NTSB Factual Report

HISTORY OF FLIGHT

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On May 28, 2004, at 1430 central daylight time, a Cessna T206H, N9548D, operated by the Drug Enforcement Administration, was destroyed on impact with a detached garage belonging to a single-family home in Homer Glen, Illinois. The pilot reported a loss of engine power to air traffic control during cruise flight. Visual meteorological conditions (VMC) prevailed at the time of the accident. The Title 14 Code of Federal Regulations (CFR) Part 91 flight was operating without a flight plan. The commercial pilot was fatally injured. The positioning flight originated from Chicago Midway International Airport (MDW), Chicago, Illinois, at 1423, and was en route to Spirit of St. Louis Airport (SUS), Chesterfield, Missouri.

According to an employee at the front counter of MDW Signature Flight Support, the airplane arrived at 1315-1330. The pilot approached the front counter and requested a "top off" and stated that he would be going "right back out." The employee, who saw the pilot a couple of times a week, said the pilot "seemed fine and his usual self" after talking to him for about 5-10 minutes. The employee stated that the pilot never complained about the airplane and did not report any mechanical related problems with the airplane to her. The pilot sat in the lobby for a "couple" of minutes with the passenger he arrived with.

The passenger, who accompanied the pilot on the flight to MDW, reported that pilot the did not indicate that there were any mechanical problems with the airplane. The passenger also reported that he did not notice any such problems during the flight to MDW.

A Signature Flight Support line service employee, who serviced the airplane, stated that the airplane arrived approximately 1300. The pilot asked him to "top off" the airplane. The line service employee then used the "100LL truck" to fill the right wing tank with 25.8 gallons of fuel and the left tank with 26 gallons of fuel.

According to the operator, the airplane was en route to SUS for a scheduled 50-hour maintenance inspection of the airplane.

At 1347, a person representing N9548D called Kankakee Automated Flight Service Station by telephone and obtained a standard preflight briefing for the MDW and SUS areas.

A partial transcript of transmissions by: N9548D; MDW Clearance Delivery (CD); MDW Air Traffic Control Tower, Ground 2 (GC); MDW Air Traffic Control Tower, Local Control 2 (LC); MDW Air Traffic Control Tower, Approach Control 2, (AP); and an Unknown entity follows.

1406:31, N9548D, "midway clearance cessna nine fi nine five four eight delta cessna two oh six at signature with victor i'll ah be v f r southbound two one seven degrees to bloomington"

1406:40, CD, "is it two one seven"

1406:42, N9548D, "ahh four eight delta correct two one seven degrees"

1406:49, CD, "kay can you pick a different heading that's not ah flying up the arrival corridor"

1406:55, N9548D, "okay would two seven zero be okay for now"

1406:58, CD, "okay standby and was that four eight delta"

1407:01, N9548D, "correct nine five four eight delta"

1407:07, CD, "four eight delta maintain v f r below two thousand in class charlie airspace departure frequency is one one niner point four five squawk five one seven five"

1407:17, N9548D, "(unintelligible) nine five four eight delta v f r below two thousand in charlie nineteen forty five and five one seven five on the squawk"

1407:23, CD, "readback correct"

1408:00, N9548D, "midway ground nine five four eight deltas a two oh six ready to taxi from signature"

1408:31, GC, "okay four six delta did you call me"

1408:34, N9548D, "nine five four eight delta from signature"

1408:36, GC, "okay four eight delta midway ground out of signature join the whiskey taxiway taxi to runway four left"

1412:45, N9548D, "midway tower nine five four eight delta ready in sequence four left"

1412:48, LC, "roger"

1418:07, LC, "four eight delta midway tower runway four left full length available taxi into position and hold"

1418:12, N9548D, "position and hold four eight delta"

1423:01, LC, "and four eight delta you want a two ninety heading"

1423:05, N9548D, "(unintelligible) four eight delta if it'll work out for you a two seventy'd be probably better"

1423:09, LC, "okay"

1423:19, LC, "and cessna four eight delta now turn left heading three six zero runway four left cleared for takeoff"

1423:27, N9548D, "three six zero four eight delta"

1424:53, LC, "four eight delta now turn left on course heading two niner zero"

1424:57, N9548D, "two niner zero four eight delta"

1424:59, LC, "and four eight delta i'm going to wait for a citation to depart three one center until you get over the ah three one center departure corridor so if you can ah give me your best forward speed ac across that"

1425:10, N9548D, "four eight delta"

1425:31, LC, "four eight delta contact chica midway approach on one one niner point four five"

1425:34, N9548D, "nineteen forty five four eight delta"

1425:43, N9548D, "midway radar nine five four eight delta one thousand four hundred"

1425:45, AP, "seven five four eight delta midway departure you're radar contact where you headed"

1425:50, N9548D, "nine five four eight delta bloomington"

