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Maintenance error leads to Cirrus owner pulling chute

By NTSB · October 12, 2016 ·

The commercial pilot was conducting a personal cross-country flight in the Cirrus SR22. He reported that, while en route to his destination at a cruise altitude of about 5,000 feet mean sea level, the engine “failed.”

He flew the airplane toward an open field near Lexington, N.C., and deployed the ballistic recovery parachute. He subsequently conducted a successful landing in the field.

An examination of the engine revealed that the crankshaft had fractured between the No. 2 main journal and the No. 2 connecting rod journal.

An examination of the crankshaft revealed that the fracture was due to fatigue that had initiated from multiple origins at the fillet radius between the No. 2 main journal and the cheek at the aft end of the journal.

The fatigue initiated from surface damage that occurred due to the No. 2 main bearing shifting. The bearing likely shifted due to the improper tightening of the crankcase through bolt nuts and subsequent insufficient clamping force of the crankcase saddle surfaces.

A review of the airplane’s maintenance records revealed that the engine was last overhauled 775 total flight hours before the accident, and no records were found indicating that the through bolts had been removed since that time.

It is likely that maintenance personnel improperly tightened the crankcase through bolts during the overhaul.

The NTSB determined the probable cause as maintenance personnel’s improper tightening of the crankcase through bolt nuts during reassembly of the engine at the last overhaul, which resulted in the failure of the crankshaft and the subsequent total loss of engine power.

NTSB Identification: ERA15IA024

This October 2014 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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Comments

  1. John Wesley says

    October 16, 2016 at 11:09 am

    There is a better way, I have lost 4 engines in flight, for various reasons, I simply shut down and feathered the miscreant and landed at a convenient airport, with no damage to life, limb or metal,

    • Bart says

      October 16, 2016 at 11:13 am

      Not a better way but another way. You double the chances of an engine failure with two engines so if you’d been flying singles you have had only two failures instead of four. That assumes none were due to fuel mismanagement.

  2. Gary Frick says

    October 15, 2016 at 8:02 pm

    I ate lunch with a cirrus test pilot and it was his opinion and I assume that of the company that in a situation as described. There are 2 reasons to pull the shut: you’ll be having dinner with your family and the insurance automatically covers the loss. I have a PPL now flying as a sport pilot in a Tecnam P2008 TC without a chute but after all the research I’ve done my new one from
    Italy will have one.

  3. Bart Robinett says

    October 13, 2016 at 2:31 pm

    Successful deployment of the parachute in these things is as controversial as not pulling it. ? In this case It was probably justified due to the nature of the emergency and it’s one of those times I might wish I had one in a Bonanza too, though maybe not over a nice field but but certainly over an East Texas pine forest, mountains or a cityscape. As one of the commentators said the insurance company owned the airplane as soon as the engine failed. Got to have a lot of scratch to fly a high dollar airplane like a Cirrus uninsured because they will be a write off pretty much no matter what you do. Not an airplane I’d like to do a forced landing in.

  4. Chris says

    October 13, 2016 at 11:18 am

    I saw the pictures of the airplane in the Kathryn’s report web page and, although I’m not sure I would have probably pulled the parachute, I can only congratulate the pilot for a great job. The airplane is the middle of an open field and it is “almost” intact. Although maybe unrepairable, the only damage visible in these pictures is the nose gear. Great job!

    Landing off-field with a sleek clean airplane in a field surrounded by tall tress is not necessarily a given success. You can hit the tress. I have heard too many reports lately of people hitting power lines with fatal results. You can overshoot the field. Even if he made it to the field fine, a soft ground or a rut could have caused the nose gear to collapse and the plane to flip. This pilot did a fine job!

    And besides, not everyone is Sully 🙂

    Chris

  5. Erick Borling says

    October 13, 2016 at 8:59 am

    Good point, John. Regular readers of this column (or if you read many accident reports) know that often, after a good glide to an emergency off-airport landing, the pilot still winds up with substantial damage and or injury. Actually making the off-airport landing is rarely, if ever practiced by non-backcountry pilots.

