Pilot Debrief

CESSNA 337G near High Springs, FL — 2010-05-27

Final reportERA10LA284
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Date
2010-05-27
Location
High Springs, FL, USA
Aircraft
CESSNA 337G
Registration
N72268
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Cruise

Probable cause

The pilot's failure to follow the published engine-out procedures after a total loss of power in the rear engine. Contributing to the accident was the inadequate maintenance and inspection of the engine by the pilot and maintenance personnel.

Contributing factors

Contributing to the accident was the inadequate maintenance and inspection of the engine by the pilot and maintenance personnel.

NTSB narrative

During cruise flight, the rear engine on the twin engine airplane incurred a total loss of power, and the pilot executed a forced landing to a field. During the landing, the airplane struck several trees, separating the left wing from the fuselage. Postaccident examination of the airplane revealed that the front propeller was bent and the rear engine's propeller was feathered. Oil spatter was visible on the underside of the horizontal stabilizer and elevator. Examination of the rear engine revealed that the end of a connecting rod was protruding from a hole in the top of the engine case. Further examination revealed numerous problems indicative of excessive wear, improper maintenance, and inadequate inspection. Maintenance records for the airplane and engines were incomplete, and the only entries were for the yearly annual inspections. No entries regarding repairs, alterations, part replacements, oil changes, or preventive maintenance were listed. According to the engine manufacturer, the engine should have been overhauled at 1,500 hours. Total time in service for the failed rear engine however was 2,404.3 hours. When asked about the airplane manufacturer's procedures for a loss of power, the pilot was unable to articulate them, and when asked about his subsequent actions, the pilot advised that he had not feathered the propellers (the rear propeller may have feathered when oil pressure was lost). According to the manufacturer, the ENGINE-OUT DURING FLIGHT checklist should have been used to determine the inoperative engine and secure it. Operational data in the owner's manual indicated that, if the airplane was configured using the checklist, it would have had sufficient residual performance to continue flight.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have followed engine out procedures to secure the inoperative engine.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 18 docket documents
View NTSB final reportView NTSB docket

Docket documents18

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