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Mechanic’s error leads to forced landing in a field

By NTSB · November 13, 2020 ·

The pilot reported that, during a ferry flight, while climbing the Cirrus SR22 to cruise altitude, the engine temperatures increased quickly and the engine then surged.

He “switched” the boost pump, adjusted the mixture lever, and then deployed the ballistic parachute system at 3,500 feet mean sea level.

During the off-airport landing in a field near Sand Creek, Wisconsin, the airplane hit an irrigation sprinkler system, sustaining substantial damage to the fuselage.

A post-accident examination by an FAA inspector revealed that two air lines were disconnected and that there were no torque lines on the lines.

According to the FAA inspector, the pilot and a mechanic who had conducted the airplane’s last maintenance reported that the airplane had been flown seven hours since the last maintenance.

The mechanic had replaced three cylinders during the maintenance, which required removal of the air lines. It is likely that, during the maintenance, the mechanic did not properly secure the air reference line, which led to a loss of engine power.

Probable cause: The mechanic’s failure to properly secure the air reference line, which resulted in a loss of engine power.

NTSB Identification: GAA19CA074

This November 2018 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. scott says

    November 18, 2020 at 3:18 am

    Unfortunate that so many accidents are caused by the very people the FAA requires you to use.
    Aviation and trucking, the greatest concerns are logbook entries.

  2. Henry K. Cooper says

    November 16, 2020 at 5:34 am

    Torque lines can be applied to hose or hardline connections, and to swayed cable ends, turnbuckle-to-cable junctions, and a host of other locations. These may be a stripe of paint, or anti-tamper strips/witness marks. They usually indicate that the hose or line has been properly torqued, or that the cable end has been properly swaged. During an inspection, if the witness marks are broken or do not align, this indicates loosening of the joint.

  3. Bob Hartmaier says

    November 16, 2020 at 5:09 am

    “A post-accident examination by an FAA inspector revealed that two air lines were disconnected and that there were no torque lines on the lines.” Can someone tell me what a “torque line” is?

  4. JimH in CA says

    November 13, 2020 at 1:59 pm

    This wasn’t a mechanic error. It was not completing the work to be done,; making sure every part was reattached properly.
    The air reference line being disconnected, looks like would cause the boost controller to ‘see’ too low upper deck pressure , and would close the waste gate, which could cause over boost pressure.

    I’m not very familiar with turbo engines, so, maybe others can clarify ‘ what would happen’ ?

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