WPR17LA004

NTSB accident investigation · Rockwell International 112A · Phoenix, AZ · October 12, 2016

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
October 12, 2016, 10:11 local (17:11 UTC)
Place
Phoenix, AZ
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N509CARockwell International 112A
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Lycoming Engines, Federal Aviation Administration
FAA report
20161012016579A
Case key
94195

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

A catastrophic engine failure due to lack of lubrication due to the absence of 2 piston cooling nozzles that backed out of their respective threaded bores, which resulted in a forced landing on unsuitable terrain.

Findings · 2

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.

Power plantAircraft › Aircraft power plant · FailureRockwell International 112A: 2 casesAll aircraft: 198 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelRockwell International 112A: 1 caseAll aircraft: 174 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

According to air traffic control transcripts, about 17 minutes after the private pilot departed for a personal, cross-country flight and immediately after being cleared to climb to 10,500 ft mean sea level (msl), the pilot advised an air traffic controller that the engine oil temperature was “running a little hot” and that he needed to level off at 7,500 ft msl to “cool off.” About 7 minutes later, the pilot repeated that the engine temperature was running high and requested a return to the departure airport but stated that he did not want to declare an emergency. The controller provided the pilot with information for an airport closer to the airplane’s position for a diversionary landing. Although a controller at that airport issued the pilot a straight-in approach, the pilot responded that the engine had lost power and that he was going to have to land because the airplane could not reach the airport. Subsequently, the pilot attempted to conduct a forced landing on a nearby road, but the airplane impacted terrain in a train yard and came to rest between trees and a wooden structure substantially damaging the airframe and wings. During a postaccident examination of the engine, a hole was found in the engine case at the No. 4 cylinder, and metal debris was found throughout the engine, indicative of a catastrophic engine failure. The No. 4 connecting rod bearing had extruded and exhibited signatures consistent with a lack of lubrication, which likely led to the catastrophic engine failure. The Nos 2 and 4 piston cooling nozzles were absent from their respective threaded bore in the crankcase; they were identified in the oil sump and had sustained destructive damage as a result of passage through the engines internal rotating components. The threaded nozzle bores for the Nos 2 and 4 piston cooling nozzles were not damaged. The No. 1 cooling nozzle remained tight and in place, and the No. 3 cooling nozzle remained in place, but was loose and rotated a quarter of a turn before it became tight. It is likely that the absence of the Nos 2 and 4 piston cooling nozzles would have an effect on the engine lubricating oil effectiveness to the internal rotating components of the engine during operation.

