National Transportation Safety Board - Aviation Accident Final Report: http://app.ntsb.gov/pdf
National Transportation Safety Board - Docket And Docket Items: http://dms.ntsb.gov/pubdms
National Transportation Safety Board - Aviation Accident Data Summary: http://app.ntsb.gov/pdf
NTSB Identification: ERA11FA414
14 CFR Part 91: General Aviation
Accident occurred Saturday, July 23, 2011 in Palm Bay, FL
Probable Cause Approval Date: 09/05/2013
Aircraft: CIRRUS DESIGN CORP SR22, registration: N122HB
Injuries: 2 Fatal,1 Minor.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
The surviving passenger stated that the pilot flew the airplane on an uneventful 56-minute flight earlier on the day of the accident. According to data from the multifunction display, the oil pressure was in the normal green arc range (30 to 60 psi) during the entire flight. After landing, no maintenance or servicing was performed. Before takeoff for the accident flight, the pilot performed a walk-around inspection of the airplane, which would require, in part, a check of the oil quantity.
According to GPS and other recorded flight data, about 17 minutes after takeoff, the oil pressure decreased below the lower end of the normal operating range; at the time, the airplane was flying in an easterly direction about 10 nautical miles west of an airport with runways of more-than-adequate length for the pilot to divert. Rather than divert, the pilot continued toward the destination. Although the oil temperature remained in the normal operating range, the oil pressure continued to decrease. Both indications would have been available to the pilot either on the multifunction display or on the analog combination oil pressure/oil temperature gauge.
While the airplane continued toward the destination, the oil pressure decreased to 10 psi, and the pilot maintained the engine power setting at 2,400 rpm (the maximum setting is 2,700 rpm). About 46 minutes after takeoff, with the engine rpm still set at 2,400 rpm, the pilot declared an emergency and advised the controller that smoke was coming from the engine. Unable to fly to suggested airports, the pilot initiated an approach for a forced landing to a large open area containing east/west- and north/south-oriented paved roads.
Witnesses reported that the engine was sputtering and “coughing” but did not note smoke trailing the airplane. For the last 1 minute 12 seconds of flight, the engine rpm decreased from 2,400 to 1,700. While descending with the autopilot disengaged and at 74 knots indicated airspeed, the airplane banked 55 degrees to the right, stalled, pitched nose-down, and impacted the ground.
Examination of the wreckage revealed oil covering the bottom left side of the fuselage from the engine firewall to the tailcone, consistent with the crankcase being pressurized and blowing oil out of the air/oil separator. Examination of the engine revealed that the oil gauge rod and cap assembly had separated from the oil filler tube and was found near the engine and propeller impact crater. Neither the oil gauge rod and cap assembly nor the oil filler breather tube were impact damaged, suggesting that the assembly was improperly secured. Although the No. 4 cylinder piston was fractured and the fracture surfaces exhibited widely spaced crack propagation marks consistent with progressive crack growth under cyclic stresses, the cyclic load was at or above the yield strength of the material. Therefore, the No. 4 cylinder piston did not contribute to the loss of engine oil supply. Examination of the ignition, lubrication, air induction, and fuel injection systems did not note any discrepancies that contributed to the catastrophic failure of the engine.
The catastrophic failure of the engine was consistent with oil starvation due to the crankcase becoming pressurized because of an unsecured oil gauge rod and cap assembly. Postaccident examination of the pistons, piston rings, and crankshaft nose seal did not indicate other typical scenarios of crankcase pressurization. A previous NTSB accident investigation of a different airplane with the same engine model determined that an unsecured oil cap allowed the crankcase to become pressurized and the oil to be vented overboard, causing subsequent catastrophic failure of the engine due to oil starvation.
The pilot’s decision to continue the flight with decreasing or low oil pressure rather than land at a suitable airport nearby and his continued operation of the engine at a high rpm setting contradicted the emergency procedures section of the pilot operating handbook and Federal Aviation Administration-approved flight manual, which contributed to the catastrophic failure of the engine.
Although the airplane was equipped with an airframe parachute, an acquaintance of the pilot reported that the pilot would only use it in the event of a structural issue that rendered the airplane uncontrollable. Otherwise, if it were controllable, the pilot intended to hand-fly the airplane to landing. If the pilot had deployed the airframe parachute, he may have increased the likelihood of a successful emergency landing.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s failure to maintain adequate airspeed while maneuvering for a forced landing, resulting in an inadvertent aerodynamic stall. Contributing to the accident were the pilot’s failure to secure the oil gauge rod and cap assembly before flight and his decision not to land immediately following loss of oil pressure, which resulted in the total loss of engine power due to oil starvation.
HISTORY OF FLIGHT
On July 23, 2011, about 1233 eastern daylight time, a Cirrus Design Corporation SR22, N122HB, registered to N122HB LLC, and operated by a private individual, experienced a loss of engine power and sustained substantial damage during an attempted forced landing to an open field near Palm Bay, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Albert Whitted Airport (SPG), St. Petersburg, Florida, to Melbourne International Airport (MLB), Melbourne, Florida. The private pilot and one passenger were fatally injured, and one passenger sustained minor injuries. The flight originated from SPG about 1145.
The rear seat passenger stated that before takeoff, the pilot, “…checked the airplane on the outside as well as all the instruments inside the airplane.” She reported the takeoff was perfect and was very smooth and she felt very safe.
According to a chronological summary of flight communications, at 1146, or approximately 1 minute after takeoff, the pilot established contact with Tampa Air Traffic Control Tower (Tampa ATCT), and advised the controller that the flight was at 700 feet climbing to 1,600 feet. The controller vectored the pilot to overfly Tampa International Airport runway 28, and air traffic control communications were transferred to a different sector of the Tampa ATCT. The pilot established contact with that sector and at 1201, he advised the controller that his new destination was Valkaria Airport (X59) in order to make a fuel stop. Communications were then transferred to Central Florida Terminal Radar Approach Control Facility (Orlando Approach Control).
