ERA17LA194

NTSB accident investigation · Avions Mudry Cie CAP 231 · Lebanon, PA · May 27, 2017

Accident · No injuriesLimited investigationFinal report
Date
May 27, 2017, 13:30 local (17:30 UTC)
Place
Lebanon, PA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N231XAvions Mudry Cie CAP 231
Defining event
Maneuvering-aerobatics: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report June 25, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20170527007089A
Case key
95259

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The partial separation of one counterweight and the subsequent seizure of the engine due to mechanical interference. Contributing to the partial separation of the counterweight was the overstress fracture of a retaining ring and the fatigue fracture of the counterweight washer for reasons that could not be determined based on the available evidence.

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 engine power sectionAircraft › Aircraft power plant · MalfunctionAll aircraft: 233 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · FailureAll aircraft: 233 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionAll aircraft: 233 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedAll aircraft: 2,247 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 private pilot reported that he was practicing aerobatics near the departure airport and that the airplane was in a 45° nose-up maneuver when he heard a "loud knock" from the engine, followed by a significant "shake." He leveled the airplane, reduced the manifold pressure, and then turned the airplane back toward the airport. Subsequently, the engine rattled and began to shake more, followed by a total loss of power. The pilot's attempts to restart the engine were unsuccessful. He planned a high base leg and sideslip onto the final approach leg of the airport traffic pattern to ensure the airplane would reach the runway. During the landing flare, the airplane floated, touched down beyond the midpoint of the grass runway, and bounced. The pilot applied hard braking, but the airplane rolled off the end of the runway, down an embankment, and nosed over. Postaccident examination of the engine revealed that it was seized and that one counterweight, which was normally secured to the crankshaft at two places, was separated at one location. The retaining ring for one side of one counterweight, which was properly installed, fractured due to overstress, and its associated washer fractured due to reverse bending fatigue. The fracture of these components allowed the roller to separate and jam between the crankcase and crankshaft, which resulted in mechanical interference. The roller's contact with the counterweight bushings and/or counterweight washers could have been caused by a several things; however, because the fatigue crack initiation sites were destroyed by postfracture damage, the root cause for the overstress fracture of the retaining ring and fatigue fracture of the washer associated with the counterweight could not be determined.

Factual narrative

On May 27, 2017, about 1330 eastern daylight time, a privately operated Avions Mudry CIE CAP 231, N231X, was substantially damaged during a forced landing at the Keller Brothers Airport (08N), Lebanon, Pennsylvania. The private pilot was not injured. The airplane was being operated under the provisions of 14 Code of Federal Regulations Part 91as a personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for the local flight which originated about 10 minutes earlier from 08N.The pilot stated that he was over 08N in the active aerobatics box practicing maneuvers, and had completed a hammerhead, a Cuban 8, another hammerhead, and two verticals. He was in a 45° nose-up climb maneuver when he heard a loud knock from the engine followed by a significant "shake." He leveled the airplane, reduced manifold pressure and announced that he was returning to 08N over the common traffic advisory frequency. As he turned towards the runway, the engine rattled and shook more, and then stopped producing power. The pilot attempted to restart the engine but was unsuccessful. He planned a high base leg and side slip onto the final approach leg of the airport traffic pattern to assure that the airplane would reach the runway. While gliding, he determined that the airplane felt unstable under 100 mph, and conducted the approach at a speed of 100 mph. During the subsequent landing flare, the airplane floated, touched down beyond midpoint of the nearly 2,700 ft long grass runway, and bounced. The pilot applied hard braking; however, the airplane rolled off the end of the runway, down an embankment, and nosed over. Examination of the AEIO-540-L1B5D engine following recovery revealed the engine was seized, and there was a hole in the crankcase near the crankcase parting line below the intake and exhaust valve pushrods. The No. 4 cylinder connecting rod cap was fractured, a nut from the No. 4 connecting rod was recovered from inside the crankcase, and the No. 4 exhaust valve cam follower was found inside the lower engine cowling. Considerable force was required to break the crankshaft free. Disassembly examination of the engine with FAA oversight revealed that one counterweight, which was normally secured to the crankshaft at two places, was separated at one location. The retaining ring, washer, and roller associated with the separated side of the counterweight were separated. The separated washer and retaining ring were fractured and were found in the oil sump, while the roller was jammed between the crankshaft and engine crankcase. The separated roller and pieces of the fractured retaining ring and washer were retained. The remaining counterweight roller retaining rings were properly installed in the counterweights. Additional retained components consisted of the other counterweight, a remnant of a connecting rod bearing, a fractured connecting rod cap with fractured section of connecting rod bolt, mating section of fracturedconnecting rod bolt without a nut, a nut associated with a connecting rod that was found from the top of the engine, and a nut associated with a connecting rod that was found inside the engine. The fractured components were forwarded to the NTSB Materials Laboratory for detailed examination.. Examination of the fractured pieces of the retaining ring associated with the counterweight revealed the fracture surfaces were consistent with overstress fracture, and the surfaces were consistent with the fractured retaining ring still present in the counterweight assembly. The general circular fracture features were consistent with rotational loading. The fracture surface of one piece of the fractured washer exhibited progressive features (such as crack arrest marks and radial patterns), consistent with reverse bending fatigue, with crack initiation on the outside faces of the washer. However, the fatigue crack initiation sites were destroyed by post-fracture damage. The outer surface of the roller exhibited both axial and radial sliding wear. No other pre-existing fracture was noted on any of the other submitted components. Examination of all circlips revealed evidence they were properly installed. Review of the maintenance records revealed the engine was last overhauled on November 5, 2009. As part of the overhaul, new counterweight bushings, washers, and retaining rings were installed. The engine had accumulated about 242 hours since overhaul at the time of the accident. According to a representative of the engine manufacturer, when operational conditions or non-standard movement cause the rollers to slam against the counterweight washers, impact bending forces on the counterweight washers can and does occur, sometimes causing fatigue cracks to initiate on the outer face of the washers (typically at the corners). The representative indicated that operational considerations for non-standard movement and impact loading by the rollers against the counterweight bushings and/or counterweight washers include: 1. Sudden stoppage, such as prop strike etc.; 2) Sudden accelerations and decelerations as in rapid throttling; 3) Counterweight Detuning; 4) Operating at excessive power/overloading; 5) Operating under detonation conditions; 6) Abnormally high torsional vibrations, and; 7) Improper installation/assembly (wrong part numbers of rollers, or miss-matched rollers in the counterweights).

Aircraft

Registration
N231X
Reported as
Avions Mudry Cie CAP 231 (UNDESIGNAT)
Category
Airplane
Serial number
12
Built
1990
Airframe hours
1,081
Engine
Lycoming AEIO-540-L1B5, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · March 15, 2017 · 3 hours before
Departed
08N · Lebanon, PA
Destination
08N · Lebanon, PA
Airport
08N · Keller Brothers Airport, runway 25, 2,692 × 120 ft, grass/turf
Equipment
Electronic primary flight display, ADS-B, Onboard weather

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
None
Certificates
Private, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
July 11, 2015
Seat
Single
Restraint
5-point
Flight hours
2,308 total · 57 in this make and model · 2,232 as pilot in command · 3 in the last 90 days · 0.2 in the last 30 days · 0.2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
4,700 ft overcast
Temperature
70 °F, dew point 57 °F
Altimeter
29.90 inHg
Observed at
LNS, 10 nm away

Docket · 8

The files NTSB released with the investigation on April 17, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.2 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.