NTSB Factual Report

HISTORY OF FLIGHT

On May 12, 2001, about 1945 eastern daylight time, a Cessna U206E, N948CG, was substantially damaged during a forced landing after a loss of engine power near New Market, Virginia. The certificated commercial pilot was seriously injured, and the private pilot was fatally injured. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the flight that departed the Eastern West Virginia Regional Airport (MRB), Martinsburg, West Virginia, destined for the Hickory Regional Airport (HKY), Hickory, North Carolina. The personal flight was conducted under 14 CFR Part 91.

The airplane was owned by the private pilot and based at HKY. According to the owner's wife, earlier in the day, both pilots departed HKY, and flew to Florence, South Carolina, as part of the "Angel Flight America" program. They then departed Florence, flew to MRB, and then departed MRB with the intent of returning to HKY.

Review of air traffic control (ATC) information obtained from the Federal Aviation Administration (FAA), revealed the airplane departed MRB, about 1915, and utilized the call sign "Angel Flight Eight Charlie Golf." The airplane was in cruise flight at 8,000 feet, and in contact with the Washington Air Route Traffic Control Center, when at 1937:04, the pilot reported a total loss of engine power. At that time, recorded radar data indicated the airplane's position was about 3.5 miles southeast of the New Market Airport (8W2), about 10.5 miles southwest of the Luray Caverns Airport (W45), and about 22 miles northeast of the Shenandoah Valley Regional Airport (SHD).

At 1937:51, the pilot stated "I've got an engine failure. I've got to get on the ground." The airplane was then cleared directly to SHD, which the controller stated was "about one o’clock and, uh thirty miles." Recorded radar data indicated the airplane was located about 20.5 miles to the northeast of SHD, and at an altitude of about 7,100 feet. The pilot replied, "I don't know if we'll make it" and the controller then directed the airplane to W45, which he stated was "about eight miles to your left." Recorded radar data indicated the airplane was located about 12 miles to the southwest of W45.

At 1938:24, the controller asked the pilot to confirm that the airplane was a single engine aircraft, and that the engine had "quit." The pilot then replied "Affirmative, We've lost the oil pressure."

At 1939:01, the pilot asked for a direction to W45, and the controller responded, "Uh, roger sir. I show Luray about your, uh, let's make it your nine o'clock and about eight miles, six miles." Recorded radar data indicated the airplane was at 6,000 feet, about 11.7 miles southwest of W45.

At 1940:41, recorded radar data indicated the airplane was at 4,200 feet, 10 miles southwest of W45. At 1941:49, the pilot reported "...we got a mountain between us and Luray [airport]. We're not gonna make that." The controller replied "alright, sir, I'm showin if you, if you look to be about a three six zero heading at about your eleven o'clock, looks to be about three miles is the New Market Airport." The pilot replied, "three miles to New Market." Recorded radar data indicated that 8W2 was about 2.4 miles on a heading of 325 degrees from the airplane's position.

At 1942:25, the pilot asked the controller for a heading to 8W2. The controller replied, "roger sir. It looks to be about, uh, if you're in a left turn, twelve o’clock and two to three miles."

There were no further communications received from the pilot and the airplane's last recorded radar position at 1942:41, was 2 miles southeast of 8W2, at an altitude of 2,000 feet.

The airplane was located in a field, approximately 1.5 miles east of 8W2.

The accident occurred during the hours of daylight and was located approximately 38 degrees, 38 minutes north latitude, and 78 degrees, 40 minutes west longitude.

PERSONNEL INFORMATION

According to the private pilot's wife, both pilot's were good friends and flew together regularly. She added that the private pilot no longer enjoyed flying alone and often was accompanied by the commercial.

The commercial pilot held ratings for airplane single and multi-engine land. He also held ratings for flight instructor, and instrument airplane. Review of the commercial pilot's logbook revealed had had accumulated about 2,840 hours of total flight experience. The commercial pilot began flying the accident airplane in January 1998, and his logbook's last entry was dated May 8, 2001. Since January 1998, he had accumulated about 350 hours of total flight experience, which included about 215 hours in the accident airplane.

The commercial pilot's most recent FAA second class medical certificate was issued on March 28, 2001.

The private pilot held a private pilot certificate with a single engine land rating. He was not instrument rated. Review of his log book revealed he had accumulated about 285 hours of total flight experience. During the time period when he began flying the accident airplane, which was in January 1998, and until the last logbook entry, which was dated January 31, 2001, the pilot logged about 125 hours of total flight experience, which included about 100 hours in the accident airplane.

The private pilot's most recent FAA third class medical certificate was issued on May 17, 2000.

