Pilot Debrief

CIRRUS DESIGN CORP SR22 near Homestead, FL — 2012-03-09

Final reportERA12LA219
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Date
2012-03-09
Location
Homestead, FL, USA
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N444VR
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The inadequate servicing and maintenance of the engine and the airplane owner and maintenance personnel's disregard of the manufacturer's recommended engine overhaul schedule and service bulletins, which resulted in an in-flight internal failure and seizure of the engine.

NTSB narrative

During cruise flight at 6,000 feet mean sea level (msl), the airplane's engine incurred a total loss of power. The flight instructor and the private pilot looked for a suitable place to land. Their first choice was an airport, but due to the prevailing wind, they were unable to make it to the airport. Their second choice was a highway, but it also proved to be unsuitable due to the amount of automobile traffic. As they descended through 2,000 feet msl, they considered deploying the Cirrus Aircraft Parachute System (CAPS) but noticed a light colored patch of ground, which appeared to be a hard dirt surface; they thought landing there would be a better option than deploying the CAPS. During the final approach, while in ground effect, the flight instructor observed a mound of dirt that was directly in front of the airplane, and he deployed 50-percent wing flaps to "balloon" the airplane over the obstacle. The wheels touched down on a water-filled marshy area, and the airplane slid over a mound of dirt and came to rest in the marshy area. A review of onboard recorded data showed that fluctuations of the No. 2 cylinder's exhaust gas temperature were present beginning at engine start. Examination of the engine revealed that the engine had a hole in the top of the crankcase and that both magnetos had separated from their mounting locations. Further examination of the engine revealed that the No. 2 connecting rod bearing had been starved of oil and released from the crankshaft. The No. 2 main bearing had shifted and the lock slot in the crankcase was damaged, which indicated that the crankcase through bolts were not properly torqued. The No. 2 main bearing was fractured, and portions were missing from the steel backing, and the No. 2 and No. 3 piston pin bushings were also missing bushing material, which indicated that, during maintenance, a service bulletin had not been complied with. Review of the manufacturer's overhaul schedule also revealed that the recommended time between overhauls was 2,000 hours. At the time of the accident, the engine had accrued 2,978.1 total hours of operation without overhaul. Review of the airplane and engine manufacturers guidance also revealed that because engine cooling was accomplished by discharging heat to the oil in the engine the engine should not be operated with less than 6 quarts of oil. The flight instructor however, stated that he added oil to the engine during the preflight to bring it up to 5 quarts. He also advised that was the level they always serviced it to, which indicated that in addition to the engine having been inadequately maintained, the engine was also continuously operated below the minimum specified oil level.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Properly checking and maintaining engine oil levels before flight.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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