1425:53, AP, "alright"

1426:12, AP, "nine five four eight delta you can fly heading two two zero now"

1426:16, N9548D, "two two zero four eight delta"

1427:00, AP, "cessna niner five four eight delta traffic for you's about ah ten o'clock three miles just crossed the final for four right northwest bound sixteen hundred feet a twin engine travelair"

1427:10, N9548D, "four eight delta's looking"

1427:33, AP, "cessna four eight delta that traffics about ah ten o'clock and two miles now northwest bound one thousand seven hundred twin engine"

1427:41, N9548D, "four eight delta still looking no ah traffic in sight"

1427:45, AP, "traffic is ah you see you see the traffic four eight delta"

1427:47, N9548D, "four eight delta traffic in sight"

1430:56, AP, "cessna four eight delta you're ahh ten and a half miles southwest of midway airport you can resume your own navigation ah did you want to leave the frequency or stay on for advisories"

1431:03, N9548D, "four eight delta i'll leave frequency"

1431:05, AP, "four eight delta roger radar service terminated frequency change approved have a good flight today"

1431:08, N9548D, "four eight delta thank you"

1431:40, N9548D, "midway midway (unintelligible) cessna four eight delta (unintelligible) i just lost my engine"

1431:45, AP, "four eight delta say your intentions"

1431:48, N9548D, "four eight delta * (click) * (click)"

1431:54, AP, "check your fuel"

1431:58, N9548D, "four eight delta yes sir"

1432:10, AP, "check your is your fuel turned on down on the floor there four eight delta"

1432:14, Unknown, "(unintelligible)"

1432:16, Unknown, "affirmative"

A witness stated, "I observed the plane flying west going over Long Run Creek. I heard the pilot trying to start the engine at least two times. He then turned to the south and I could again hear the pilot trying to start the engine at least four or five times. The engine would kick over and die out immediately. The propeller was turning slowly because he was trying to start the engine. There was no smoke or fire that I observed. At that point I was unable to observe the plane because of the trees which obstructed my view. About a minute passed and then I heard a crash. It appeared that the pilot was trying to land in the farm field located on the north side of 139th Street."

A second witness stated that there was a small airplane flying north of his residence that drew his attention because the airplane was flying "low". The airplane started to fly eastbound and then banked "hard." He stated that there was no smoke or any "weird" noise.

A third witness stated that he was working about 100-150 feet from the accident site when the accident occurred. The sound of the airplane initially drew his attention to the airplane, and he then saw it "coming in and looping" in what was an attempt to land in a field across from the residence where the accident occurred. The airplane was just above the trees when he heard an attempted start for the third time and after each start attempt, the engine would "fire up" and "die down" a few seconds later. The airplane was at tree height at the property next to the accident site. The right wing clipped the closest southwest tree next to the garage and then "fell straight down," and the airplane immediately exploded. He added that black smoke would come out from the bottom sides of the airplane at each start attempt. He said that that the color of the smoke was similar to that emitted from an engine with a blown cylinder head or blown cylinder.

PERSONNEL INFORMATION

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The pilot's employment duties with the operator included serving as a pilot-in-command on single-engine airplanes. He held a commercial pilot certificate with single-engine land, multiengine land, instrument airplane, helicopter, and instrument helicopter ratings. He also held a certified flight instructor certificate with airplane single-engine, airplane multiengine, and instrument airplane ratings. As of the last logbook entry dated May 20, 2004, the pilot accumulated a total flight time of 3,602.2 hours, of which 1,545.6 hours were in Cessna 206 airplanes. Of the total flight time in Cessna 206 airplanes, 658.7 hours were in Cessna 206 turbocharged models.

Logbook records indicate that the pilot's first flight in an airplane occurred on April 3, 1979. He was issued a private pilot certificate with a single-engine land rating on July 26, 1979.

On July 7, 1998, the pilot logged his first flight in a Cessna TU206F as a "familiarization flight," 1.6 hours in duration with 4 landings. The next flights using Cessna T206H and Cessna TU206F airplanes, occurred from December 13, 1998 to December 17, 1998, which had a total flight duration of 9.9 hours and an entry stating that the last flight in this period was a company standardization flight, 90-day VFR, and a flight review.

On July 18, 2002, the pilot received a standardization checkride conducted by the operator using a Cessna U206G. The standardization pilot stated that the pilot "met or exceeded the performance standards for the maneuvers performed as defined by the [practical test standards] (commercial standards)".

On November 8, 2003, the pilot last received training through operator sponsored training at SIMCOM. Logbook records indicate the pilot received 12 hours of training using a PC-12 fixed motion simulator toward completion of phase three of the Federal Aviation Administration's (FAA's) Pilot Proficiency Award Program, an instrument proficiency check, and ground and flight instruction in high-altitude operations.