AIRCRAFT INFORMATION

The airplane was equipped with a Teledyne Continental Motors (TCM) IO-520F3B engine. According to manufacturing records, the engine was rebuilt by TCM, Mobile, Alabama, in April of 2000, and installed on the accident airplane in June 2000, at a tachometer time of 4470.1 hours. Additionally, at that time, the airplane had undergone an annual inspection.

At the time of the accident, the engine had been operated for about 70 hours since it was installed.

METEOROLOGICAL INFORMATION

The weather reported at SHD, which was located about 25 miles south-southwest of the accident site, at 1944, was: wind from 350 degrees at 7 knots, gusting to 14 knots, visibility 10 statue miles, clear skies, temperature 22 degrees C, dew point 11 degrees C, altimeter 30.00 in/hg.

The accident site was about 55 miles southwest of MRB, which at 1953, reported clear skies, with 10 statue miles of visibility.

The visibility and sky conditions at area airports with recorded weather observations, were as follows:

Charlottesville-Albemarle Airport (CHO), Charlottesville, Virginia, which was located about 33 miles south-southeast of the accident site: at 1953, clear skies, visibility 10 statue miles.

Orange County Airport (OMH), Orange, Virginia, which was located about 40 miles southeast of the accident site: at 1925, overcast ceiling at 10,000 feet, visibility 10 statue miles

Culpeper Regional Airport (CJR), Culpeper, Virginia, which was located about 40 miles east of the accident site: at 1942, scattered clouds at 10,000 feet, visibility 10 statue miles.

Winchester Regional Airport (OKV), Winchester, Virginia, which was located about 40 miles northeast of the accident site: at 2000, scattered clouds at 6,000 feet, visibility 10 statue miles.

AERODROME INFORMATION

According to an airport facility directory, the New Market Airport contained a single 2,920-foot long, 60-foot wide, asphalt runway, oriented on 060/240 degree heading.

WRECKAGE INFORMATION

The airplane was examined at the accident site by an FAA inspector. The airplane struck the top of a residence and a tree, before it came to rest inverted on the field. A golf course was located approximately 1/2 miles north of the accident site.

All major components of the airplane were accounted for at the accident site. Streaks of oil were present on the bottom of the fuselage and small holes were observed on the top portion of the engine crankcase near the number 5 cylinder. Additionally, the number 5 cylinder connecting rod was observed separated from its crankshaft journal. The engine was retained for further examination.

Further examination of the engine was conducted at Hagerstown Aircraft Services, Hagerstown, Maryland, on May 16, 2001, under the supervision of a Safety Board investigator.

The engine was removed from the airplane and mounted on a "nose-stand" for disassembly. Both magneto’s were removed and produced a spark on all towers when rotated by hand. All spark plugs were removed. Their electrodes were intact and dark gray in color. Small pieces of metal flakes were observed inside the oil filter and oil pick-up screen. When the oil sump was removed, two pieces of a connecting rod cap, two broken connecting rod bolts, two connecting rod bearings, three valve lifters, pieces of a piston, and other miscellaneous metal fragments were located in the sump.

All connecting rods, with the exception of the number 5 cylinder connecting rod, moved freely on their respective journals and did not exhibit any evidence of distress. The number 5 cylinder connecting rod and bolts were severely damaged.

The numbers 1, 2, 3, and 4 pistons were removed. Their domes exhibited light deposits, their rings were free to rotate and no scoring was observed on their skirts. The number 5 piston pin had separated from its piston and exhibited impact damage. The bottom portion of the number 5 piston was broken into several small pieces which were observed in the engine. The top portion of the number 5 piston remained lodged in the cylinder. The number 6 piston and attached connecting rod remained inside the cylinder and could not be removed due to damage in the skirt area.

During the disassembly, it was noted that the torque values for the cylinder hold down nuts, through bolts and nose bolts, were with-in limits, except for two cylinder hold down nuts for the number three cylinder. The nuts turned about 1/8 of an inch and less than an 1/8 of an inch, respectively, before reaching the required torque of 41 ft/lbs. Additionally, measured torque values for the engine connecting rod bolts varied between 150 to 450 in/lbs.

According to the engine manufacturer, the required installation torque for the connecting rod bolts was between 690 to 710 in/lbs. A representative of the engine manufacturer also stated that it was not uncommon for connecting rod torque values to vary significantly after an engine experiences a catastrophic failure.

The intact number 1, 2, 3, and 4 pistons and connecting rod assemblies; the fractured number 5 connecting rod assembly; the number 5 cylinder with piston lodged in the barrel, the number 5 piston pin with plugs, and the fractured piston skirt pieces were retained and forwarded to the Safety Board's Material's Laboratory, Washington, DC, for further examination.

