N6539P – Cessna (Textron Aviation) P210 – 2004-11-12 NTSB Accident Report

HISTORY OF FLIGHT

On November 12, 2004, at 1147 eastern standard time, a Cessna P210, N6539P, was destroyed during a forced landing in Paint Lick, Kentucky. The certificated commercial pilot was fatally injured. Instrument meteorological conditions prevailed, and the airplane, which departed Talladega Municipal Airport (ASN), Talladega, Alabama, at 1003, was operating on an instrument flight rules flight plan to Port Columbus International Airport (CMH), Columbus, Ohio. The personal flight was conducted under 14 Code of Federal Regulations Part 91.

According to combined Federal Aviation Administration (FAA) voice transcripts (with some punctuation added for clarity):

At 1104, the pilot reported: "indianapolis center, centurion six five three niner papa checking in with you level flight level one niner zero," and the controller acknowledged the call.

About 18 minutes later, the controller began issuing a change in routing.

At 1127:09, the pilot reported: "and ah, center, centurion six five three niner papa, i got a little problem here," and the controller responded, "go ahead."

The pilot then stated: "and six five three niner papa got an engine ah lost cabin pressure altitude, ah, failure, got to descend."

The controller then cleared the pilot to descend to "one one thousand let me know if you need any more than that, london altimeter is ah, three zero zero niner." The pilot then responded with "one zero, ten thousand."

At 1127:36, the controller asked: "november three niner papa, you say you're havin' engine trouble or just cabin pressure problem?" and the pilot responded: "...i've got engine trouble and cabin pressure problem."

At 1127:44, the controller advised: "okay london airport is ah, at four o'clock and sixteen miles -- ah be the closest one there and just let me know what you want to do."

The pilot then requested a vector to the airport, and the controller responded: "turn right to a heading of one four zero," which the pilot acknowledged.

At 1128:09, the controller advised the pilot of the airport identifier, and at 1128:23, advised the pilot that the "weather at london is saying overcast at ah five hundred -- do you still wanna try to get there?"

The pilot responded: "...stand by sir, i've got to, i've got to get oxygen on here, i'm"

At 1129:46, the pilot stated: "okay six five three niner papa, i'm with you sir," and the controller responded: "...roger and ah, are you making any engine power at all?"

At 1129:53, the pilot responded: "six five three niner papa, yes sir, showing manifold pressure of ah one five, fifteen inches sounds good, ah, i've got fuel flows of...one hundred pounds per hour. ah i think i probably lost the turbo charger, i've got really not a big difference in engine sound ah but um ah let me get a little lower here. ah can you give gimme that vector again please?"

The controller responded that the pilot needed to turn to heading 150, and the airport was 17 miles away. The pilot acknowledged the heading, and stated: "we got oxygen on here."

At 1130:24, the controller repeated that the ceiling was 500 feet, and that Bluegrass Airport was "six hundred feet so i'm not seeing anywhere closer that might be any better.

At 1130:39, the pilot responded: "six five three niner papa, i will ah factor that in sir. i'm going to continue in the turn here and assess the situation and ah, i'll be calling you back here shortly."

At 1130:49, the controller stated: "okay, just ah, let me know. there is some g-p-s approaches in to london. there is a v-o-r approach that comes in from the southwest," which the pilot acknowledged.

At 1131:34, the pilot asked: "...could you look, ah, for some, ah better ah landing conditions ah, to the north?"

At 1131:46, the controller responded that Louisville International Airport was 3,400 overcast, and that the heading would be 340 or 330, "and ah we'll get a mileage away from that if you want to start turning to a three three zero heading we'll get you a clearance to louisville international."

At 1132:00, the pilot acknowledged: "...right turn to heading three three zero, just to keep you advised we're at seventeen inches of manifold pressure now at this lower altitude. looks like the turbo charger problem, engine seems healthy."

At 1132:15, the pilot stated that he wanted to "conserve...altitude" and maintain 10,000 feet, and the controller cleared him to do so.

At 1133:05, the controller cleared the pilot to Louisville, with a heading of 310 degrees, which the pilot acknowledged. The pilot then asked for the "designator" for Louisville, which the controller provided.

At 1134:23, the pilot stated: "(unintelligible) the airport again," and the controller asked him to "say again please."

At 1134:31, the pilot responded: "six five three niner papa, we're declaring an emergency. i've got low oil pressure. i need the closest airport."

At 1134:36, the controller responded: "and november three niner papa, we've got madison airport at ah north, heading three six zero heading and ah, about ah --- one seven miles."

The airport the controller was referring to was Madison County Airport (I39), Richmond, Kentucky.