The transcription of communications with Orlando Approach Control indicates the pilot established contact while proceeding towards the destination airport. At 1227:13, the controller directed the pilot to descend and maintain 1,500 feet which he acknowledged. The flight continued and at 1231:16, the pilot declared “mayday mayday mayday” followed by a declaration, “…with smoke coming from out of the engine and engine flutter.” The controller advised the pilot that Melbourne International Airport was located at his 9 o’clock position and about 9 miles and his destination airport (X59) was located at his 12 o’clock position and 7 miles. The pilot acknowledged the communication but advised the controller that he could not make either airport and he was looking for an off airport site. As the flight proceeded the controller advised the pilot the location and distance from MLB, but at 1232:12, he advised the controller, “we got fire we doing an off site landing.” The controller acknowledged the comment from the pilot and at 1233:27, broadcast on the frequency for the pilot that radar contact was lost. The pilot did not respond and there were no further recorded transmissions from the pilot.
The rear seat passenger later stated that shortly after turning to the south she felt the airplane shudder, then it became quite. After hearing the pilot tell the right front seat passenger to get into a position, she ducked to make herself as small as possible.
Three witnesses who were located about ½ nautical mile northwest from the crash site reported the airplane flew over their position about 400 to 500 feet in a direction that was determined to be about 100 degrees magnetic. They reported that the engine was sputtering and “coughing”, but they did not see any smoke trailing the airplane. The airplane kept descending, and at the last minute banked hard to the right with the wings reported to be vertical. The nose pitched down, and they lost sight behind trees. They heard an impact, saw white colored smoke, called 911, and proceeded to the site where they rendered assistance until first responders arrived.
The rear seat passenger also stated that the airplane bounced twice then began to flip. When the airplane came to rest, she unbuckled herself and ran away from the airplane to begin looking for help, but noted “…miles and miles of field….”
The pilot and passenger were removed from the wreckage, and all occupants were transported to a hospital for medical intervention.
The airplane crashed during daylight conditions.
PERSONNEL INFORMATION
The pilot, age 65, held a private pilot certificate with rating(s) airplane single engine land, instrument airplane, and held a third class medical certificate issued June 5, 2011, with a limitation to have available glasses for near vision.
Review of the pilot’s logbook which was designated as being Logbook Number “3”, revealed the first entry was dated January 12, 2004, and the last entry was dated July 19, 2011. The carry forward time was 1,606.8 hours, of which all were in “Airplane SEL” column. The pilot-in-command (PIC) carry forward time was recorded to be 1,517.7 hours. He recorded time in a Cessna 182 airplane (N228JA) beginning January 12, 2004, through November 27, 2006, a LC-42 (Colombia N358DM) beginning December 5, 2006, through March 30, 2010, a Piper PA-28 (N3035D) beginning June 2, 2010, through July 25, 2010, and the accident airplane exclusively from October 28, 2010, through the last logged flight. His logged total time was 3,043.4 hours. His last logged flight review in accordance with 14 CFR Part 61.56 (a) occurred on May 21, 2010. His total logged flight time in the accident airplane from the No. 3 logbook was 153.4 hours. His total time in the last 90 days was recorded to be 63.6 hours all as PIC in the accident airplane. His total time in the last 30 days was recorded to be 14.2 hours all as PIC in the accident airplane.
The No. 3 logbook total time as PIC was recorded to be 2,744.6 hours. All of the hours listed for the make and model airplane were recorded to be as PIC, with 3 entries dated October 31, 2010, November 1, 2011, and November 3, 2010, also listed as dual received.
Safety Board interview with a friend of the accident pilot revealed that with respect to the CAPS, he and the pilot had a conversation. The accident pilot advised that he would try to fly the airplane to the ground and would only deploy the CAPS in the event of structural failure or if there was an issue of inability to control the airplane.
AIRCRAFT INFORMATION
The airplane was manufactured by Cirrus Design Corporation in 2003, as model SR22, and was designated serial number 0517. It was powered by a 310 horsepower Continental Motors IO-550-N engine and equipped with a single acting constant speed three-bladed Hartzell propeller.
Engine rpm, oil pressure, oil temperature, manifold pressure, fuel flow, voltage, and amperage were displayed on analog instruments located on the right side of the instrument panel. The combination analog gauge for the oil temperature and oil pressure depicted the green arc (normal) range, red line maximum for oil temperature, and also red line minimum and maximum oil pressure. The analog oil pressure indicator receives a pressure signal from an oil pressure sensor mounted at the aft end of the engine below the oil cooler. Discoloration of the markings on the analog oil pressure gauge faceplate were noted during the postaccident investigation; however, the markings for the caution range, and red line maximum and minimum oil pressure were in the location as depicted in Section 2 of the Pilot’s Operating Handbook and FAA Approved Flight Manual (POH/AFM).
Engine indications were also displayed on the “MAP” or “ENGINE” pages of the Avidyne multi-function display (MFD), which was installed to the right of the primary flight display (PFD), or about the center of the instrument panel. The engine parameters displayed on the MFD’s “ENGINE” or “MAP” pages are derived from analog signals from sensors for cylinder head temperature (CHT), exhaust gas temperature (EGT), manifold pressure (MAP), oil pressure, oil temperature, and rpm which are converted to digital units by a data acquisition unit (DAU). The oil pressure display on the MFD depicts the red line minimum value of 10 psi, green arc (normal) range of 30 to 60 psi, yellow arcs (caution) range for 10 to 30 psi and 60 to 100 psi, and red line maximum limit of 100 psi (cold). The oil temperature display on the MFD depicted the green arc (normal) range of 100 to 240 degrees Fahrenheit, and a maximum (red line) value of 240 degrees Fahrenheit.
