Pilot Debrief

ROCKWELL INTERNATIONAL 112A near Phoenix, AZ — 2016-10-12

Final reportWPR17LA004
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Date
2016-10-12
Location
Phoenix, AZ, USA
Airport
DVT
Aircraft
ROCKWELL INTERNATIONAL 112A
Registration
N509CA
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Climb

Probable cause

A catastrophic engine failure due to lack of lubrication due to the absence of 2 piston cooling nozzles that backed out of their respective threaded bores, which resulted in a forced landing on unsuitable terrain.

NTSB narrative

According to air traffic control transcripts, about 17 minutes after the private pilot departed for a personal, cross-country flight and immediately after being cleared to climb to 10,500 ft mean sea level (msl), the pilot advised an air traffic controller that the engine oil temperature was “running a little hot” and that he needed to level off at 7,500 ft msl to “cool off.” About 7 minutes later, the pilot repeated that the engine temperature was running high and requested a return to the departure airport but stated that he did not want to declare an emergency. The controller provided the pilot with information for an airport closer to the airplane’s position for a diversionary landing. Although a controller at that airport issued the pilot a straight-in approach, the pilot responded that the engine had lost power and that he was going to have to land because the airplane could not reach the airport. Subsequently, the pilot attempted to conduct a forced landing on a nearby road, but the airplane impacted terrain in a train yard and came to rest between trees and a wooden structure substantially damaging the airframe and wings. During a postaccident examination of the engine, a hole was found in the engine case at the No. 4 cylinder, and metal debris was found throughout the engine, indicative of a catastrophic engine failure. The No. 4 connecting rod bearing had extruded and exhibited signatures consistent with a lack of lubrication, which likely led to the catastrophic engine failure. The Nos 2 and 4 piston cooling nozzles were absent from their respective threaded bore in the crankcase; they were identified in the oil sump and had sustained destructive damage as a result of passage through the engines internal rotating components. The threaded nozzle bores for the Nos 2 and 4 piston cooling nozzles were not damaged. The No. 1 cooling nozzle remained tight and in place, and the No. 3 cooling nozzle remained in place, but was loose and rotated a quarter of a turn before it became tight. It is likely that the absence of the Nos 2 and 4 piston cooling nozzles would have an effect on the engine lubricating oil effectiveness to the internal rotating components of the engine during operation.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot should have declared an emergency when oil temperature was high.

NTSB coding

Evidence available

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

Docket documents12

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