MEDICAL AND PATHOLOGICAL INFORMATION

The private pilot was examined on May 14, 2001, by the Office of the Chief Medical Examiner, Richmond, Virginia. An autopsy was not performed.

Toxicological testing was conducted on the private pilot by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.

TESTS AND RESEARCH

The retained portions of the engine were examined by a Safety Board Metallurgist on July 10, 2001. Examination of the number 5 connecting rod assembly revealed that although heavily damaged by post fracture mechanical contact, sufficient fracture surfaces remained to establish that the fractures in the rod and cap were consistent with bending overstress separations. No indications of preexisting cracking, such as fatigue, were found at either fracture location and no heat tinting was noted at the bearing area. Additionally, no fretting was noted on the split line surfaces of the rod and the original machining marks were clearly visible. The number 5 connecting rod bearing was severely bent and folded, but not fractured. The non-bearing outer diameter surfaces had mechanical damage associated with the overall deformations but did not show indications of movement within the rod prior to separation, such as scoring or fretting. Additionally, no heat damage was observed.

The number 5 cylinder piston pin was separated from the rod. The body of the pin was dented, scuffed and marked, but not fractured. However, the aluminum plugs in each end of the pin were severely battered and deformed from their normal cylindrical shape into a shape resembling a truncated cone.

The number 5 piston was extracted from the cylinder. The piston contained multiple fractures through the pin bosses and the skirt below the upper oil control ring. The fractures and underside of the crown also exhibited multiple post fracture mechanical dents and impact marks. Many of the marks were consistent with contact with the end plugs of the piston pin. Several small pieces of the separated skirt and bosses were recovered separately. Many of the small pieces were matched to the crown, but only an estimated 75% of the pin bosses and much less than 25% of the skirt below the upper oil control ring was recovered. Microscopic examination of the fractures surface on the recovered piston pieces were typical of overstress fracturing and no indications of preexisting cracking, such as fatigue were observed.

Examination of the number 5 cylinder revealed that the cylinder bore exhibited a uniformly crosshatched hone pattern with no indications of localized wear, piston scuffing or metal transfer. Except near the mechanical damage at the base, the barrel surface was smooth and displayed a ring groove. The cylinder head was intact and both valves were in place and appeared undamaged. The combustion chamber contained light tan deposits with no indications of mechanical or thermal damage.

Examination of the numbers 1, 2, 3 and 4 connecting rod assemblies showed that all rods exhibited slight fretting on one of the split line faces. The other faces displayed the as-manufactured machine pattern. The fretting was very light and had not yet completely removed the original machining marks in the area. The rod bolts all appeared intact and undamaged.

Examination of the numbers 1, 2 3, and 4 pistons revealed various amounts of tan deposits on the crown with no indications of detonation damage. The piston skirts displayed the original area of dry lube coating with little or no wear or scuffing. Further examination of the pistons, conducted at Teledyne Continental Motors, Mobile, Alabama, included hardness and dimensional checks of the pistons, piston pins and piston rings. The testing revealed the components met their applicable drawing requirements.

ADDITIONAL INFORMATION

Air Traffic Controller Interview

The controller who directed the accident flight was interviewed by a Safety Board ATC Specialist. During the interview, the controller stated he initially directed the airplane to SHD because the airplane's heading "looked to be taking him right over the top [of the airport]." He also stated that SHD was serviced by an approach control, standard instrument approaches, emergency equipments, and SHD was "the first thing" that came to his mind. When asked why he chose W45, the controller stated because "it was off the left wing" of the airplane, had a published approach, and he had worked approaches into W45 on previous occasions.

The controller said he did not asked the accident pilot about sky conditions or weather. He also did not solicit any pilot reports from other airplanes at lower altitude. The controller stated that the weather was visual flight rules (VFR), and he knew it was VFR because it was a "nice day" outside.

When specifically questioned about the performance characterizes of the Cessna 206, the controller stated "I know he's slow, doesn't climb fast, that's all I know." He said that he did not know prior to this emergency that a Cessna 206 was a single engine airplane.

With regards to providing "clock position directions," the controller stated, "I don't know what [the accident pilot] knows. I thought the clock position heading was the easiest thing to do."

FAA Order 7110.65, "Air Traffic Control," paragraph 10-2-14, "Guidance to Emergency Airport," stated:

"When necessary, use any of the following for guidance to the airport:

1. Radar.

2. DF

NTSB Probable Cause

A loss of engine power due to a failure of the number 5 piston for undetermined reasons. A factor in this accident was the inadequate emergency handling provided by the air route traffic controller.