A representative of the MFD manufacturer reports that the MFD installed in the airplane at the time of the accident based on the installed software would not display a text alert message on the MFD when engine parameters go into the yellow (caution) or red (maximum) range(s); however, the digits on the “ENGINE” or “MAP” pages instrument displays for the parameters would turn yellow or red as appropriate when the recorded values are in the yellow (caution) or red line (minimum or maximum) range(s). Additionally, engine data is only displayed when the “MAP” or “ENGINE” pages are selected, and the single value for EGT and CHT displayed on the “MAP” page depicts the maximum value from any of the six cylinders. No determination can be made as to what page is selected at the time of an accident or incident.
Flight parameters display on the PFD installed on the pilot’s instrument panel.
The POH/AFM indicates that the PFD provides the functions of the attitude indicator, heading indicator, airspeed indicator, altimeter, vertical speed indicator (VSI), directional gyro, course deviation indicator, and altitude pre-select controller in a single display. In addition, the PFD communicates with the GPS1, GPS2, NAV1, NAV2, multi-function display, and autopilot system. The POH/AFM also indicates that CHT and EGT indications are not required by certification standards, and there is no limitation for EGT or CHT. Rather, the engine limitations are specified to be maximum rpm (2,700), maximum oil temperature (240 degrees Fahrenheit), minimum oil pressure (10 psi), and maximum oil pressure (100 psi).
The airplane was also equipped with a light emitting diode (LED) illuminated annunciator panel located to the left of the PFD, which consist of lights and 6 separate annunciators. One of the six annunciators is a red colored “OIL” warning light which illuminates to indicate either high oil temperature or low oil pressure. The light is illuminated by a switch in the oil temperature gauge/data acquisition unit (DAU) if the oil temperature reaches 240 degrees Fahrenheit or if the oil pressure drops to 10 PSI or less. If the oil light illuminates in-flight, the systems description section of the POH/AFM indicates to refer to the oil temperature and pressure gauges to determine the cause.
The POH/AFM was located in the pilot’s hangar during a postaccident inspection of it; however, a spiral bound excerpts of the POH/AFM was found in the wreckage.
Review of the engine logbook revealed the engine installed at the time of manufacture by serial number was the same engine installed at the time of the accident; there was no record that it had been removed. The engine was manufactured on February 26, 2003, and the first entry dated March 13, 2003, indicated the engine was serviced with 8 quarts of Phillips 20W 50 straight mineral oil. An entry in the engine logbook dated May 27, 2011, at airplane hour meter 1234.9, engine total time 1234.9, indicates an “annual inspection” was performed. The same entry indicates that new cylinder assemblies kit P/N 655465-A4, #1 S/N AC10LA424, #2 S/N AC10JB625, #3 S/N AC10JB633, #4 S/N AC10JB623, #5 S/N AC10LA395, #6 S/N AC11AB077” were installed. The entry also indicates that new piston pin and plug assemblies P/N 630046 were installed in accordance with (IAW) TCM overhaul maintenance manual and TCM maintenance manual. The engine was serviced with 9 quarts AeroShell 100 mineral oil. New induction boots were installed on the Nos. 3 and 4 cylinders. The work was performed by Santa Fe Aero Services, and signed off by an A&P/IA.
Review of paperwork provided by Santa Fe Aero Services dated May 26, 2011, associated with the annual inspection and work performed revealed discrepancy 1.18 indicating, “Cylinder Piston Pins Sheared.” The resolution or corrective action indicates, “Installed New Piston Pins P/N 630046 On all Cylinders as Required.” Additional paperwork from Santa Fe Aero Services indicates discrepancy 1.1 in which the, “…Avidyne EX5000 MFD Shut Down.” The resolution indicates that the MFD was removed and sent to the manufacturer for warranty replacement. The MFD they received from the manufacturer was defective out of the box and was returned to the manufacturer. The 2nd MFD received was installed into the airplane and was operational.
Correspondence from Sante Fe Aero Services to the pilot in response to a reported e-mail from him indicates that their inspection of the engine while at their facility discovered, “…three cracked cylinder heads, a very serious matter….” Following removal of the cylinders they found, “…three severed piston rods, which is typically the type of internal damage caused by extended incorrect operation.” The correspondence also indicated that after the defective MFD was removed from the airplane it was sent to the manufacturer; however, no data could be retrieved from the unit. Also, the correspondence reiterates a comment from the pilot in which he reportedly indicates that the defective MFD had just been installed 2 weeks earlier, and, “had never worked since installation.” Postaccident review of the airframe logbook revealed the previous entry specifying the MFD was dated February 2, 2011, which indicates that software release 7 was installed into MFD per Avidyne Service Bulletin (SB) 10, and the functional check was satisfactory.
Postaccident follow-up with Sante Fe Aero Services confirmed that the 3 cracked cylinders each had cracked piston pin plugs and not three severed piston pins as reported in the paperwork.
Calculations revealed that based on the hour meter reading at the time of the accident (1281.6), the engine had accumulated 46.7 hours since the new cylinder assemblies were installed.
METEOROLOGICAL INFORMATION
A surface aviation observation taken at Lakeland Linder Regional Airport at 1150, or approximately 15 minutes before the MFD recorded the oil pressure to be below the lower end of the normal operating range, indicates the wind was from 140 degrees at 5 knots, the visibility was 15 statute miles, broken clouds existed at 2,700 feet, and 25,000 feet. The temperature and dew point were 32 and 23 degrees Celsius, respectively, and the altimeter setting was 30.19 inches of Mercury.
A surface aviation observation taken at Melbourne International Airport (MLB), Melbourne, Florida, at 1214, or approximately 18 minutes before the accident indicates the wind was from 090 degrees at 9 knots, the visibility was 10 statute miles with thunderstorms in the vicinity. Scattered clouds existed at 1,700 feet, the temperature and dew point were 32 and 24 degrees Celsius respectively, and the altimeter setting was 30.16 InHg. The crash site was located about 10 nautical miles and 200 degrees from MLB.
