MIA06LA067

NTSB accident investigation · Cirrus SR20 · Orlando, FL · March 18, 2006

Accident · No injuriesLimited investigationFinal report
Date
March 18, 2006, 12:45 local (17:45 UTC)
Place
Orlando, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N777YMCirrus SR20
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2007
Report
Approved by Office Director
Parties
FSDO-15 Orlando, Fl.
FAA report
20060318006509A
Case key
63371

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

Catastrophic engine failure due to a low oil level brought about by excessive blow-by and cylinder detonation. Contributing factors in this accident were the inadequate instructions contained in Service Bulletin M89-9 and the ditch.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfApproach - vfr pattern - downwind
Maintenance,service bulletin/letter - inadequateFactor
Fluid,oil - low levelCause
Forced landingDescent - emergency
On ground/water encounter with terrain/waterLanding - roll
Terrain condition - ditchFactor

Analysis

The pilot said that he was on the downwind leg for runway 07 when he observed the engine oil pressure caution light illuminate. Shortly thereafter, the engine lost power. He declared an emergency and landed on runway 13, touching down two-thirds down the runway. The airplane overran the end of the runway and struck a ditch. Eight hours before the accident flight, the owner/operator attempted to determine why there was a low oil quantity and oil was being vented out of the crankcase breather. An airframe and powerplant (A&P) mechanic examined the engine and could find no oil leaks. He also performed a cylinder compression check as outlined in Teledyne Continental Motors' (TCM) Service Bulletins M89-9, "Excessive Crankcase Pressures." No discrepancies were noted. The engine, a Teledyne Continental IO-360-ES (serial number 1393), was disassembled and examined. According to TCM's report, "The connecting rod assemblies exhibited thermal discoloration. The connecting rod bearings exhibited lubrication distress and thermal smearing of the surface babbit, exposing the copper layer. The number four piston head exhibited preignition/detonation damage. The thermal damage had penetrated through the interior of the piston. Portions of the piston rings were missing from thermal damage. The piston pin was intact. The pin plug was damaged from extreme thermal exposure." The magnetos were functionally checked and tested satisfactorily. The 12 spark plugs were also tested. Core nose cracks on five of the 12 spark plugs were attributed to detonation "but did not cause any side effects detrimental to normal engine operation." TCM's Service Bulletin M89-9, entitled "Excessive Crankcase Pressures," requires only a "differential pressure test of the cylinders" to check for cylinder preignition/detonation and excessive blow-by, and does not contain the verbiage contained in TCM's SB03-3, "Differential Pressure Test and Borescope Inspection Procedures for Cylinders."

Factual narrative

On March 18, 2006, approximately 1245 eastern standard time, a Cirrus SR20, N777YM, registered to Boykie Leasing Trading LLC and piloted by a private pilot, was substantially damaged when it overran the runway and struck a ditch at the Orlando Executive Airport, Orlando, Florida. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 CFR Part 91 without a flight plan. The pilot, the sole occupant on board, was not injured. The cross-country flight originated from Pompano Beach Airpark, Pompano Beach, Florida approximately 1115.

The pilot said that when he was on the downwind leg for runway 07, he observed the engine oil pressure caution light illuminate. Shortly thereafter, the engine lost power. He declared an emergency and landed on runway 13, touching down two-thirds down the runway. The airplane overran the end of the runway and struck a ditch.

Eight flight hours before the accident flight, the owner/operator attempted to determine why there was a low oil quantity and oil was being vented out of the crankcase breather. An airframe and powerplant (A&P) mechanic examined the engine and could find no oil leaks. He also performed a cylinder compression check as outlined in Teledyne Continental Motors' (TCM) Service Bulletins M89-9, "Excessive Crankcase Pressures." No discrepancies were noted. NTSB's investigator-in-charge (IIC) reviewed the SB and noted a "differential pressure test of the cylinders" was all that was required to check for cylinder preignition/detonation and excessive blow-by. There was "no mention for borescoping the cylinders." The investigator suggested Service Bulletins M89-9 be amended to include the verbiage found in SB03-3 .

The engine, a Teledyne Continental IO-360-ES (serial number 1393), was disassembled and examined at the company's factory in Mobile, Alabama, on May 16, 2006. According to TCM's report, "The connecting rod assemblies exhibited thermal discoloration. The connecting rod bearings exhibited lubrication distress and thermal smearing of the surface babbit, exposing the copper layer. The number four piston head exhibited preignition/detonation damage. The thermal damage had penetrated through the interior of the piston. Portions of the piston rings were missing from thermal damage. The piston pin was intact. The pin plug was damaged from extreme thermal exposure."

On August 2, 2006, the Unison 6314 magnetos (serial numbers 03090575, left; 03090578, right) were functionally tested. According to Unison's report, both magnetos "continuously fired all 6 spark plugs gaps, and there appeared to be no degradation of the operation" of the magnetos.

The 12 Champion RHM38E spark plugs installed in the engine were also tested. According to Champion's report, all but one of the spark plugs passed 180 PSIG pressurized spark testing. The one failure noted had a 'weak' spark. Resistance values were unusually high. Five of the returned spark plugs had core nose cracks that was attributed to detonation "but did not cause any side effects detrimental to normal engine operation." The report concluded, "No spark plug condition or defects were found that could have contributed to engine loss of oil pressure and subsequently total engine power loss."

Aircraft

Registration
N777YM
Reported as
Cirrus SR20
Category
Airplane
Serial number
1393
Airframe hours
632
Engine
Teledyne Continental IO-360 ES, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Scott Roth
Registered owner
Boykie Leasing and Trading. LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 1, 2006
Departed
PMP · Pompano, FL
Destination
ORL · Orlando, FL
Airport
ORL · Executive Airport, runway 13, 4,638 × 100 ft, asphalt

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
43
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
January 1, 2006
Seat
Left
Flight hours
94 total · 93 in this make and model · 14 as pilot in command · 21 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 39 °F
Altimeter
30.05 inHg
Observed at
ORL

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.