on the airframe, lower-than-normal exhaust gas temperature indications were observed on the engine's left-side (Nos. 2, 4, and 6) cylinders. Excessive soot and smoke were also observed on the engine's left side. During a subsequent test run, the engine initially did not achieve full power. Further examination revealed that both of the No. 2 cylinder intake valve springs were fractured, and visible rust was observed on the surfaces of the springs. The springs showed evidence of fatigue fractures that had originated from rust pits on the fracture surfaces. After the valve springs were replaced, the engine was capable of operating normally at full power. An annual inspection was completed on the engine less than 2 months (13 engine operating hours) before the accident. As part of the annual inspection, the engine manufacturer's operating manual required the removal of the cylinder rocker covers and inspection of the valve area for breakage and proper lubrication. It is likely that maintenance personnel did not adequately inspect the No. 2 cylinder valve area during the annual inspection, which allowed the rust to go undetected and resulted in the in-flight failure of the No. 2 cylinder valve springs.

Factual narrative

On December 4, 2014, about 1100 eastern standard time (EST), a Cessna 205, N8296Z, was force landed in a farm field following a total loss of engine power during the initial climb from Sussex Airport, Sussex, New Jersey (FWN). The commercial pilot had minor injuries and five passengers were not injured. The airplane was substantially damaged. The airplane was registered to Markelwin Aviation LLC and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a skydiving flight. Day, visual meteorological conditions prevailed, and no flight plan was filed. The flight was originating at the time of the accident.The pilot reported the following. About 1,200 to 1,300 feet above mean sea level, or about 800 to 900 feet above the ground, during the initial climb, a "mechanical failure" of the engine occurred. Due to the low altitude, he force landed the airplane in a muddy farm field, south of the airport. The airplane's nose gear struck a ditch and the airplane nosed over before coming to a stop. The pilot and passengers exited the airplane without further incident. An inspector with the Federal Aviation Administration responded to the accident site and examined the wreckage. The aft fuselage and empennage exhibited structural damage from impact forces. The propeller was bent aft and the engine remained attached at the firewall. The engine turned freely when the propeller was rotated manually. On December, 17, 2014, the engine was test run on the airframe, which was equipped with a digital engine monitor, displaying EGT for each cylinder. Due to vibration as a result of impact damage, the engine was not run higher than 1,700 rpm. During the run, the left side cylinders (numbers 2, 4, and 6) experienced a drop in EGT while the right side of the engine ran within the normal range. Black exhaust smoke was observed from the left side engine exhaust manifold. After the test run, the fuel nozzles for the left side of the engine were observed to be clogged with a black substance and the spark plugs were soot-covered. The fuel manifold valve was opened and no anomalies or obstructions were observed. Additionally, each spark plug lead produced spark when the propeller was rotated by hand. The fuel nozzles and spark plugs were then cleaned and the engine was test run again, with the same result of the left side exhibiting significantly less EGT verses the right side (200 degrees F versus 1,000 degrees F) after about 1 minute of operation. Prior to the EGT drop, a magneto check was performed at 1,700 rpm with no anomalies noted. After the second test run, the air intake and exhaust were inspected and observed to be free of obstructions. Some oil was noted inside the number 2 cylinder. The engine was shipped to the manufacturer's facility for further examination. After an initial inspection, the engine was prepared for a run in the test cell. Once installed, the engine started on the first attempt without hesitation. The enginespeed was brought to 1,000 rpm to warm up the engine to normal operating temperatures. The engine was run at 1,200 rpm for five minutes to stabilize. The engine throttle was advanced to 1,600 rpm, 2,100 rpm, and 2,450 rpm and held for five minutes at each rpm setting to stabilize. The engine throttle was then advanced to the full open position and the engine began to "stumble" and lose power. Investigators then began troubleshooting the fuel system. Subsequent engine runs would result in the engine only being capable of attaining 1,800 rpm. Further troubleshooting revealed both number 2 cylinder intake valve springs were broken. Visible rust was observed on the surfaces of the springs. The broken valve springs were replaced and the engine was run again. After replacing the valve springs, the engine was capable of operating normally at full power. The engine throttle was rapidly advanced from idle to full throttle six times, where it performed normally without any hesitation, stumbling or interruption in power. No further anomalies noted that would have prevented normal operation or production of rated horsepower. The fractured inner and outer intake valve springs from the number 2 cylinder were subsequently examined by investigators. Both springs showed fatigue fractures originating from rust pits on the surfaces. A review of the engine maintenance logbooks revealed that a 100 hour/annual inspection was completed on October 14, 2014, at 7,857.8 hours tachometer time. About 13 hours of operating time had accrued since the last inspection of October 14. About 1,501 hours had accumulated on the engine since its last major overhaul. According to the engine manufacturer's operating manual, under the 100-hour inspection procedures, it states, "Remove valve rocker covers, and inspect visible parts of the valve mechanism for breakage and lack of lubrication. All parts should be covered with oil."

Aircraft

Registration
N8296Z
Reported as
Cessna 210 5(205)
Category
Airplane
Serial number
205-0296
Built
1963
Airframe hours
7,870
Engine
Cont Motor IO-470-S, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Skydiving · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 1, 2014 · 13 hours before
Departed
FWN · Sussex, NJ
Destination
FWN · Sussex, NJ
Airport
FWN · Sussex Airport, runway 21, 3,499 × 75 ft, asphalt

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
46
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
490 total · 40 in this make and model · 428 as pilot in command · 110 in the last 90 days · 40 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 39 °F
Altimeter
30.28 inHg
Observed at
FWN, 5 nm away

Docket · 13

The files NTSB released with the investigation on September 14, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.2 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.

Other investigations on N8296Z · 1

Matched to the same aircraft by N-number and date.