A center weather advisory from Jacksonville Air Route Traffic Control Center valid for the day of the accident until 1320 hours local, indicated that from Ormond Beach Municipal Airport (OMN) to Vero Beach Municipal Airport (VRB), a line 25 nautical miles wide of widely scattered thunderstorms with heavy precipitation moving little. The maximum tops were at 38,000 feet, and expect gradual increase in coverage and intensity in eastern Florida thru the period.
COMMUNICATIONS
The pilot was last in contact with the Central Florida Terminal Radar Approach Control facility. There were no reported communication difficulties.
FLIGHT RECORDERS
The airplane was not equipped nor was it required to be equipped with a cockpit voice recorder (CVR) or flight data recorder (FDR). The airplane however was equipped with components that record and retain non-volatile memory (NVM) associated with flight. The components that retained NVM consisted of the PFD, MFD, and also the autopilot digital flight control (DFC). All components were manufactured by Avidyne.
Personnel from the NTSB Vehicle Recorders Division successfully downloaded the NVM for each of the retained components, and prepared a Specialist’s Factual Report. According to the report, all retained components recorded data from the accident flight. Parameters available from multiple sources (PFD, MFD, or DFC 90) were plotted from one source only. The report contains in part a Google Earth Plot overlaying the entire accident flight path, and also tabular data downloaded from the components. The tabular data indicates that the engine rpm remained set to about 2,400 from about 1150, to about 1231:32, although between these times slight variation of engine rpm was noted. The autopilot was engaged about 1147, and remained engaged until about 1 minute before the accident, or 1232. The tabular data also indicates that from 1231:32, to the last recorded data at 1232:44, the rpm steadily decreased from 2,400 to 1,700.
Plotting of the data downloaded from the components onto the Google Earth Plot indicates that about 1202, or approximately 17 minutes after takeoff, the oil pressure began to decrease from 45 psi. The airplane at that time was located about 10 nautical miles and 265 degrees from the approach end of runway 09 at Lakeland Linder Regional Airport (LAL), Lakeland, Florida. Data downloaded from the MFD indicates that about 1206, the oil pressure dropped and remained below 30 psi for the remainder of the flight. The airplane at that time was located about over the center of LAL. At no point during the flight did the oil temperature increase above red line (240 degrees Fahrenheit); the highest recorded oil temperature was 227 degrees. The oil pressure decreased below 10 psi at 1222:06, and remained below that value for the remainder of the recorded data.
Further review of the factual report from the Vehicle Recorders Division revealed that with respect to the EGT recordings for all cylinders, the values for the No. 4 cylinder were consistently greater than the other five cylinders for nearly the entire flight until about 1231:14. At that time the EGT temperature for the No. 4 cylinder was the lowest of all cylinders and remained the lowest recording temperature of the other cylinders for the remainder of the flight. At 1231:44, the EGT reading for the No. 4 cylinder was recorded to be 0, and remained that value for the duration of the recorded data, which occurred at 1233:03.
Non-volatile memory downloaded from the primary flight display, multi-function display, and autopilot controller revealed that about the end of recorded data, the airspeed was about 74 knots and the bank angle was about 55 degrees.
WRECKAGE AND IMPACT INFORMATION
Examination of the accident site revealed the area was in a large open unoccupied area with paved roads oriented on north/south and east/west headings. The main wreckage was located at 27 degrees 56.227 minutes North latitude and 080 degrees 42.156 minutes West longitude.
Further examination of the accident site revealed a ground scar on a road with nearby green colored glass lens oriented on a magnetic heading of 314 degrees. Airplane debris along an energy path of 314 degrees was documented for location, which consisted in part of the separated propeller which was located adjacent to a crater in the grass/ground about 42 feet from the road ground scar location, and the engine assembly which was located in an inverted position approximately 108 feet from the road ground scar and 24 feet north of the energy path centerline. Additional debris along the energy path consisted of a fractured connecting rod with piston pin which was found adjacent to the crater in the grass/ground, and the oil gauge rod and cap assembly which was found in the grass adjacent to the lower engine cowling, or forward of the crater created by the propeller impact. The airplane came to rest 115 feet from the road ground scar as measured to the firewall.
Examination of the airplane wreckage which came to rest on a magnetic heading of 100 degrees as determined by the wing and firewall resting position revealed the cockpit and firewall were upright and were displaced to the right while the empennage was resting on its left side. Oil residue (fresh) was noted on the left side of the fuselage/empennage from the firewall to the tailcone. All components necessary to sustain flight remained attached or in close proximity to the main wreckage. The aft fuselage structure mostly separated just aft of the front crew seats and came to rest oriented 90 degrees to the left remaining attached only by control cables and wiring. The empennage mostly separated from the fuselage just forward of the horizontal stabilizer (FS 289 bulkhead) but remained attached by control cables and wiring. Flight control cable continuity was confirmed for all primary flight controls. The flaps were fully extended, and the pitch trim was full airplane nose up.
Inspection of the Cirrus Airframe Parachute System (CAPS) revealed the safety pin was out (normal for flight), and the activation handle was stowed; the CAPS system was not deployed. The activation handle holder bracket was bent downwards approximately 15-20 degrees; activation cable continuity was confirmed. Postaccident, the rocket motor solid propellant grains were burned and no anomalies were noted. The igniter assembly & base were fired as an assembly and no anomalies were noted. Testing of the reefing line cutters was performed. Timing using an analog watch revealed one fired in approximately 7 seconds, and the second fired in approximately 8 seconds (specification is 8 seconds).
