Accident Details
Probable Cause and Findings
A loss of engine power due to a malfunction of the turbocharging system likely due to contaminated oil. Also causal were the pilot's decision to continue the takeoff although the airplane was not performing normally and his failure to maintain adequate airspeed following the loss of engine power, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Contributing to the accident was the engine manufacturer's inadequate guidance regarding inspection and maintenance of its turbocharged engines.
Aircraft Information
Registered Owner (Historical)
Analysis
HISTORY OF FLIGHTOn August 15, 2015, at 1002 eastern daylight time, a Cessna T206H, N63TV, impacted trees and terrain after a loss of engine power during initial climb at Essex County Airport (CDW), Caldwell, New Jersey. The commercial pilot was fatally injured, and the airplane was destroyed. The airplane was registered to Stalactite, LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the positioning flight, destined for Teterboro Airport (TEB), Teterboro, New Jersey.
According to a friend of the pilot, the pilot planned to fly to TEB, pick up the owner of the airplane and fly with him to South Hampton, where the owner had a residence. The friend owned a Cessna 182 and was interested in purchasing a Cessna 206 like the one the pilot was flying, so the pilot invited him to come to CDW before the flight and see the airplane.
The friend arrived at the airport about 0930 and noticed that the pilot had already completed the preflight inspection of the airplane. The pilot appeared to be "fine, his usual self, and doing good that morning," The pilot's friend was in the fixed base operator's (FBO) lobby when he heard the airplane's engine start. The airplane stayed on the ramp for a few minutes and then taxied out. About 10 minutes later, the pilot's friend saw the airplane as it passed by a window in the FBO. The airplane seemed quieter than it should have to him, and he thought that it did not seem to be moving very fast. About 10 minutes later, a line service agent entered the FBO and said that there had been an airplane accident.
According to information provided by the Federal Aviation Administration (FAA), the pilot contacted the CDW air traffic control tower, requested to taxi, and advised the controller that he had the current weather that was being transmitted by CDW's automatic terminal information service. The controller subsequently instructed the pilot to taxi to runway 22 and to hold short of the runway at intersection "November," which was normally used for airplanes departing on runway 22. The airplane taxied to the designated location and remained there for about 5 minutes. According to FAA inspectors, during the time that the airplane remained stationary, a student pilot heard the airplane's engine go from near idle to full power about five times and reported that the engine did not "sound right."
The air traffic controller cleared the pilot for takeoff with a left turnout. Shortly after becoming airborne, the pilot advised that he had a "problem," declared an emergency, and requested to "return to the field immediately." The controller cleared the pilot to land on any runway, and the pilot reported that he was unable to maintain engine power. There were no other communications from the pilot.
Review of security camera video revealed that, during the takeoff, the airplane appeared to accelerate slowly and rotated about 1,800 ft. after the pilot initiated the takeoff roll." Once airborne, the airplane began to pitch slightly up and down while remaining in ground effect and then slowly climbed. The airplane momentarily reached an altitude that was just above the trees that surrounded the airport, then began to lose altitude, and turned left about 90°. The airplane disappeared from view of the camera, and a smoke cloud then rose from behind a tree line.
According to witnesses who saw the airplane just before impact, the airplane was at the same height as the trees and appeared to be gliding toward the ground. One witness stated that the airplane appeared to be "in slow motion;" it then banked sharply to the left and pitched steeply down. Another witness reported that the airplane made "a hard-left turn, went into a nose dive, and exploded when it hit the ground." Three additional witnesses reported similar observations. The witnesses heard no noise coming from the airplane before the impact. PERSONNEL INFORMATIONAccording to FAA and pilot records, the pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane, a flight instructor certificate with a rating for airplane single-engine, and a ground instructor certificate with an advanced ground instructor rating. His most recent FAA third-class medical certificate was issued on March 30, 2015. He had accrued about 1,941 total hours of flight experience, 16 hours of which were in the accident airplane make and model. AIRCRAFT INFORMATIONThe airplane was a 6-place, single-engine, high-wing monoplane of conventional metal construction. It was equipped with fixed-tricycle-type landing gear and was powered by a turbocharged, 310-horsepower, Lycoming TIO-540-AJ1A engine, driving a three-blade, McCauley, controllable pitch propeller.
