ERA18LA168

NTSB accident investigation · Stinson L 5 · Thomson, GA · June 14, 2018

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 14, 2018, 18:00 local (22:00 UTC)
Place
Thomson, GA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N45TXStinson L 5
Defining event
Maneuvering: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA FSDO
FAA report
20180614007889A
Case key
97483

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

Failure of maintenance personnel to inspect the crankshaft after two previous propeller strikes, which resulted in failure of the crankshaft and a total loss of engine power. Contributing to the crankshaft failure was insufficient torque applied to the thrust nut.

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 · Damaged/degradedStinson L-5: 1 caseAll aircraft: 233 casesProbable cause
Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Inadequate inspectionStinson L-5: 1 caseAll aircraft: 233 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelStinson L-5: 1 caseAll aircraft: 320 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · PilotStinson L-5: 1 caseAll aircraft: 167 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

While in cruise flight, the pilot noticed an increase in oil temperature and loss of oil pressure. Shortly thereafter, the engine lost total power, and the propeller stopped rotating. The pilot performed a forced landing to a lake, which resulted in substantial damage. Examination revealed that the propeller could not be rotated by hand, and the crankshaft was fractured at the No. 2 crank pin. Review of maintenance logbooks revealed that the most recent engine overhaul was performed about 24 years and 711 flight hours before the accident. Since that time, the propeller had been removed and replaced on two separate occasions due to propeller strikes. There was no record of any crankshaft inspections following either of the propeller strikes, contrary to manufacturer guidance. Additional damage found on the Nos. 1 and 2 cylinders was caused by the crankshaft failure and pistons that impacted their respective rods and skirts. In addition to the main fracture, a separate crack was discovered slightly aft of the No. 1 main bearing and had propagated nearly the width of the crankshaft, but had not fully failed. The thrust nut, which required 375 ft-lbs of torque, was easily removed without effort or special tools, indicating that it was torqued to a value significantly below specification. This could cause axial play along the crankshaft and contribute to the progression of the crankshaft failure that was likely initiated during the previous 2 propeller strikes. The crankshaft likely failed after its structural integrity was compromised during previous propeller strikes. The improper torque on the thrust nut likely exacerbated the failure of the crankshaft.

Factual narrative

On June 14, 2018, about 1800 eastern daylight time, a Stinson L-5, N45TX, was involved in an accident near Thomson, Georgia. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that the preflight inspection, engine runup, takeoff, and climb were normal. About 40 minutes into the flight, while flying at 2,200 ft mean sea level and 10 miles from the departure airport, he noticed the oil temperature “jumped” to the top of the green arc and the oil pressure was near the bottom of the green arc. He reduced engine power, adjusted the mixture to full rich, and turned toward the airport. Shortly thereafter, the engine lost total power and the pilot’s attempts to restore power were unsuccessful; the propeller was stationary and did not move during attempts to restart the engine. The pilot performed a forced landing to a lake and the airplane sank after the pilot egressed. The airplane was recovered and visually examined by a Federal Aviation Administration (FAA) inspector. The airplane’s left wing was substantially damaged. The inspector attempted to rotate the propeller by hand, but the propeller would not move. Review of the maintenance logbooks revealed that the last engine overhaul was performed on March 29, 1994. On two separate occasions, June 8, 2002, and September 16, 2002, the propeller was replaced due to a propeller strike/damage. There was no record of crankshaft inspections found in the maintenance logbooks. The last annual was performed on September 14, 2017, at 6,113.2 tachometer time. At the time of the accident, the airplane had flown 10.6 hours since the annual inspection and 711 hours since engine overhaul. The airplane was recovered for detailed teardown and examination of the engine. Removal of the Nos. 1 and 2 cylinders revealed that the crankshaft fractured at the No. 2 crank pin. (see Figure 1.) Figure 1 Crankshaft fracture The thrust nut was removed in order to open the crankcase. The amount of torque required to loosen the thrust nut was not measured, but was significantly less than the 375 ft-lbs specified by the engine overhaul manual, as it required no special tools and little effort to remove. Upon opening the crankcase, it was confirmed that the crankshaft was fractured along with ancillary damage caused by the Nos. 1 and 2 pistons and connecting rods impacting their respective skirts. In addition to the main fracture, a separate crack was discovered slightly aft of the No. 1 main bearing that had propagated nearly the width of the crankshaft, but had not fully failed. On October 18, 2016, Lycoming issued a Mandatory Service Bulletin No. 533C (Superseded 533B) with recommended action for sudden engine stoppage, propeller/rotor strike, or loss of propeller/rotor blade or tip for all Lycoming reciprocating aircraft engines. The SB included detailed checklists for the inspection.

Aircraft

Registration
N45TX
Reported as
Stinson L 5 (C)
Category
Airplane
Serial number
44-17397
Built
1944
Airframe hours
1,641
Engine
Lycoming O-435, 185 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 14, 2017 · 10 hours before
Departed
HQU · Thomson, GA
Equipment
Electronic flight bag or handheld device

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
47
Injuries
None
Certificates
Flight instructor, Commercial, Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Waiver time limited special
Seat
Front
Restraint
4-point
Flight hours
528 total · 92 in this make and model · 469 as pilot in command · 1 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 72 °F
Altimeter
30.00 inHg
Observed at
HQU, 6 nm away

Docket · 5

The files NTSB released with the investigation on November 3, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.5 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.