# NTSB ERA15LA071: Cessna 210 5(205), N8296Z, Sussex, NJ, December 4, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: December 4, 2014, 11:00 local (16:00 UTC) - Place: Sussex, NJ - Coordinates: 41.193054, -74.627777 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.1931&lon=-74.6278&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor, 5 uninjured - Status: Completed, report October 19, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Textron Aviation, FAA/FSDO, Continental Motors, Inc. - NTSB case key (mKey): 90461 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA071 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90461/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90461 - Page: https://openairdocs.org/ntsb/ERA15LA071 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Inadequate inspection (probable cause); cases with it: [Cessna 210-5(205), 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2073202), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Inspection: scheduled/routine inspection](https://openairdocs.org/ntsb-findings/02061520): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Cessna 210-5(205), 1 case](https://openairdocs.org/ntsb-findings/02061520/cases.md?model=2073202), [All aircraft, 167 cases](https://openairdocs.org/ntsb-findings/02061520/cases.md) - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Cessna 210-5(205), 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=2073202), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Inadequate inspection (probable cause); cases with it: [Cessna 210-5(205), 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=2073202), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/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 inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna 210-5(205), 2 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=2073202), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 210-5(205), 4 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2073202), [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: [Cessna 210-5(205), 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2073202), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 210-5(205), 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=2073202), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N8296Z-2018-06-08), registration cancelled 2018-06-08, S/N 205-0296, built 1963 (OpenAirDocs) - Reported make and model: CESSNA 210 5(205) - Registry model: [Cessna 210-5(205)](https://openairdocs.org/model/cessna-210-5-205) (registry code 2073202) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 205-0296 - Year built: 1963 - Airframe hours: 7870 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: minor; 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 ## 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 20141204024039A](https://openairdocs.org/incident/20141204024039A), Dec 4, 2014: Cessna 210-5(205), Sussex, NJ, Substantial damage. Pilot departed runway 21 when at about 1000' AGL the engine began surging and was not developing power,the pilot returned to the airport overshot the runway… ## Other investigations on N8296Z (1) 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. - [NTSB FTW70F0224](https://openairdocs.org/ntsb/FTW70F0224), Oct 2, 1969: Cessna 205 (N8296Z), Lake Village, AR, substantial damage ## Docket (13 files) The files NTSB released with the investigation on September 14, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90461. 8.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 620 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431742&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum for Record – NTSB Examination Notes (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431743&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20NTSB%20Examination%20Notes-Master.PDF - Memorandum for Record – Sussex NJ (FWN) Weather (item 3, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431749&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Sussex%20NJ%20(FWN)%20Weather-Master.PDF - Continental Motors Engine Run Report (item 4, .PDF, 12 photos, 665 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431744&FileExtension=.PDF&FileName=Continental%20Motors%20Engine%20Run%20Report-Redacted.PDF - Continental Motors Metallurgical Report (item 5, .PDF, 6 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431745&FileExtension=.PDF&FileName=Continental%20Motors%20Metallurgical%20Report-Master.PDF - Certification of Party Representative (item 6, .PDF, 500 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431746&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-Redacted.PDF - Excerpts – Airframe and Engine Logbooks (item 7, .PDF, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431747&FileExtension=.PDF&FileName=Excerpts%20%E2%80%93%20Airframe%20and%20Engine%20Logbooks-Redacted.PDF - Excerpts – IO-470 Operators Manual (item 8, .PDF, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431748&FileExtension=.PDF&FileName=Excerpts%20%E2%80%93%20IO-470%20Operators%20Manual-Master.PDF - Evidence Control Form and Attachments (item 9, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431750&FileExtension=.PDF&FileName=Evidence%20Control%20Form%20and%20Attachments-Redacted.PDF - Photo 1 –Main Wreckage (Photo Courtesy of FAA) (item 10, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431751&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 – Aft Fuselage Damage (Photo Courtesy of FAA) (item 11, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431752&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Aft%20Fuselage%20Damage%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 – Number 2 Cylinder Valve Springs (item 12, .PDF, 733 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431753&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Number%202%20Cylinder%20Valve%20Springs-Master.PDF - Photo 4 – Number 2 Cylinder Intake Valve Springs Removed (item 13, .PDF, 830 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40431754&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Number%202%20Cylinder%20Intake%20Valve%20Springs%20Removed-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.