At 1134:46, the pilot responded: "six five three niner papa, we're we're settin' up for that -- and i'm gonna pull power here. i've got ah -- low as i said low oil pressure."

At 1134:52, the controller stated: "november five three niner papa, roger, can you change frequency now? i can give you Lexington approach. that's in their airspace, they can help you out," and the pilot responded "six five three niner papa give it to me."

At 1134:59, the controller advised the pilot to descend and maintain 4,000 feet, "you've got your emergency," and to contact Lexington approach on frequency 120.5, which the pilot acknowledged.

During this timeframe, the Indianapolis Center and Lexington controllers coordinated the handoff and cleared the airspace.

At 1135:27, the pilot stated: "lexington approach, centurion six five three niner papa with an emergency," and the controller responded: "november three niner papa, lexington approach, roger. lexington altimeter three zero one five. what approach do you want at richmond madison?"

At 1135:36, the pilot answered: "i can't figure that out. give me the designator for this uh emergency landing airport."

At 1135:44, the controller responded: "...the closest airport um in your vicinity is about one zero miles north of your position about one five miles north of your position richmond madison airport."

There were then several calls between the pilot and the controller, confirming that the designator was india three nine.

At 1136:24, the controller stated: "centurion uh three niner papa, at pilot's discretion, descend and maintain three thousand two hundred."

At 1136:30, the pilot responded: "six five three niner papa p-d uh (unintelligible) i need some help here sir. i need these i need somebody to compute up for me a vertical descent profile to get me in. i'm about to lose my engine and uh i need somebody to be figuring out my current altitude and distance to the airport if you could please and give me a descent profile. i, i need to expect that i'm going to lose complete power here at any time. i'm at this point, i'm still maintaining a hundred and fifty knots on the airspeed ah but i'm going to have to try to level here to conserve that altitude and get my glideslope."

At 1137:00, the controller stated: november three niner papa, roger, your position is one two miles south of the richmond madison airport and i'm showing you at one twelve thousand, three hundred feet, twelve thousand three hundred feet.

At 1137:14, the pilot asked for the airport elevation, and at 1137:38, the controller reported it as 1,000 feet.

At 1137:42, the pilot reported: "...three niner papa, we got engine failure in progress here. uh, okay, give me a vector sir."

At 1137:47, the controller advised the pilot to fly heading 010 for the airport, which the pilot acknowledged, as well as, "we're setting up for maximum glide."

At 1138:08, the controller asked for number of "souls on board," and the pilot responded "one."

At 1138:15, the pilot stated: "the engine's coming apart sir."

At 1138:28, the pilot stated: "sir, can i get somebody, i'm gonna get oil all over the windshield here. i need somebody to be giving me a vertical descent profile for this airport...," and the controller responded "november three niner papa you are five miles from the airport. you're still at uh ten thousand six hundred."

At 1138:47, the pilot responded: "okay, six five three niner papa, i'm going to get over that (unintelligible) airport and circle down. i'm getting oil on the windshield," and the controller responded: "roger, i'll advise when you're over the airport sir."

At 1138:57, the pilot controller asked: "...are you i-m-c?" and the pilot responded: "...no sir, but i'm about to be."

At 1139:16, the controller stated: "november three niner papa, if uh able, you may be able to pick up an (unintelligible) interstate highway seventy five, just off to your right about one mile."

At 1139:26, the pilot asked: "...how far to the airport sir?" and the controller responded that he was 4 miles to the south of it, at 9,800 feet.

At 1139:35, the pilot stated: "continue the descent. i'm about to enter the cloud layer here. i'm going to be needing to make some ovals on east west headings uh, to uh, make this descent through the clouds. do you have a ceiling at that airport? can you give me anything about the weather there?" The controller responded: "...we'll see if we can get the awos weather for ya."

At 1140:34, the pilot asked for the airport's radio frequency, which the controller provided.

At 1141:21, the controller stated: "you're a half mile south of the airport now."

At 1141:26, the pilot stated: "six five three niner papa, got total, complete engine failure, uh, and we're going to be setting up. i, i need some kind of a plan here for uh this descent in there. i'm showing seven thousand two hundred, uh, i'm gonna make a left turn here and uh, i'm right over the airport now."

At 1141:48, the controller responded: november three niner papa, affirmative. you're directly over the airport and if you just circle uh, in that area for your descent i'm showing you at seven thousand two hundred."

At 1141:57, the pilot asked: "six five three niner papa, did you get me a ceiling at that airport?" and the controller responded "we're working on it. they do not have a awos frequency we're, we'll try and call somebody over at the airport..."