Factual narrative

On October 12, 2016, about 1011 mountain standard time, a Rockwell International 112A airplane, N509CA, was substantially damaged when it was involved in an accident near Deer Valley Airport (DVT), Phoenix, Arizona. The pilot and passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to air traffic control transcripts provided by the Federal Aviation Administration, the airplane departed from Falcon Field Airport (FFZ), Mesa, Arizona, about 0942 destined for Lake Havasu City Airport (HII), Lake Havasu City, Arizona. About 0955, a Phoenix Terminal Radar Approach Control Facility controller cleared the pilot to climb to his requested altitude of 10,500 ft mean sea level (msl). About 0959, the pilot advised the controller that the engine oil temperature was “running a little hot” and that he needed to level off at 7,500 ft msl to “cool off.” About 3 minutes later, the controller told the pilot his altitude was showing 7,200 ft msl and then asked him if he was going to be “okay,” and the pilot replied that he would be but that the oil temperature was still high and that he was going to monitor it a little longer. About 1006, the pilot repeated that he was having trouble with the oil temperature and stated that he wanted to land at FFZ. The controller advised the pilot that he was about 8 miles from Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, and the pilot stated that he would fly close to DVT in case he had to land there and repeated that he was not declaring an emergency. About 1007, the controller switched the flight to the DVT air traffic control tower and advised a controller of the flight’s issues. About 1008, the DVT tower controller issued the pilot a straight-in approach for runway 7R, but the pilot responded that his engine had lost power and that he was going to have to land because the airplane would not be able to reach DVT. The controller then gave the pilot his location and told him that there was a freeway to his right. The pilot replied that he would not be able to reach the freeway and was going to attempt to land on a nearby road. The airplane subsequently impacted terrain in a train yard about 3 miles west of DVT. The airplane came to rest between a tree and a wood-frame structure. The wings and airframe were substantially damaged. The engine remained attached to the engine mount, which had separated from the firewall during the impact sequence. During examination of the engine, a hole was found at the top of the engine crankcase at the No. 4 cylinder. No evidence of preimpact fire was found. The No. 4 connecting rod bearing had extruded and exhibited signatures consistent with a lack of oil lubrication. The connecting rod had separated from its respective crankshaft journal and exhibited localized heat distress signatures. Connecting rod bearing material was found in the engine crankcase and in the oil suction screen. The combustionchambers were undamaged, and no evidence of foreign object ingestion was found. The valves were intact and undamaged, and no valve-to-piston contact was observed. No oil residue was observed in the exhaust system gas path. The magnetos remained secured to their respective mounting pads, and the ignition harness remained secured at each magneto. Both magnetos produced spark at the end of their respective spark plug leads during hand rotation. The fuel flow divider remained secured at its mounting bracket at the top of the engine. No evidence of internal mechanical malfunction or obstruction to the fuel flow was found. The fuel nozzles remained secured at each cylinder. The fuel injection servo remained secured at its mounting pad, and the throttle and mixture controls remained secured at their respective control arm at the servo. The spark plugs remained secured at each position with their respective leads attached. The spark plug electrodes remained undamaged. The top spark plugs were removed, and they exhibited coloration consistent with normal operation. The starter, alternator, and vacuum pump remained secured at their respective mounting pads. The accessory gears remained undamaged; however, flecks of metal were embedded in the case. The normalizing turbocharger and associated system components remained secured at their respective mountings. The turbocharger was not damaged, and the turbine was free to rotate. The numbers 2 and 4 piston cooling nozzles were absent from their respective threaded bore at the crankcase. Both nozzles were in the oil sump and had sustained damage due to their meshing with the engines internal rotating components. The threaded bores for the Nos 2 and 4 nozzles were not damaged. The No 1 piston cooling nozzle remained secure in its position, and the No 3 piston cooling nozzle was in its position; however, it was loose and could be rotated a quarter of a turn before it became tight. Lycoming SSSP 1776-1, Table of Limits, Section V, page 1-35 required each piston cooling nozzle be torqued to 100 in/lb during assembly. The three-bladed propeller assembly remained attached to the engine crankshaft. One of the propeller blades was bent rearward. The propeller governor drive was intact and free to rotate. The propeller governor gasket screen contained metal debris. An engine logbook entry dated September 7, 2016, indicated that the manifold pressure (MAP) indicator was inaccurate and that a mechanic had to troubleshoot it. A logbook entry dated September 30, 2016, indicated that the engine vernatherm, which is a thermostatic bypass valve that controls the flow of oil to the oil cooler, was replaced with a serviceable unit. The oil filter was replaced, and the left and right magneto ignition timing was verified. A run-up and leak check were performed, and the pilot was to conduct a test flight to observe the engine oil operating temperature.

Aircraft

Registration
N509CA
Reported as
Rockwell International 112A (A)
Category
Airplane
Serial number
409
Built
1975
Engine
Lycoming I0360 SER, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Sho Co Kids LLC
Registered owner
Sho Co Kids LLC
Airworthiness certificate
Standard, Normal
Departed
FFZ · Mesa, AZ
Destination
HII · Lake Havasu City, AZ
Airport
DVT · Phoenix Deer Valley
Equipment
None

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
45
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
275 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 34 °F
Altimeter
30.02 inHg
Observed at
DVT, 3 nm away

Docket · 12

The files NTSB released with the investigation on October 7, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.6 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.