Pilot Debrief

CESSNA U206 near Harpswell, ME — 2017-09-01

Final reportERA17LA307
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Date
2017-09-01
Location
Harpswell, ME, USA
Aircraft
CESSNA U206
Registration
N4615X
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

Probable cause

A total loss of engine power due to maintenance personnel's failure to apply proper torque to the cylinder flange nuts and through bolts, which resulted in shifting of the Nos. 1, 2, and 3 main bearings, loss of lubrication, and failure of the crankshaft.

NTSB narrative

The pilot reported that, while en route to his destination, he heard a “loud bang,” followed by a complete loss of engine power. After determining that the airplane was not within gliding distance of the nearest airport, the pilot performed an off-airport landing, during which the airplane impacted a small drainage ditch, nosed over, and came to rest inverted, resulting in substantial damage. Disassembly of the engine revealed mechanical damage in multiple locations inside the crankcase. The No. 1 main bearings had shifted slightly out of the support and displayed deformation. The No. 2 main bearings displayed bearing shift signatures. One was missing, and the other had extruded out of the bearing support. Multiple pieces of the missing bearing were found in the oil sump. The No. 3 main bearings were intact and had moved in a clockwise direction when viewed from the back of the engine, had shifted slightly out of the support, and the oil passage holes were partially blocked. The crankshaft was fractured at the crankshaft cheek between the No. 2 main journal and the No. 2 connecting rod journal. The No. 2 connecting rod journal and connecting rod bearings displayed incipient signatures of lubrication distress. Review of the engine maintenance records revealed that, about 500 flight hours before the accident, all the cylinders had been replaced with overhauled cylinders and new pistons had been installed along with reconditioned lifters and seals. If a bearing shifts for any reason after removal of one or more cylinders, or during replacement of one or more cylinders, the oil holes in the bearing can become misaligned with the oil passages in the crankcase, partially cutting off the oil supply to the bearing. If the engine is then put back into service, the reduced oil supply to the bearing can cause increased heat and friction that can result in the bearing shifting more, further reducing its oil supply. Eventually, the bearing can shift enough to cause the oil supply to be cut off completely, resulting in a catastrophic failure. This is usually referred to as a "spun bearing." To prevent a spun bearing, the manufacturer specified a multiple-step torquing process for proper cylinder installation. The process required that the through bolt nuts be torqued on both sides of the engine, even if only one cylinder was being installed. The manufacturer warned that "failure to torque through bolt nuts on both sides of the engine can result in a loss of main bearing crush with main bearing shift and subsequent engine failure." Given the observed damage, it is likely that maintenance personnel did not apply sufficient torque to the cylinder flange nuts and through bolts during installation of the cylinders, which resulted in shifting of the Nos. 1, 2, and 3 main bearings, a loss of lubrication, and failure of the crankshaft.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Proper maintenance procedures for engine assembly were not followed.

NTSB coding

Evidence available

  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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