N486DACirrus Design SR20 · 2007

On March 16, 2018, about 1038 eastern daylight time, a Cirrus Design Corp (Cirrus) SR22, N816CD, collided with a Cirrus SR20, N486DA (using call sign Connection 461), while both airplanes were on approach to land at Palatka Municipal – Lt. Kay Larkin Field (28J), Palatka, Florida. There were no injuries to the pilot of the SR22, or to the flight instructor and pilot undergoing instruction in the SR20. Both airplanes were substantially damaged. Both airplanes were being operated under the provisions of Title 14 Code of Federal Regulations Part 91; the SR20 was conducting an instructional flight. Visual meteorological conditions prevailed at the time and no flight plan was filed for either flight. The SR22 flight originated about 0932 from Jacksonville Executive Airport at Craig (CRG), Jacksonville, Florida, while the SR20 flight originated about 0953 from the Orlando Sanford International Airport (SFB), Orlando, Florida.

The pilot of the SR22 stated that after takeoff he proceeded to 28J, and with his radio tuned to the common traffic advisory frequency (CTAF), he heard transmissions from 2 pilots. The transmissions from one pilot were clear, while the transmissions from the other was not. He continued monitoring the CTAF and flew towards 28J, asking how many aircraft were in the traffic pattern at 28J. The pilot whose transmissions were clear announced two, to which he announced he could not understand the transmissions from the other pilot. At that time he believed the flight instructor of the SR20 asked how do you hear me or words to that effect. He reported the transmission from that pilot was low and he had trouble discerning what was said. While he was trying to determine what was said an unknown pilot said, "I hear you." For safety concerns he flew about 26 nm to Northeast Florida Regional Airport (SGJ), where he performed two touch-and-go (T&G) landings, then, thinking it might be safe at 28J, proceeded there.

The pilot of the SR22 further reported making his initial radio call on the 28J CTAF when the flight was 11 to 12 miles away. The flight continued towards 28J and when he was 6 miles away, he made a position report on the 28J CTAF. At that time there were still the same two airplanes in the traffic pattern. The transmissions from one airplane were "crystal clear", and that pilot reported departing the airport traffic pattern. He flew over 28J at 2,000 ft msl, which he announced, and then turned onto downwind leg for runway 27, flying at 1,000 ft and 100 knots. He called downwind, midfield downwind, base, and final, but did not see the other airplane that was in the airport traffic pattern. He performed a touch-and-go landing on runway 27, then decided to do one more before returning to CRG.

The SR22 pilot made radio calls on the CTAF announcing crosswind, and midfield left downwind, maintaining about 1/4 mile abeam the runway on the downwind leg. When he was abeam the numbers on the downwind leg of the airport traffic pattern flying at 100 knots, he watched an airplane roll onto the runway, and once that airplane began the takeoff roll, he started slowing and added the first notch of flaps. He also heard another airplane announce they were on a 6-mile final for the runway. When the SR22 was 45° from the approach end of the runway, he turned onto base leg of the airport traffic pattern at about 900 ft maintaining 90 knots where he lowered another notch of flaps. He then turned onto final of the airport traffic pattern between 500 and 600 ft making radio calls for each of the legs, but he did not see the other airplane in the airport traffic pattern. He set up for landing maintaining 80 knots on final with full flaps extended, the landing and strobe lights on. When over the runway just about ready to begin to flare, he heard a "bang" sound and the nose came up. At that time he attributed the sound to be associated with a catastrophic engine failure. He did not have control over his airplane which veered to the right.