FAA records indicate the pilot was not involved in any previous accidents, incidents, or enforcement actions.

The pilot was issued a second-class airman medical certificate on November 13, 2003, with the following limitation: "must wear corrective lenses for near and distant vision".

AIRCRAFT INFORMATION

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The 1999 Cessna T206H, serial number T20608062, was certificated as a normal category airplane on October 1, 1998, under Title 14 CFR Part 23 as listed in the airplane's type certificate data sheet. The airplane received an airworthiness certificate on July 12, 1999, and was registered to the operator on September 1, 1999. The airplane was subsequently operated as a public aircraft.

The airplane was powered by a Textron Lycoming TIO-540-AJ1A, serial number L-10190-61A, engine with a maximum continuous power rating of 310 brake horsepower at 39 inches of mercury (Hg) and 2,500 revolutions per minute (rpm). According to the Cessna T206H Pilot Operating Handbook (POH), the limitations section lists the powerplant instrument markings for the tachometer's green arc (normal operating range) as 2,000 - 2,400 rpm. The engine oil pressure minimum and maximum limitations are listed as 20 pounds per square inch (psi) and 115 psi, respectively. The engine oil pressure instrument's green arc (normal operating) ranges from 50-90 psi, a red line (minimum) of 20 psi, and a red line (maximum) of 115 psi.

The POH lists the airspeed indicator marking for the normal operating range's green arc as 59 - 149 knots indicated airspeed (KIAS).

The airplane was equipped with a 76 cubic foot capacity, 6-place, fixed oxygen system manufactured by B/E Aerospace, which was installed in the airplane when the operator took receipt of the airplane. The POH states that one permanent, microphone-equipped mask is provided for the pilot, and five disposable type masks are provided for the passengers. All the masks are the partial-breathing type, equipped with vinyl hoses and flow indicators.

The Cessna T206H Maintenance Manual, revision 6, includes a controller and turbocharger operational flight check at a cruise altitude of 17,000 feet pressure altitude. The steps that follow are listed in the maintenance manual as:

(4) Engine Speed - 2,400 RPM.

(5) Part-Throttle M.P. - 30 in Hg.

(6) Fuel Flow - Lean to 20.0 GPH.

(7) Propeller Control - (a) Slowly decrease engine RPM until manifold pressure starts to drop, indication the wastegate valve is closed. If the wastegate valve closes at engine speeds below the RPM shown in Figure 201, the turbocharger performance is normal. (b) Note the outside air temperature and RPM where the manifold pressure begins to drop. Refer to the chart in Figure 201 with these values and assure that no bootstrapping occurs above the line.

The controller and turbocharger operational flight check is not included in any of the aircraft manufacturer's maintenance inspection checklists, and it is not a required check.

Maintenance Information

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On December 13, 2002, at a total time of 391.7 hours, the engine was removed from the airplane in order to comply with Airworthiness Directive (AD) 2002-19-03 by having a Lycoming representative extract six core samples from the crankshaft propeller flange. The samples were sent to Lycoming for metallurgical testing, the results of which found that the crankshaft was "rejected."

On February 30, 2003, the engine was disassembled "only enough" to facilitate replacement of the crankshaft affected by Lycoming Service Bulletins (SBs) 552 and 553. The engine was reassembled, test run, and returned to service.

On March 7, 2003, the engine was installed on the airplane, a ground run was performed, and no leaks were reported to have been found.

On April 20, 2004, at a total time of 589.1 hours, the engine and airframe were last inspected during an annual inspection. During the engine inspection, the number five cylinder, part number 05K22680, serial number 11, was removed due to low compression, repaired, and reinstalled. The engine oil was changed, the oil filer replaced, and the oil screen was cleaned. An oil sample was taken and normal lab results were reported of the sample. The left and right magneto harnesses were replaced. SB 342, SB 480D, SB 529B, and AD 2003-14-03 were complied with.

The airplane discrepancy log did not list any discrepancies pertaining to the airplane fuel system or powerplant over a year prior to the last discrepancy dated April 21, 2004.

The airplane accumulated a total time of 628 hours at the time of the accident.

The 50-hour maintenance interval items that were to be checked on the airplane upon its arrival at SUS were: check the battery electrolyte level, check brakes and brake lining for wear, check nose landing gear strut for leakage, check tire for wear and condition, change the oil, change the oil filter, and clean the oil sump screen. Additional inspection items included inspection of the alternator charging system and an oil sample and oil filter analysis.

There was no record that a controller and turbocharger operational flight check was performed on the airplane since its registration to the operator.

ME

NTSB Probable Cause

The seized turbocharger, the altitude/clearance not maintained/obtained during approach to a forced landing on an agricultural field, and the unsuitable landing area encountered by the pilot. Contributing factors were the inadequate emergency procedures by the manufacturer, the trees, and the residential area.