During that timeframe, controllers were making calls to attempt to get the pilot current weather conditions at Madison County Airport.

At 1142:10, the pilot stated: "...appreciate that help sir, could you tell me about the terrain down there below the cloud deck?" and the controller responded that there were antennas about 5 miles to the south of the airport, but if the stayed directly above the airport, he should be fine there.

At 1643:33, the pilot asked he was over mountainous terrain or relatively flat terrain, and the controller responded: "i believe it's fairly flat."

At 1142:56, the controller stated: "...weather at bluegrass [airport] is six hundred overcast, visibility eight, and altimeter three zero one five," and the pilot responded: "...doesn't sound good."

At 1143:12, the controller asked the pilot how much fuel he had onboard, and the pilot responded that he had 400 pounds.

At 1143:29, the pilot requested the direction of the runway at Madison County, and the controller responded: "one eight and three six," which the pilot acknowledged.

At 1144:20, a pilot from another airplane stated: "...the pilot in distress, there's an interstate going just east of that madison i-thirty nine airport. there's a big, long interstate going just east of that airport," and the controller responded: "thank you."

At 1144:34, the other pilot stated: "probably not even a half a mile," then subsequently stated: "that interstate runs north south runs north south of the uh, parallel to the airport and the runway is also north and south."

At 1144:59, the controller stated: " november three niner papa the uh, interstate there is uh runs along a north and south line too, if, uh, when you break out you don't have the airport its just a half mile east of the airport north south," and the pilot responded: "five three niner papa, gotcha."

At 1145:19, the other pilot stated: "and the runway length is forty five hundred feet..."

At 1146:19, the controller stated: "centurion three niner pap is uh on half mile west of the airport now and i show your altitude at two thousand six hundred. lexington altimeter three zero one five."

At 1146:29, the pilot stated: "five three niner papa. yes sir, we're having a lot of difficulties maintaining control of the airplane at this and it's i-m-c..."

At 1147:09, the controller stated: "centurion three niner pap is one mile west of the airport."

At 1147:30, the controller stated: "centurion three niner papa, i show you now a mile south of the airport and equipment is standing by."

At 1147:51, the controller stated: "centurion three niner papa, radar contact is lost."

At 1147:54, the pilot stated: "five three niner."

At 1147:58, the controller stated: "say again please," but there were no further transmissions from the airplane.

A review of radar and transponder data revealed that the airplane's last recorded altitude, about 1 nautical mile southwest of the airport, was 1,800 feet, or about 800 feet over the terrain.

The accident occurred during the hours of daylight, in the vicinity of 37 degrees, 37.11 minutes north latitude, 84 degrees, 21.82 minutes west longitude.

AIRCRAFT INFORMATION

The airplane was powered by a Teledyne Continental Motors (TCM) TSIO-520-P engine. According to airplane and engine maintenance logbooks, on June 20, 2003, at Van Bortel Aircraft, Inc., Arlington, Texas, all engine cylinders were removed due to low compression. The cylinders were reinstalled on the engine with new rings, piston pins, seals, valves and springs. In addition, the wastegate oil fitting o-rings were replaced. Time on the engine, since major overhaul, was listed as 952.0 hours.

On July 1, 2004, a 100-hour inspection was performed, including an oil and filter change, and engine time listed in the logbook was 1,100.0 hours.

PERSONNEL INFORMATION

The pilot held a commercial certificate, with airplane single engine land, and instrument airplane ratings. On his latest FAA second class medical certificate application, dated September 19, 2003, the pilot reported 1,000 hours of total pilot flight time. The pilot's latest logbook was not recovered.

METEOROLOGICAL INFORMATION

Weather, reported at 1154, at Blue Grass Airport (LEX), Lexington, Kentucky, about 25 nautical miles to the northwest, included winds from 030 degrees true, at 11 knots, and overcast skies at 600 feet above the ground. The accident site elevation was about 20 feet higher than the Blue Grass Airport.

WRECKAGE AND IMPACT INFORMATION

The wreckage was located about 1 1/2 nautical miles southwest of Madison County Airport, in an area of rolling hills.

The wreckage came to rest among several trees, and a separated transmission wire was draped over the airplane's left wing and fuselage. The airplane's fuselage, including all cockpit instruments, was mostly consumed by a postimpact fire.

All flight control surfaces were accounted for at the scene. Actuator position correlated to a 5-degree flap setting, and 10-degrees tab down/nose up elevator trim. The main landing gear were up, the nose landing gear was separated from the airframe, and the fuel selector was off.