The flight instructor of the SR20 reported that when near 28J he heard runway 27 was in use. They continued to 28J and descended to 2,500 ft msl. When the flight was 10 miles from 28J, he made his first radio call announcing their position, and intention. The flight continued and he made another radio call when the flight was 7.5 miles from 28J. At the second radio call the pilot of one aircraft announced that he could not hear him well. He switched the radio to comm 2 and made another radio call. A pilot who was on the ground reported that he could hear them loud and clear. He then switched to comm 1 and the radios were working OK. Their flight continued towards 28J, and he announced on the 28J CTAF that they were coming from the south, and would be entering left downwind at a 45° for runway 27. They joined the left downwind for runway 27, and turned base and final making radio calls on the 28J CTAF for each leg of the airport traffic pattern. He announced they would be performing touch-and-go landings and would be remaining in the airport traffic pattern. The PUI completed two landings, and remained in the traffic pattern while the flight instructor announced on the 28J CTAF every call of the airport traffic pattern. While on the downwind leg for the third landing, they heard a pilot announce that they were on a 6-mile final for runway 27. That pilot announced that he was advise when he was near the lake. Because of an airplane that was on short final approach which they had in sight, he elected to have the PUI extend the downwind leg. When they were abeam the airplane that was on final, they turned onto the base leg, which he announced on the CTAF. The PUI then turned onto final, which he announced, and he also announced when the flight was on short final. At that time, he also announced that this would be their last landing, and they would be departing to the northeast. When the PUI was just about to flare, he heard an explosion. Their airplane drifted to the right and stopped.

The flight instructor of the SR20 further reported after coming to rest, he saw a propeller, secured the engine, and turned everything off, but he did not touch the radios, adding that he does not recall how the radios were configured. He believed he would have secured the electrical system before getting out of the airplane, and once out of it never returned to it. He estimated their flight was at 28J for about 20 minutes when the collision occurred.

The four seat, low-wing Cirrus SR22 airplane, serial number 0150, was manufactured in 2002. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430 transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. The pilot was not recording audio transmissions, but reported he was wearing a Bose headset and was communicating on the common traffic advisory frequency (CTAF) using the comm 1 radio.

The pilot of the SR22 reported that since becoming a co-owner of the airplane in September 2017, there had not been any work done to the airplane's radios.

The four-seat, low-wing Cirrus SR20 airplane, serial number 20-1831, was manufactured in 2007. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430W transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. None of the occupants were recording audio transmissions. At the time of the collision, the strobes, navigation and landing lights were on.

According to the operator of the SR20, a review of the discrepancy sheets for the period December 1, 2017, through the last discrepancy dated March 14, 2018, revealed no radio-related discrepancies during in that period of time.

The four seat, low-wing Cirrus SR22 airplane, serial number 0150, was manufactured in 2002. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430 transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. The pilot was not recording audio transmissions, but reported he was wearing a Bose headset and was communicating on the common traffic advisory frequency (CTAF) using the comm 1 radio.

The pilot of the SR22 reported that since becoming a co-owner of the airplane in September 2017, there had not been any work done to the airplane's radios.

The four-seat, low-wing Cirrus SR20 airplane, serial number 20-1831, was manufactured in 2007. It was equipped with a Garmin GMA 340 audio select panel and two Garmin GNS 430W transceivers. It was not equipped with traffic collision avoidance system (TCAS) or ADS-B. None of the occupants were recording audio transmissions. At the time of the collision, the strobes, navigation and landing lights were on.

According to the operator of the SR20, a review of the discrepancy sheets for the period December 1, 2017, through the last discrepancy dated March 14, 2018, revealed no radio-related discrepancies during in that period of time.

Postaccident examination of the SR20 revealed the comm 1 antenna, which was mounted on the centerline of the roof, just behind the doors, was missing. That area sustained significant impact-related damage consistent with contact by the propeller from the SR22. The comm 1 and 2 antennas from the SR22 were not damaged.

Both airplanes were powered and the selected radio frequencies and audio select panel were documented. The SR20 comm 1 transceiver was tuned to 122.80 MHz and the comm 2 transceiver was tuned to 122.80 MHz. The comm 1 and 3 radio selector switches were selected to listen on the audio select panel, and comm 3 "MIC" was selected to transmit on the audio select panel. The SR22 comm 1 transceiver was tuned to 122.80MHz and the comm 2 transceiver was tuned to 119.62 MHz. The comm 1 was selected to listen on the audio select panel, and comm 1 "MIC" was selected to transmit on the audio select panel.

Ground testing of the radios installed in the SR20 revealed comm 1 radio was unreadable and comm 2 radio was readable. The positions of the radios were swapped and the previously readable comm 2 radio became unreadable while the comm 1 radio was readable. Detailed examination of both transceivers revealed that they were within the manufacturer's specifications. Functional checks of all comm and MIC audio inputs of the audio select panel revealed that they were also within the manufacturer's specifications.

Ground testing of the radios of the SR22 found both operational in transmit and receive mode.