Examination of the cockpit revealed both seats remained attached to their respective seat tracks. The airplane was not equipped with inflatable restraints. Postaccident operational testing of the pilot and co-pilots seat restraints revealed no discrepancies noted. The data storage card from the MFD, the PFD, and the autopilot DFC were retained for readout. Further examination of the cockpit revealed a spiral bound version of the POH/AFM was located. The combination analog oil temperature and oil pressure gauge was separated from the instrument panel but remained electrically connected. Inspection of the instrument revealed the oil pressure needle was missing, and the oil temperature reading was off scale low. The annunciator panel located to the left of the PFD was located; however, the illumination is from LED’s; therefore, no determination could be made whether the “OIL” annunciation was illuminated at the time of the accident. A digital camera located in the wreckage was retained for further examination.
The engine was rolled upright by hand and cursory examination revealed the crankshaft was fractured near the crankcase; the forward portion of the crankshaft flange remained attached to the propeller hub. Initial inspection of the engine revealed holes in the top portion of the crankcase halves above the Nos. 4, 5, and 6 cylinder positions, and the connecting rods for cylinder Nos. 4, 5, and 6 were detached from the crankshaft. The oil gauge rod and cap assembly cap was not attached to the oil filler tube. The induction tube for the No. 4 cylinder which is immediately adjacent to the oil filler breather tube exhibited an impact mark on the aft portion of the tube. The upper surface of the oil filler breather tube was positioned below the upper portion of the induction tubes for the Nos. 4 and 6 cylinders. Inspection of the No. 4 cylinder air induction tube adjacent to the oil filler breather assembly opening revealed no evidence of substantial contact mark. Visual inspection of the oil filler breather assembly revealed oil and debris adhering to the circumference of the sealing surface, and scratches 180 degrees apart on each of the lock tabs. The scratches on each lock tab were located 90 degrees from the cap insertion location. Inspection of the oil gauge rod and cap assembly revealed dark discoloration on the upper portion of the dipstick. The discoloration was consistent with the distance to the smaller diameter hole inside the oil filler breather tube. Also, debris was noted adhering to the horizontal and vertical surfaces with the top part of the oil gauge rod and cap assembly as viewed with it installed in the normal position. An air/oil separator was installed, and a scat hose that vents the air from the air/oil separator overboard is mounted on the left lower engine mount and exits the lower cowl in the same location as the left exhaust pipe; the scat hose interior was oil soaked along its length. The air/oil filter housing was impact damaged. Oil was present on the interior surfaces of the upper and lower engine cowlings, and also present over the top of the cylinders and covered the forward side of the vertical baffling behind the Nos. 1 and 2 cylinders. Oil spray was also present on the engine weldments and nose landing gear assembly. The oil filter was in-place. Inspection of the engine cowlings revealed evidence of fire damage. The engine was retained for further examination at the manufacturer’s facility.
Examination of the engine at the manufacturer’s facility with Safety Board oversight revealed approximately 1.25 quarts of oil remained in the oil sump. The crankshaft was fractured aft of the crankshaft flange. The connecting rods for cylinder Nos. 3, 4, 5, and 6 were fractured and separated from the crankshaft, while the connecting rods for cylinder Nos. 1 and 2 remained connected to the crankshaft. The camshaft was not fractured, and the crankshaft to camshaft timing was verified. The oil sump contained ferrous debris, and the oil pump housing contained scratches consistent with hard particle passage. The oil pressure relief valve and seat contained no obstructions and exhibited signatures of proper seating. Inspection of the oil filter revealed flakes and slivers consistent from the damaged internal components. The air/oil separator was disassembled which revealed no evidence of preimpact failure or malfunction. Inspection of the spark plugs revealed none exhibited damage consistent with detonation. No damage was noted to the left magneto ignition harness, while the right magneto ignition harness was fire and impact damaged. Both magnetos were placed on a test bench and noted to produce a spark across a 7mm gap through the full range of test bench rpm. Bench testing of the throttle and fuel control metering assembly, engine-driven fuel pump, fuel manifold valve, fuel injector lines, and fuel injector nozzles was performed. Calibrated testing of all fuel system components revealed no evidence of preimpact failure or malfunction. Prior to removal of all cylinder assemblies, tightening and loosening torque check of each deck stud and cylinder through-bolt was performed. The results were recorded and contained in the manufacturers report. Following removal of the cylinder assemblies, the No. 4 cylinder piston, part number (P/N) 654857, was noted to be fractured.
Inspection of the crankcase nose seal revealed impact damage. The crankcase halves were then split and inspection of the main bearing support mating surfaces revealed no signs of fretting or bearing tang lock-slot elongation. The main bearing support diameters were intact and exhibited no signs of bearing movement or elongation. The oil galleys and passages in both crankcase halves were clear and unrestricted. The crankshaft main bearings exhibited normal operating signatures. There were slight signs of lubrication distress, and the bearings exhibited contamination imbedded in the surface layer. Some of the bearings had worn through the Babbitt layer into the copper layer. The pieces of No. 4 cylinder piston, oil filler breather assembly, and oil gauge rod and cap assembly were retained for further examination. A copy of the report from the engine manufacturer is contained in the NTSB Public Docket for this case.
Examination of the propeller revealed one blade exhibited slight smooth radius aft bend and exhibited chordwise scratches on the cambered side of the blade. The second blade was bent aft just outboard of the de-ice boot and exhibited chordwise scratches on the cambered side of the blade, and the third blade did not have any apparent damage. Rotational scarring was noted on the propeller hub forward of the crankshaft flange associated with contact by the TKS tube.
MEDICAL AND PATHOLOGICAL INFORMATION
All three occupants were transported to the Holmes Regional Medical Center, located in Melbourne, Florida. The pilot and right front seat passenger died while hospitalized the following day. The right rear seat occupant was treated and released.
Postmortem examinations were performed on the pilot and right front seat passenger by the District Eighteen Medical Examiner’s Office, Rockledge, Florida. The cause of death for both was listed as multiple blunt force injuries.
