AOPA Turbine Pilot Magazine - June 2020 - 90

P&E

SAVVY MAINTENANCE

is allowed to decrease below the engineout minimum control speed known as VMC,
marked on the airspeed indicator by a blue
radial line.)
NTSB INVESTIGATION

90 |

The NTSB investigation team included
representatives from the FAA, Cessna
Aircraft, and Continental Motors. The
left propeller was found to be feathered,
and the landing gear actuators were in the
down and locked position.
Both Continental GTSIO-520 engines
were recovered from the wreckage and
shipped to Mobile, Alabama, where
they underwent forensic teardowns by
Continental technicians under the supervision of an FAA inspector. In the left engine,
the number one (rearmost) main bearing
was found to be "rotated, damaged, and
distorted severely" with bearing material
extruded from the steel backing and with
fragments of the bearing found in the oil
sump. The number three main bearing also
exhibited accelerated wear and "wiping"

of the Babbitt material. Damage signatures
consistent with excessive heat caused by
oil starvation were found in the number
1 and number 3 main bearings, the number one and number two connecting rod
bearings, and the corresponding crankshaft
journals. The camshaft gear was damaged,
with five gear teeth sheared off. Several pistons exhibited valve strike signatures.
Examination of maintenance records
revealed that the left engine had been
overhauled by RAM Aircraft about three
years and 300 hours prior to the accident,
and there had been no subsequent cylinder removals or other maintenance that
would have required retorquing of any
engine through bolts.
Near the end of the detailed work order
for the annual inspection, there was an
entry that read: "Investigate no oil pressure
on left engine; re-prime left oil pump, filter,
standpipe." When questioned by investigators, the owners of the maintenance facility
said that the airplane's engines sat idle for
weeks because of the annual inspection

and paint job. They explained that the oil
tends to "settle" in the sump and cause
the oil pump to lose its prime. They stated
that after the inspection, the engines were
"motored" with the starter and that the left
engine showed no oil pressure. The oil system was then primed, and oil pressure was
restored to the engine prior to start.
About a year later, the NTSB issued its
final report on this accident. Its determination of probable cause was: "The pilot's
failure to follow established engine-out
procedures and to maintain a proper airspeed after the total loss of engine power
on one of the airplane's two engines during
the initial climb. Contributing to the accident was the total loss of engine power due
to a loss of torque on the crankcase bolts
for reasons that could not be determined
because of impact- and fire-related damage to the engine."
LITIGATION

The aircraft owner and father of the
deceased pilot filed a civil lawsuit.

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AOPA Turbine Pilot Magazine - June 2020

Table of Contents for the Digital Edition of AOPA Turbine Pilot Magazine - June 2020