According to FAA and maintenance records, the airplane was manufactured in 2009. Its most recent annual inspection was completed on April 17, 2015. At the time of the inspection, the airplane and engine had accrued 1,155.4 total hours of operation.
According to the maintenance provider who had maintained the airplane since December 2011, anything that bothered the owner about the airplane would get fixed. Most of the items that were addressed by the maintenance provider were cosmetic or routine maintenance, such as oil and filter changes, gauges, starter replacement, lights, accessories, battery replacement, and compliance with airworthiness directives and service bulletins. The maintenance provider reported that the owner's landings could be a little rough, so they had also replaced some tires as he had experienced a few flat tires, and, as a result, the owner would keep a spare set in the airplane in case he blew a tire on landing.
Review of maintenance records revealed that the airplane's engine had been receiving regular oil changes since new as well as spectrometric oil analysis. Review of oil analysis reports provided by the maintenance repair organization indicated that a sample of the engine's oil that was taken on March 5, 2012, contained elevated levels of iron, nickel and chromium. Another sample taken on December 19, 2013, contained elevated levels of aluminum, chromium, iron, and nickel. In a report dated March 9, 2015, the laboratory commented about an oil sample that had been taken on March 4, 2015, stating that:
"These numbers are a lot easier to take than the high aluminum, chrome, iron, and nickel we saw last time. The shorter oil run obviously helped, but most of the metals are lower on a ppm/hour basis too, meaning that the engine really did wear better. If anything, nickel could still stand to be lower. 13 ppm is almost high enough to get a mark, so that's one we'll be monitoring next time. There's a trace of fuel to report this time, but that's not anything to worry about. It's likely just from normal use. Much better at 1,151.6 hours S[ince ]New."
In a report dated August 12, 2015, for an oil sample that was taken on August 4, 2015 (11 days before the accident), the laboratory commented that:
"Steady as she goes for this sample out of N63TV. If we're being picky you could say that iron should have come down as a result of the shorter oil run, but 39 ppm isn't bad at all for one of these engines after 20 hours on the oil. Everything else is in good shape, so we'd be surprised if the extra iron on a per-hour basis turned out to be an issue. No problems with the oil itself were found, making for a very nice report overall."
Maintenance records indicated that two repairs requiring replacement of major components of the engine had been accomplished. The first repair followed a report from the owner that the engine was experiencing high oil consumption. According to a maintenance entry dated January 21, 2013, and the associated work order, this resulted in the maintenance provider inspecting for the cause of the oil leaks by first washing down the engine, and then after a test flight, tightening loose rocker box return line coupling clamps, replacing a cracked air/oil separator, replacing leaking oil dipstick gaskets, and replacing a leaking fitting on the turbocharger wastegate actuator. During this inspection and maintenance action, maintenance personnel noticed oil on the inlet scroll of the turbocharger and oil on the belly of the airplane, so they replaced the turbocharger "due to oil leaking past shaft seal intake system."
The second repair occurred about 4 months later, when the owner again reported high oil consumption. According to a maintenance entry dated May 22, 2013, and the associated work order, this resulted in the maintenance provider checking the compressions and borescoping the cylinders.
During this inspection and maintenance action, maintenance personnel found pooled oil in the Nos.3, 5, and 6 cylinders. Per guidance from a Lycoming representative, they attached an airspeed indicator to a modified oil dipstick cap and then ran the engine. No excessive crankcase pressure was found. Next, they ran the engine to get the temperature up and shut down the engine at 1,300 rpm. Then they borescoped the cylinders again and found that all of the pistons were damp, all of the spark plugs were dry, and there was pooled oil in the Nos. 3, 5, and 6 cylinders. After these tests, maintenance personnel removed the Nos. 3, 5, and 6 cylinders and found the oil control rings stuck in the pistons. They installed new Nos. 3, 5, and 6, cylinder assemblies.
The maintenance records did not indicate that the check valve on the turbocharger oil supply line was cleaned or replaced following either of these engine repairs.
Turbocharger System Information
The airplane was equipped with a turbocharging system manufactured by Hartzell Engine Technologies (HET) that forced air into the engine's combustion chamber, allowing the engine to maintain sea-level manifold pressure as altitude increased. The turbocharging system consisted of a tur...
Data Source
Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA15FA312