The M.E.’s office obtained admittance blood specimens of the pilot and right front seat passenger from the Holmes Regional Medical Center. Forensic toxicology was performed on the admittance specimens of the pilot and passenger by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, and also by Wuesthoff Reference Laboratory. The FAA toxicology report for testing of the pilot admittance specimens stated the results were negative for carbon monoxide, cyanide, and volatiles. Unquantified amounts of Etomidate and Lidocaine were detected in the liver and blood specimens, while an unquantified amount of morphine was detected in the blood specimen. Morphine was detected in the kidney (0.161 ug/ml), and also in the liver (0.043 ug/ml). The Wuesthoff toxicology report for testing of the pilot admittance specimens stated the results were negative for the immunoassay screen and volatiles.
The FAA toxicology report for testing of the passenger admittance specimens stated the results were negative for carbon monoxide, and cyanide. Testing for volatiles and drug screen were not performed. The Wuesthoff toxicology report for testing of the passenger admittance specimens stated the results were negative for the blood drug screen, immunoassay screen, and volatiles.
FIRE
The top forward portion of the engine, and forward portion of the engine cowling exhibited heat damage consistent with a short duration in-flight fire. Additionally, electrical wiring of the alternator mounted on the front portion of the engine exhibited heat damage.
TEST AND RESEARCH
According to a pilot who flew the accident airplane on June 21, 2011, he departed MLB about 1600 hours with a passenger on-board for a planned flight to New Smyrna Beach Municipal Airport, New Smyrna Beach, Florida. Before departure the engine oil was checked and found to register between 6.0 and 6.5 quarts on the dipstick. After takeoff while in a climb at 110 knots indicated airspeed, the mixture leaned to 16 gallons-per-hour per the MFD, flaps retracted, and at 3,000 feet over Lake Washington climbing to 4,500 feet, he noticed the oil temperature rise to 220 degrees. Although he reported the oil temperature red line as being 230 degrees Fahrenheit, it is in fact 240 degrees Fahrenheit. He noticed the oil annunciator light flicker, and both the MFD and analog oil temperature indications were the same. He lowered the nose and accelerated to 170 knots and turned to return to MLB. When he lowered the nose and began accelerating, the oil temperature decreased and before he landed at MLB it was in the normal range. He landed uneventfully, and reported the whole flight lasted approximately 10 minutes. He did not recall the hour meter reading at the start or completion of the flight, and reported the oil temperature was the only issue during that flight; the oil pressure was within limits. After landing, the airplane was pushed into the hangar, where the oil level was checked and found to be the same as it was noted during the preflight inspection. After landing the pilot and passenger immediately called the airplane owner and advised him of the oil temperature issue. The owner advised that he had noticed that before, and in their (pilot and passenger) opinions, the owner did not seem surprised by the issue.
According to data retained in the MFD pertaining to the flight on June 21, 2011, the oil temperature steadily increased to a maximum value of 234 degrees, or 6 degrees below maximum red line, but the oil temperature decreased and remained within normal parameters for the remainder of the flight. The oil pressure for the entire flight was noted to be in the normal green arc range of between 30 and 60 psi. Additionally, the No. 4 cylinder EGT was recorded to be 1,503 at one point during the flight, while the lowest reading for the remaining five cylinders at that time was 1,403, which was attributed to be from the No. 1 cylinder. Further, the EGT reading for the No. 4 cylinder was consistently greater than any of the other five cylinders during the entire flight.
Review of the engine maintenance records revealed no entry indicating any kind of trouble shooting or maintenance to determine the reason for the high oil temperature. Further, the maintenance records did not reflect installation of the air/oil separator, and a representative of the airplane manufacturer reported the air/oil separator was not installed when the airplane was manufactured.
Data downloaded from the MFD pertaining to the flight earlier that day from MLB to SPG which lasted about 56 minutes, revealed a maximum oil temperature of about 228 degrees which was correlated with engine rpm of approximately 2,440 and oil pressure reading of about 44 psi. The oil temperature decreased below that value and remained in the normal operating range for the flight, while the oil pressure was in the normal green arc range (30 to 60 psi) for the entire flight. Further, the EGT reading for the No. 4 cylinder was consistently greater than any of the other five cylinders during the entire flight. Readings from the No. 4 cylinder EGT were above 1,500 degrees at three separate points along the flight. For example, at 0945:54, the EGT readings for the Nos. 1 thru 6 cylinders were recorded to be 1,410, 1,425, 1,448, 1,502, 1,432, and 1,439 degrees Fahrenheit, respectively.
Inspection of the pilot’s hangar several days after the accident revealed a plastic bucket containing a dark colored liquid was noted on a stand. The liquid was presented by friends of the pilot to be oil from the last oil change. Additionally, an oil filter was also presented by friends of the pilot to be from the last oil change. Further inspection of the pilot’s hangar revealed an unopened case of AeroShell SAE 50 100W oil, several unopened bottles of AeroShell SAE 50 Oil 100W, and several pint sized bottles of oil additive.
A friend of the pilot who helped the airplane owner change the engine oil last reported that during that process, a hole was punctured in the top of the oil filter and a rubber tipped air nozzle was pressed into the hole and shop air pressure was applied into the oil filter. The friend reported air was blown into the filter in an attempt to push the oil into the engine to prevent leakage onto the engine during removal of the oil filter.
Visual inspection of the oil filter presented to NTSB as being from the last oil change revealed it was not cut open. The top of the oil filter contained a hole that was consistent with being made by a number 2 or 3 phillips screwdriver. The oil filter was marked as being “AA48109”,“TEMPEST”, and “The Original Aviation Spin-On Oil Filter.”
Review of the engine logbook revealed an entry dated July 6, 2011, indicating the oil and oil filter were changed by the owner. The entry does not indicate that the oil filter was cut open and checked for ferrous materials. The oil change entry further indicates that the hour meter reading was 1265, and 7 quarts Aeroshell 100 and 1 quart Cam Guard were added.