The engine compartment and propeller were found separated from the fuselage. One of the two propeller blades was bent back, and neither blade exhibited leading edge nicks or chordwise scoring.

The top of engine compartment was streaked with oil. Removal of the cowling revealed a 6-inch diameter hole in the top of the engine, between the number five and number 6 cylinders. The engine was retained for further (teardown) examination.

TESTS AND RESEARCH

On January 12, 2005, an engine disassembly and examination were performed at the manufacturer's facility, under National Transportation Safety Board oversight.

The left side crankcase half (cylinders 2, 4, 6) was breached above the number 6 and number 4 cylinder mounts decks. The internal surfaces of the left side crankcase, in the vicinity of the numbers 4 and 6 cylinder decks, exhibited mechanical damage, with the majority in the vicinity of the number 6 cylinder bay.

The right side crankcase half (cylinders 1, 3, 5) was breached above and forward of the number 5 cylinder mount deck. The internal surfaces of the right side crankcase, in the vicinity of the numbers 3 and 5 cylinder decks, exhibited mechanical damage, with the majority in the vicinity of the number 5 cylinder bay.

There was no evidence of fretting between the crankcase halves, nor of bearing shift or rotation. The crankcase main oil passages were not obstructed.

Oil residue was on the number 4, 5, and 6 bottom spark plugs. All spark plugs exhibited signatures consistent with normal wear.

The oil sump exhibited impact damage, and was breached about 2 inches from the bottom, on the right, forward side. About 1 pint of oil was drained. The oil contained fragments from connecting rods, piston rings, a cylinder skirt, the crankcase and pistons.

The oil suction screen was not restricted. Metallic shavings/particles were found in the folds of the oil filter media.

The number 6 cylinder skirt had connecting rod strike damage at the 12 o'clock and 6 o'clock positions. The piston had to be driven out of the head, which resulted in indentations in the head. The piston skirt was fractured at the oil scraper (wiper) ring, and fragments were found in the oil sump. The piston pin plug exhibited mechanical damage on one end.

The numbers 2 and 3 main bearing journals exhibited thermal discoloration, with the number 3 being the more severe.

The numbers 1, 2, and 3 connecting rods were undamaged, but exhibited thermal discoloration. The numbers 4 and 5 connecting rods were fractured above the yoke, with fragments of the yoke, cap, and related parts exhibiting mechanical damage and thermal discoloration. Both connecting rod I-beams exhibited thermal discoloration and mechanical damage, while the number 5 I-beam was also fractured. The number 6 connecting rod was fractured on both sides of the yoke, but those pieces were missing from the engine. Connecting rod cap fragments were located in the oil sump, and exhibited twisting through the radius.

The numbers 1, 2, and 3 connecting rod bearings lost their free-lengths, and the babbits were smeared, exposing the copper layer; conditions consistent with a lack of sufficient lubrication and subsequent heat distress. The number 3 bearing exhibited the most wear, of an estimated 80 percent of its surface. The numbers 4 and 5 connecting rod bearing fragments were found in the oil sump, and exhibited thermal and mechanical damage. The number 6 connecting rod bearing was found in four pieces, in the sump, with the pieces exhibiting mechanical damage and babbit smearing, including an exposed copper layer.

The crankshaft and counterweight assembly exhibited mechanical damage from the forward set of counterweights to the number 9 short cheek.

The oil transfer tubes were intact and unrestricted. The oil transfer collar and associated crankshaft bearing surfaces were intact, and undamaged, and exhibited signatures consistent with normal operation.

The camshaft exhibited mechanical damage on the forward part of the shaft.

A subsequent Teledyne Continental Motors laboratory examination of the number 6 rod, cap, fasteners, and bearing concluded that all fractures were from overload, that the bearing exhibited signs of rotation, and "no signs of cavitation, oil starvation, thermal distress or hard particle embedment."

On December 20, 2005, a turbocharger disassembly and examination was performed at the manufacturer's facility, under Safety Board oversight. The oil outlet flange was damaged during the teardown process to access a bolt that secured the turbine housing to the bearing housing.

There were no abnormal wear, witness marks, or heat characteristics on any of the housings, although the turbine housing had a patch of a black substance on the outside, adjacent to the bearing housing oil inlet line.

The turbine wheel was turned, but under resistance. The oil feed holes on the back plate of the outboard thrust bearing were clear of obstructions, as were the main oil squirt holes in the bearing housing.

No turbine shaft or piston ring groove anomalies were noted. A "sludge dam" had accumulated at the piston ring groove; however, the oil residue in the groove area was not coked or abrasive.

