ERA19LA008

NTSB accident investigation · North American Navion A · Stonewall, MS · October 5, 2018

Accident · No injuriesLimited investigationFinal report
Date
October 5, 2018, 14:45 local (19:45 UTC)
Place
Stonewall, MS
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N969TRNorth American Navion A
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report August 10, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors, FAA/FSDO
FAA report
20181005024469A
Case key
98454

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

The fatigue failure of the No. 3 cylinder exhaust valve, which resulted in a fractured camshaft and a total loss of engine power.

Findings · 3

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)Aircraft › Aircraft power plant · FailureNorth American NAVION A: 1 caseAll aircraft: 497 casesProbable cause
Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · Fatigue/wear/corrosionNorth American NAVION A: 1 caseAll aircraft: 373 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 stated that, while en route to his destination, the airplane's engine sputtered and then lost total power. During the subsequent forced landing to a highway, the airplane landed hard, and the landing gear collapsed; the airplane sustained substantial damage to the fuselage. A postaccident examination of the engine revealed the No. 3 cylinder exhaust valve fractured where the stem transitioned to the valve head seat. The valve head impacted the No. 3 piston and became lodged between the crankcase and the camshaft, which resulted in the fracture of the camshaft. Fatigue cracking, which initiated at multiple sites, propagated through the valve stem. The presence of a tapered stem near the fracture surface, high temperature oxide deposits, and fatigue striations on the fracture surface suggested that the stem underwent spallation or erosion of the oxides formed during high temperature exposure, which would reduce the stem cross-section over time, increasing the likelihood of initiating fatigue cracking. Additionally, a localized area of wear on the top face of the valve stem was most likely due to the valve not rotating during operation, which could create hot spots or improper thermal dissipation in the hottest parts of the valve and lead to valve damage or failure.

Factual narrative

On October 5, 2018, about 1445 central daylight time, a North American Navion A, N969TR, was substantially damaged during a forced landing near Stonewall, Mississippi. The private pilot was not injured. The airplane was registered to the pilot and was being operated as Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that departed Key Field Airport (MEI), Meridian, Mississippi, at 1438, and was destined for Jack Edwards National Airport (JKA), Gulf Shores, Alabama.The pilot stated that he was flying at 3,500 ft when the engine sputtered. He informed air traffic control that he wanted to return to MEI and turned back toward the airport, but the engine stopped producing power. The pilot realized that he was not going to be able to reach MEI or any other airport and made a forced landing to a highway. The pilot said he bled off airspeed to avoid hitting cars and landed hard. The airplane's landing gear collapsed, and the airplane slid about 200 ft and came to rest upright on the road, which resulted in substantial damage to the fuselage. A postaccident examination of the engine revealed the No. 3 cylinder exhaust valve fractured where the stem transitioned to the valve head. The valve head was found lodged between the crankcase and the camshaft, and the camshaft was fractured between the No. 3 intake and exhaust lobes. Metallurgical examination of the liberated valve head and the valve stem revealed that the valve head was damaged from repeated contact with the piston and the valve stem exhibited fracture surfaces consistent with fatigue. The fatigue cracking propagated through the valve stem, initiating at multiple crack initiation sites on the stem surface. The valve stem also exhibited tapering near the fracture surface, and surface oxidation and deposits of lead-based compounds which were also present on the exterior of the stem adjacent to the fracture surface. A small depressed area was also noted on the top face of the valve stem, which was consistent with repeated contact with the adjacent rocker. The last annual inspection of the airplane and engine was on August 1, 2018. At the time of the accident, the engine had accrued a total of 1,705.0 hours and 641.5 hours since overhaul. Further review of the engine maintenance logbook revealed that on May 4, 2014, at an engine total time of 1,390.4 hours and 322.1 hours since overhaul, a mechanic "removed and reinstalled all six cylinders with new base seals, push rod tubes seals, intake tube seals, exhaust gaskets and rocker gaskets after resurfacing valves and seats."

Aircraft

Registration
N969TR
Reported as
North American Navion A (No Series)
Category
Airplane
Serial number
NAV-4-342
Built
1946
Airframe hours
3,336
Engine
Continental E-225-4, 205 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2018 · 11 hours before
Departed
MEI · Meridian, MS
Destination
JKA · Gulf Shores, AL
Equipment
Onboard weather, Handheld GPS, Electronic primary flight display, Electronic multifunction display, Satellite tracking 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
48
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
April 30, 2017
Seat
Left
Restraint
Lap only
Flight hours
568 total · 264 in this make and model · 439.2 as pilot in command · 11 in the last 90 days · 8.3 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 7 knots
Visibility
10 statute miles
Lowest ceiling
8,000 ft broken
Temperature
91 °F, dew point 68 °F
Altimeter
30.02 inHg
Observed at
MEI, 15 nm away

Docket · 8

The files NTSB released with the investigation on June 8, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.3 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.