The oil filter presented to NTSB to be from the last oil change was cut open during the postaccident examination of the engine and the filter element did not contain ferrous particles.
The normal procedures section of the POH/AFM lists steps to be checked during preflight inspection of the airplane. The steps include in part a check of the engine oil quantity, to look for leaks, and to verify that the oil gauge rod and cap assembly and oil access door are secured. The emergency procedures section of the POH/AFM lists steps to follow in the event of low oil pressure. A warning indicates that prolonged use of high power settings after loss of oil pressure will lead to engine mechanical damage and total engine failure, which could be catastrophic. A note indicates that if low oil pressure is accompanied by normal oil temperature, it is possible that the oil pressure sensor, gauge, or relief valve is malfunctioning. In any case, land as soon as practical and determine cause.
The steps for low oil pressure in the POH/AFM are:
1. Power Lever ................................................MINIMUM REQUIRED
2. Land as soon as possible.
Inspection of an oil filler breather tube and oil gauge rod and cap assembly from an engine returned to the engine manufacturer for core credit revealed scratches on each lock tab of the oil filler breather tube similar in location and length to the scratches of each lock tab of the oil filler breather tube from the accident engine.
Examination of the No. 4 cylinder piston, oil filler breather tube, and oil gauge rod and cap assembly was performed by the NTSB Materials Laboratory located in Washington, D.C. The NTSB Materials Laboratory Factual Report indicates that the results of the examination of the piston revealed it was comprised primarily of the crown and piston ring belt and one region between the oil control and scraper ring grooves. The topside of the crown exhibited tan/yellow colored deposits over much of the surface. No pitting or pockmarking of the piston crown was noted. The upper and lower surface of the piston exhibited dark brown coloration consistent with exposure to elevated temperatures, and the area beneath the piston pin boss exhibited mechanical damage. The majority of the fracture surfaces of the piston had a rough appearance with widely spaced crack propagation marks, consistent with progressive crack growth under cyclic stresses. One vertical fracture in the skirt exhibited a comparatively flat and smooth appearance. Cyclic crack growth marks and radiating lines were observed at different locations along the skirt. Mechanical exposure of the fractured faces of the vertical cracks revealed cyclic crack growth marks and radiating lines consistent with the crack originating near the oil scraper ring groove on the inside surface of the skirt wall. Examination of the two vertical cracks using a scanning electron microscope (SEM) revealed features occasional regions that exhibited features consistent with quasi-cleavage fracture consistent with progressive crack growth under cyclic stresses.
The NTSB Materials Laboratory Factual Report indicates that the oil filler breather tube, and oil gauge rod and cap assembly were examined which revealed light scratches on each of the lock tabs of the oil filler breather tube. The cap portion of the oil gauge rod and cap assembly was examined for impact marks or indications of mechanical deformation but none were found. The examination of the oil gauge rod and cap assembly revealed an approximately 8 degree bend near the top of the oil gauge rod and cap assembly. When the oil gauge rod and cap assembly was inserted into the oil filler breather tube, but not secured, the bend near the top of the stick caused the oil gauge rod and cap assembly to rest at an angle on the top of the tube, leaving an opening on one side of the tube. In that condition, when the oil filler breather tube and oil gauge rod and cap assembly was turned upside-down, the oil gauge rod and cap assembly fell out of the oil filler breather tube under its own weight. The oil gauge cap and rod assembly was then inserted into the tube and the cap was quarter-turned back and forth by hand; it could be secured and unsecured without difficulty. When the oil gauge cap and rod assembly was secured to the oil filler tube, the oil gauge rod and cap assembly laid flat against the top of the oil filler breather tube and a rubber gasket on the oil gauge rod and cap assembly formed a seal against the top of the oil filler breather tube. The NTSB Materials Laboratory Factual Report is contained in the NTSB public docket for this case.
According to the NTSB Vehicle Recorder Division Image Device Factual Report, the digital camera located with the wreckage (Canon PC1249 Powershot Camera) is an 8 Megapixel “point and shoot” type digital camera. Upon arrival at the audio laboratory the camera appeared to have minor damage. The picture files were downloaded from the Kingston 4 gigabyte Secure Digital (SD) formatted memory card normally and without difficulty. There were 127 still photographs and 9 movies files stored on the memory card. Of these, two photographs were taken on the day of the accident, and the date stamp was correct, though the time stamp was incorrect. Both of the pictures were of a sign inside a restaurant at the Albert Whitted Airport in St. Petersburg Florida Further review of the pictures taken during a flight in the accident airplane on July 22, 2011, depict the instrument panel or portions of it. One picture which clearly shows the analog oil pressure and temperature gauge depict both needles in the green arc range.
As previously reported, the flaps were found fully extended during the postaccident investigation and about the end of recorded data, the airspeed was about 74 knots and the bank angle was about 55 degrees. A stall speed chart located in the POH/AFM indicates that at maximum gross weight, most forward center of gravity, flaps fully extended, and bank angle of 45 degrees, the stall speed in terms of knots indicated airspeed (KIAS) is 73, while the stall speed at 60 degrees of bank is 87 KIAS. Interpolation revealed that about 52 degrees of bank, the stall speed is 80 KIAS.