The cold side of the journal bearing was within service limits and the radial holes were open and clear.

Aluminum material was found on the inside diameter of the radial passages of the journal bearing on the turbine side of the turbocharger.

The inside diameter of the backplate where the thrust spacer was positioned exhibited circumferential track marks.

There were small slivers of metal in the turbine side oil feed and the hot side journal bearing. Subsequent spectral analysis revealed the presence of aluminum and tin, the latter being identified by the engine manufacturer as babbit material.

On June 16, 2006, the TCM Chief Technology Officer provided a submission to the Board. The letter stated, in part, that the engine had external oil lines that provided oil to the turbocharger wastegate (bypass) valve actuator, then returned it to the engine crankcase. The hoses would have been supplied by the airframe manufacturer, and routed per airframe service publications. During a subsequent litigants' examination, the hose assembly was found to have "fretting" that penetrated the hoses.

The hose assembly, consisting of three hoses, was forwarded to the Safety Board Materials Laboratory for further examination. According to the Laboratory's Factual Report, dated March 21, 2007, each hose consisted of a synthetic rubber inner hose, and a reinforced outer layer consisting of steel wire braid. During low pressure air tests, an air leak was detected in one of the three hoses. That line also had wear damage that extended through the steel braid in two locations, at opposite ends of the line. At one of the locations, wear extended completely through the braid. The inner hose had a 1/4-inch diameter hole at the braid wear area that extended partially through the thickness of the hose. A rate of oil leakage was not quantified.

In a letter dated May 11, 2007, the TCM Manager of Product Performance indicated that an oil starvation event would "commonly produce bearing damage signatures of varying degrees to all of the individual connecting rod bearings. In addition, it's not uncommon for the number one and/or number six connecting rod bearings to exhibit little or no damage after an oil starvation event." The manager also noted that the turbocharger utilized engine oil pressure to power "a hydraulically actuated wastegate valve which controls the turbocharger boost pressure (and turbocharger speed.) The wastegate valve diverts exhaust gases to the turbine section of the turbocharger to increase compressor boost pressure...and diverts exhaust gases away from the turbine to reduce boost pressure and turbocharger speed. With a loss of oil pressure, the wastegate actuator goes to an open position, acting to divert exhaust gas away from the turbine."

A Materials Engineering Report, dated June 4, 2007, documented an additional litigants' examination of pertinent materials at McSwain Engineering, Pensacola, Florida, on September 26, 2006. According to the report, an examination of the stainless steel wires around the hole of the affected hose revealed evidence of long-term rubbing. In addition, "x-ray energy spectroscopy of deposits on the abraded wires revealed the presence of aluminum and silicon typical of a cast aluminum alloy as used for the manufacture of the engine mount in the vicinity of the abrasion." The report also noted hose pressure testing in a water bath, with leakage at 25 psi.

In February 2008, the number 6 connecting rod assembly was examined at the Safety Board Materials Laboratory. According to the Factual Report, the assembly included an incomplete connecting rod, a cap (two pieces, which each containing a portion of a connecting rod bolt), two bearings (each containing two pieces), a portion of connecting rod bolt with a nut and cotter pin still attached, a connecting rod bolt (in two pieces) with a nut (in two pieces) and a portion of a cotter pin. Most of the pieces had been subjected to "significant mechanical damage that had obliterated some fracture features."

A more detailed examination of the connecting rod fracture face revealed that it was "relatively intact, and "did not display any deformation at the inner and outer surfaces adjacent to the fracture face." The inner surface exhibited ratchet marks, "slight vertical steps that link slightly offset planes of fatigue cracking at a fatigue origin area," on a relatively flat plane perpendicular to the surface. There were also areas in the fracture face that displayed "a rough grainy surface," oriented on a slant plane, "typical of an overload event."

The outer surface also exhibited ratchet marks in a flat plane perpendicular to the outer surface. In addition, there was an arc between the inner and outer surfaces typical of a final crack arrest position.

Taken jointly, the connecting rod fracture and crack features "are consistent with high stress fatigue initiating at both the inner and outer surfaces…propagating inwards."

The connecting rod cap and both connecting rod bolts exhibited fracture features consistent with overload.

The connecting rod bearing had been subjected to flattening action and mechanical damage, but there were "no indications of significant wear or any overheating."

ADDITIONAL INFORMATION

According to a representative of the pilot's family, he reviewed the pilot's charge slips and maintenance records, "and didn't pick up a pattern of large oil additions." He also provided a copy of a note that appeared to be written by the pilot to his mechanic that included the statement: "oil consumption has not been high."

**This report was modified on February 15, 2008.**