# NTSB ERA18LA165: Cessna 182, N3889D, Arecibo, PR, June 10, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 10, 2018, 12:34 local (16:34 UTC) - Place: Arecibo, PR - Coordinates: 18.221651, -66.590759 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=18.2217&lon=-66.5908&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: Serious injuries - Injuries: 1 serious, 4 minor - Status: Completed, report June 8, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors Inc - NTSB case key (mKey): 97433 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97433/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97433 - Page: https://openairdocs.org/ntsb/ERA18LA165 ## Probable cause Maintenance personnel's failure to properly apply torque to the engine through bolts, which ultimately resulted in the crankshaft failure and the 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: [Cessna 182A, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=2072704), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Cessna 182A, 2 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=2072704), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/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: [Cessna 182A, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=2072704), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Cessna 182A, 20 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=2072704), [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 182A, 15 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=2072704), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 182A, 34 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072704), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot stated that shortly after takeoff on the skydiving flight, the airplane's engine made a "clicking" sound and lost power. The pilot subsequently performed a forced landing to a field, during which the airplane flipped over and sustained substantial damage to the fuselage, right wing, and tail. Examination of the engine revealed the crankcase web mating surfaces at the Nos. 2, 3, and 4 bearing saddles exhibited pitting consistent with fretting, which was indicative of improper preloading (torque) of the through bolts. Additionally, the No. 2 main bearing was displaced from its saddle and severely worn, and the crankshaft fractured due to fatigue. A review of maintenance records revealed the engine's camshaft and lifters were replaced about 280 hours before the accident; this was the last documented time during which the applicable through bolts and associated nuts would have been assembled. Given this information, it is likely that maintenance personnel failed to properly apply torque to these through bolts during this maintenance, which ultimately resulted in the crankshaft failure and the subsequent loss of engine power. ## Factual narrative On June 10, 2018, about 1234 Atlantic Standard time, a Cessna 182, N3889D, was substantially damaged during a forced landing after it experienced a total loss of engine power shortly after takeoff from the Antonio (Nery) Juarbe Pol Airport (ABO), Arecibo, Puerto Rico. The pilot was seriously injured, and the four passengers sustained minor injuries. The airplane was privately owned and operated by Skydive Puerto Rico as a Title 14 Code of Federal Regulations Part 91 skydiving flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight that had just departed ABO.The pilot stated that shortly after takeoff from runway 8, about 275 ft above the ground, he made a left turn to avoid descending jumpers. While in the turn, the airplane started to vibrate, and the engine made a "clicking" sound while losing power. The pilot was unable to maintain altitude and made a forced landing to a field. The airplane flipped over, which resulted in substantial damage to the firewall, fuselage, right wing strut, and vertical stabilizer/rudder. The propeller was also damaged. A postaccident examination of the engine by a Federal Aviation Administration (FAA) inspector revealed the crankshaft was fractured. Preparation was made to have the engine removed from the airframe and shipped to the manufacturer. Due to the limited availability of resources in Puerto Rico after Hurricane Maria, there was a delay in having the engine shipped. During this time, and unbeknownst to the National Transportation Safety Board (NTSB), the engine was sold while the investigation was still on-going. The FAA was able to locate the engine in Puerto Rico and the new owner assisted in having the engine shipped to the manufacture in Mobile, Alabama, where the engine was disassembled and examined under the supervision of the NTSB. The examination revealed the crankshaft was fractured at the No. 3 cheek just forward of the No. 2 connecting rod and aft of the No. 2 main crankshaft journal. The No. 2 main bearing was displaced from its saddle and was severely worn. The head of the No. 2 cylinder's connecting rod bolt was fractured and not recovered. The crankcase web mating surfaces at the Nos. 2, 3, and No. 4 bearing saddles exhibited pitting consistent with fretting. The fractured ends of the crankshaft were examined at the NTSB Materials Laboratory. The examination revealed the fracture surfaces were consistent with fatigue cracking. A review of the engine logbook revealed the engine was last overhauled on October 2, 1997, about 21 years prior to the accident. According to the Continental Standard Practice Maintenance Manual, the recommended time between overhauls for this model engine was 1,500 hours or 12 years. At the time of the accident, the engine had accrued a total of 2,821.2 hours and 1,111.2 hours since major overhaul. Further review of the engine logbook revealed the engine was removed from the airplane on September 15, 2017, "due toexcessive camshaft and lifter wear." A work order associated with this repair stated that the engine's camshaft and lifters were replaced at a tachometer time of 2,541 hours and 831 hours since overhaul (280 hours prior to the accident.). On January 5, 2018, at 965 hours since overhaul (146.2 hours prior to the accident), the No. 4 cylinder was removed and reinstalled after the piston rings were staggered. The engine underwent two additional 100-hour inspections, with the last being completed on June 5, 2018, at an engine time of 1,087 hours since overhaul. The pilot held a commercial pilot certificate with ratings for airplane single and multiengine land, and instrument airplane. His last FAA first-class medical certificate was issued on December 12, 2017. The pilot reported a total of 2,285 flight hours, of which, 1,187 hours were in the same make/model as the accident airplane. ## Aircraft - Registration: [N3889D](https://openairdocs.org/deregistered/N3889D-2019-09-06), registration cancelled 2019-09-06, S/N 34589, built 1957 (OpenAirDocs) - Reported make and model: CESSNA 182 (A) - Registry model: [Cessna 182A](https://openairdocs.org/model/cessna-182a) (registry code 2072704) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 34589 - Year built: 1957 - Airframe hours: 3931.2 - Engines: CONT MOTOR O-470-L 220 horsepower reciprocating - Damage: Substantial damage - Flight: Skydiving, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 5, 2018, 24 hours before - Departed: ABO, ARECIBO, PR - Destination: ABO, ARECIBO, PR - Flight plan: VFR - Airport: ABO, Antonio (Nery) Juarbe Pol Airp - Equipment: ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review March 2, 2018; seat: left; restraint: lap only; flight hours: 2,285 total, 1,187 in this make and model ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none ## 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 20180610015439A](https://openairdocs.org/incident/20180610015439A), Jun 10, 2018: Cessna 182A, Arecibo, PR, Substantial damage. On jun 11, 2018 at 1615 hrs. (UTC), aircraft N3889D, a Cessna 182A, operated by skydive puerto rico departed from runway 8 in Antonio Juarbe pol airport (abo)… ## Docket (9 files) The files NTSB released with the investigation on April 22, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97433. 10.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482842&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Record of Conversation - Pilot (item 2, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482843&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20-%20Pilot-Master.PDF - FAA Record of Conversation - Pilot and Passengers (item 3, .PDF, 471 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482844&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20-%20Pilot%20and%20Passengers-Master.PDF - Maintenance Records (item 4, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482845&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Photos (item 5, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482846&FileExtension=.PDF&FileName=Photos-Master.PDF - NTSB Materials Laboratory - Factual Report (item 6, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482847&FileExtension=.PDF&FileName=NTSB%20Materials%20Laboratory%20-%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 549 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482848&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Evidence Control Forms (item 8, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482849&FileExtension=.PDF&FileName=Evidence%20Control%20Forms-Master.PDF - Continental Standard Practice Manual, Page 6-4 (item 9, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482850&FileExtension=.PDF&FileName=Continental%20Standard%20Practice%20Manual,%20Page%206-4-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.