Research of NTSB investigated airplane accidents and incidents from 2007 through 2013, in which oil was listed as a cause, factor, or finding revealed 1 investigation (NTSB Case # WPR09LA197) of a Beech A36 airplane equipped with a Continental Motors, Inc., IO-550 series engine. The NTSB Brief of Accident for this investigation indicates that during cruise portion of a 14 CFR Part 91 flight, the propeller/engine rpm increased despite attempts by the pilot to reduce it. Subsequently the pilot heard a loud bang and loss of engine power with white smoke coming onto the windscreen, which resulted in a forced landing and subsequent substantial damage. Postaccident inspection of the engine by the FAA revealed the oil gauge rod and cap assembly was not secured to the oil filler breather tube; neither exhibited any damage. Oil residue was along the left side of the airframe and engine cowling. Also, 2 nuts used to secure the propeller governor to the propeller governor mounting pad on the engine crankcase were loose; residual oil was noted in the surrounding area of the propeller governor. Disassembly inspection of the engine revealed separation of the Nos. 2, 3, and 4 cylinder connecting rods from the crankshaft, and about 1 quart of oil remained in the oil sump. Ferrous debris was noted inside the oil sump and also adhering to the oil filter element.
Continental Motors, Inc., (formerly Teledyne Continental) prepared Service Bulletin (SB) M89-9, titled, “Excessive Crankcase Pressures.” It states in part that excessive crankcase pressure in flight can be induced by ram air entering through an improper fitting oil cap seal and or defective crankshaft nose seal. The SB lists procedures of the ground that can be performed to determine the crankcase pressure using an airspeed indicator plumbed into specified components of the engine. The SB also indicates that the maximum crankcase pressure is 4.0 psi. Although the SB does not mention it, additional ways to pressurize the crankcase is to have blow-by past the piston rings and/or piston of a cylinder due to ring gap alignment, or erosion of a piston.
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NTSB Identification: ERA11FA414
14 CFR Part 91: General Aviation
Accident occurred Saturday, July 23, 2011 in Palm Bay, FL
Aircraft: CIRRUS DESIGN CORP SR22, registration: N122HB
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On July 23, 2011, about 1232 eastern daylight time, a Cirrus Design Corporation SR22, N122HB, registered to N122HB LLC, and operated by a private individual, sustained substantial damage during an attempted forced landing to an open field near Palm Bay, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Albert Whitted Airport (SPG), St. Petersburg, Florida, to Melbourne International Airport (MLB), Melbourne, Florida. The certificated private pilot and one passenger were fatally injured, and one passenger sustained minor injuries. The flight originated from SPG about 1146.
According to preliminary air traffic control information, after takeoff the flight proceeded towards the destination airport and air traffic control (ATC) communications were transferred to several facilities. About 1225, while in contact with a sector of the Central Florida Terminal Radar Approach Control facility, the pilot requested clearance to descend and maintain 2,000 feet which was approved. The flight continued and about two minutes later the controller cleared the flight to descend and maintain 1,500 feet which the pilot acknowledged. The controller also advised the pilot of the location of weather returns, and he reported that he may deviate to the south to avoid a cell.
The rear seat passenger later stated that when the flight was getting close to MLB, the pilot explained to her and the right front seat passenger of adverse weather over MLB, and he would divert to Valkaria Airport (X59), Valkaria, Florida, to get fuel and wait for the storm to pass MLB. Shortly after turning to the south, she felt the airplane shudder, then it became quite.
The preliminary ATC information indicates that about 1231, while flying about 1,100 feet, the pilot declared mayday and advised the controller that there was smoke coming out of the engine. The controller immediately informed the pilot of the location of MLB and X59 airports from his position; the pilot advised the controller that he was unable to land at either one and was looking for an off-site landing. The controller again informed the pilot of the distance from MLB and X59, and the pilot informed the controller that there was a fire and he needed to make an off-site landing. The controller asked the number of souls on board and the pilot responded with three. There was no further recorded communication from the pilot. About 1233, the controller broadcast on the frequency that radar contact was lost; there was no reply.
The rear seat passenger further stated that after hearing the pilot tell the right front seat passenger to get into a position, she ducked to make herself as small as possible. The airplane bounce twice then began to flip. When the airplane came to rest, she unbuckled herself and ran away from the airplane to begin looking for help, but noted "...miles and miles of field...."
Three witnesses who were located about 1/2 nautical mile northwest from the crash site reported the airplane flew over their position about 400 to 500 feet in a direction that was determined to be about 100 degrees magnetic. They reported that the engine was sputtering and "coughing", but they did not see any smoke trailing the airplane. The airplane kept descending, and at the last minute banked hard to the right with the wings reported to be vertical. The nose pitched down, and they lost sight behind trees. They heard an impact, saw white colored smoke, called 911, and proceeded to the site where they rendered assistance until first responders arrived.
Preliminary inspection of the accident site revealed the airplane first impacted on a paved road of an unpopulated open area. The airplane came to rest about 115 feet from the road contact point with the engine separated from the airplane and the propeller separated from the engine. The Cirrus Airframe Parachute System (CAPS) was not deployed. Engine powertrain components were found along the energy path between the road contact point and the resting location of the airframe. Initial inspection of the engine revealed holes on the top of the engine crankcase halves.
The plane that crashed July 23 in Palm Bay encountered engine problems at 1,100 feet, a National Transportation Safety Board preliminary report reveals.
The pilot, Paul Douglas Morrison, 65, and his wife, Margo, 50, died later of injuries. A passenger, Sasha Marger, 20, of Dallas, Texas, suffered minor injuries.
The trio had planned to travel from Albert Whitted Airport in St. Petersburg to Melbourne International Airport, according to the flight plan. But because of adverse weather, Morrison diverted to Valkaria Airport to refuel and wait for a storm to pass.
That’s when the four-seat, single-engine plane shuddered, then became quiet. Morrison radioed a flight controller and reported smoke coming out of the engine while flying at about 1,100 feet, the report shows.
Then he attempted an emergency landing in “The Compound,” the undeveloped region of southwestern Palm Bay.
According to three ATV riders a half-mile from the crash site, the engine was sputtering and “coughing” during the descent. At the last minute, the plane banked hard to the right — with its wings reportedly vertical — and the nose pitched down.
Then the plane crashed, creating a plume of white smoke.