  6. Randy Coller says

    October 13, 2016 at 7:13 am

    Once he deployed the balistic chute, there was no opportunity to conduct a successful landing. He went from PIC to passenger and was just along for the ride. There was no “successful landing.”

    • John says

      October 13, 2016 at 8:19 am

      I very much disagree! The return to earn was absolutely successful. The BRS performed as designed. He had a an emergency (loss of engine power is just that!) and dealt with it in an absolutely appropriate manner. His decision making AND subsequent actions to deal with this life threatening emergency were exactly on point. Misplaced bravado that implies otherwise is unhelpful, and likely has resulted in more than one fatality over the years. When the crank broke the insurance company owned the aircraft and they were going to pay the same amount regardless… the full hull value less deductibles. The probability of injuries or death resulting from an engine failure is definitely non-zero. In 2013 the NTSB lists “System Malfunction – Powerplant” and the number one cause of accidents for GA aircraft, and the number two cause of fatalities. Had the pilot elected to attempt to fly to the point of impact (as implied) while having a functional BRS wouldn’t that have been accepting an unnecessary and arguably negligent risk?

      • J.P.Klink says

        October 13, 2016 at 8:32 am

        godcall # !!!

      • cmwilcox says

        October 13, 2016 at 10:13 am

        I completely agree with Mr. Coller. Not only did the pilot doom the fate of the airplane to the scrap heap, but also by placing a misguided reliance on fate, he shirked the pilot responsibilities granted with his license.

        The fact that he was able to navigate to an open field in the Lexington NC area means that he should have also been able to execute a forced landing in that field. Firing the BRS and coming down under the parachute could have allowed the winds to carry the airplane into the trees or hills prevalent in that area. This would be more possible if the BRS were actuated near the 5000 ft MSL altitude but the report does not provide that info.

        Mr. Borling uses the rationalization that since off-airport landings are rarely practiced, the use of the BRS as a “get home free” device is a good idea. Since when is a lack of training, proficiency, or skill now an acceptable aviation paradigm? Is the next argument, “since pilots rarely practice partial panel flying” just pulling the red handle when the attitude indicator rolls over? Or maybe the landing light burns out on a night flight and you can’t see the runway.

        Geeze, cut the cop-outs and become better pilots. Your unsuspecting passengers are thinking they are flying with licensed competent pilots, not lazy fools with a pilot card and a twitchy hand to pull the red-handle.

        • Dan says

          October 16, 2016 at 8:35 pm

          To those saying that pulling the chute relegated the Cirrus to “the scrap heap”, I say B.S.. If you check the records, you will find that a fairly high number of these planes are easily repaired and are still flying. The most important statistic though, is that the majority of Cirrus pilots that have pulled the chute because of a mechanical failure or other emergency in flight have lived to fly another day. That’s the most important thing about these accidents- saving lives. Pulling the handle doesn’t make you a bad pilot, making bad decisions that kill people does.
          (Previous owner of 2 Cirrus SR-22’s)

    • Lee Ensminger says

      October 13, 2016 at 10:11 am

      Randy, I just don’t agree with your “The plane was on fire and missing half of the starboard wing, but because I channeled my inner Chuck Yeager and had The Right Stuff, I was able to land it on a softball diamond!” attitude. He had a catastrophic engine failure, flew the aircraft to an open field to minimize danger to others on the ground, then deployed the BRS to enable a landing that offered him the best chance to walk away uninjured, which it seems he did. Sounds to me like some very sound aeronautical decision making. The fact that the aircraft is damaged when the chute is deployed is, to me, inconsequential compared to sparing his life and potentially the lives of others.

    • Rich says

      October 15, 2016 at 11:06 am

      Maybe a successful descent but certainly not what anyone who has ever landed an airplane would define as a landing.
      I agree that once you pull that chute you become a passenger and not a pilot.
      But that’s just me.

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