Pilot Debrief

CIRRUS DESIGN CORP SR22 near Cross City, FL — 2011-01-28

Final reportERA11LA130
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Date
2011-01-28
Location
Cross City, FL, USA
Aircraft
CIRRUS DESIGN CORP SR22
Registration
N8135B
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

A total loss of engine power resulting from the failure of the camshaft due to fatigue cracks. Contributing to the accident was the inadequate quality inspection of the camshaft after initial manufacture.

Contributing factors

Contributing to the accident was the inadequate quality inspection of the camshaft after initial manufacture.

NTSB narrative

The airplane’s engine lost power during cruise flight at 9,000 feet, and the pilot declared an emergency. Air traffic control (ATC) personnel initially provided the pilot with headings to a nearby airport. However, when the pilot realized that he would not reach the intended airport, he deployed the airplane’s parachute, and the airplane came to rest upright in a field. Postaccident examination of the engine revealed that the camshaft was completely fractured due to fatigue cracks near the flange at the oiling holes. Further examination showed that the fatigue cracks initiated at the edge of the oiling holes and were caused by burrs left when the camshaft was originally manufactured. The burrs folded over during subsequent shot-peening operations, which formed laps at the corners of the holes; the laps acted to concentrate stresses at the edges of the holes and also shielded the underlying material during shot peening. The laps prevented formation of the beneficial compressive stresses that result from shot peening. This allowed subsequent formation of fatigue cracks. The accident camshaft was determined to have been the 19th camshaft of its type manufactured. Because the camshaft was not a serialized part, specific manufacturing records could not be located. However, the quality control inspection procedures that were in place at the time the camshaft was manufactured required an inspection of the oil holes for proper de-burring. A search of FAA database revealed no similar camshaft fracture failure between 1995, and February 2012, excluding the accident event.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have diverted earlier upon first engine surge indication.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • Photos
  • 25 docket documents
View NTSB final reportView NTSB docket

Docket documents25

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