Review of Audio Recorded from Other Airports

Review of FAA certified audio recordings from the departure airports for both aircraft, and also SGJ for the SR22 revealed that with respect to the transmissions from the pilot of the SR22, the beginning of one transmission was not clearly enunciated, while several portions of transmissions from both pilots of the SR20 were difficult to discern and/or were poorly enunciated. There was no mention by any air traffic control facility for either flight about any issue with either airplane's radios.

Exemplar Audio Panel Configuration

Testing of an exemplar airplane operated by L3 Commercial Training Solutions revealed that with the audio select panel configured exactly like it had for the SR20 (MIC 3 selected to transmit), with any comm 1 or comm 2 selected to receive, neither radio would transmit when the push-to-talk switch was pressed. Testing also revealed that when electrical power was removed from the airplane, pushing of the buttons on the audio select panel would not change the setting when the audio select panel was powered up again.

Pilots' Postaccident Interactions

The pilot of the SR22 stated that postaccident, he and both pilots of the SR20 interacted, and during that interaction he relayed to the flight instructor that he never saw him and could not understand his calls. The flight instructor indicated, "I made this call, I made the call" referring to position reports on the CTAF. He asked the flight instructor if he heard him and his position report calls to which the flight instructor of the SR20 said yes. The flight instructor was asked why didn't he say something on the CTAF due to the traffic conflict, and his reply was, "I was just wondering why you were on top of us."

The flight instructor of the SR20 reported that after exiting the airplane, he and the pilot of the SR22 talked. During that conversation he was able to confirm that the SR22 pilot was the person who broadcast on the 28J CTAF that he could not hear the SR20's transmissions. He also indicated that after the SR22 pilot had said he could not hear them well, he never heard any more radio calls from him. The pilot of the SR22 indicated to the flight instructor of the SR20 that he never saw their airplane and asked him if he could hear his radio calls. He informed the SR22 pilot that he never heard his radio calls.

Arrival and Departure Time Estimates

Based on departure times, cruise speeds, and distances between departure airports, it is estimated that the SR22 arrived at 28J about 0947, departed about 0954, arrived at SGJ about 1009, departed there about 1017, and arrived at 28J about 1032. The SR20 arrived at 28J about 1017.

On December 3, 2011, at 2151, eastern standard time, a Cirrus Design Corp. SR20, N486DA, registered to Boston Aviation Leasing II LLC and operated by Aerosim Flight Academy, conducted a forced landing to an interstate highway near Jacksonville, Florida, following a total loss of engine power. The airplane was undamaged and the flight instructor and student were not injured. Night visual meteorological conditions prevailed and the flight was on an instrument flight rule (IFR) flight plan for the Title 14 Code of Federal Regulations Part 91, instructional flight. The flight last departed from Orlando Sanford International Airport (SFB), Sanford, Florida, about 2030.

In a written statement, the instructor said that he and his student were on an IFR cross-country flight. They departed the Jacksonville Executive Airport at Craig (CRG), Jacksonville, Florida around 1500, and made 2 stops.

On the last leg of the flight while descending from 3,000 feet to 2,000 feet, approximately 12.3 nautical miles from CRG, the engine "coughed". This event did not seem abnormal to the flight crew but seconds later the engine "coughed" again followed by a "bang", engine vibration, and a decrease in engine revolutions per minute (RPM) to 1,800. The instructor advised Jacksonville approach control that the airplane had experienced a partial loss of engine power and the controller provided distances to CRG and Naval Air Station Jacksonville (NIP). The instructor advised Jacksonville approach that the airplane could not reach either airport and he elected to perform a forced landing to an interstate highway. During the descent, the airplane experienced a total loss of engine power, and the instructor maneuvered the airplane under and around bridges and signs to complete the landing.

The instructor held a commercial pilot certificate with ratings for airplane single engine land, airplane multiengine land and instrument airplane as well as a flight instructor certificate with ratings for airplane single engine, multi-engine, and instrument airplane. His most recent Federal Aviation Administration (FAA) second class medical certificate was issued on May 1, 2008. FAA data indicted the instructor had acquired 829 total flight hours as of December 3, 2011. The instructor's last regulatory check ride prior to this incident occurred on August 23, 2011. The instructor provided a written statement but an NTSB Form 6120.1 Pilot/Operator Aircraft Accident/Incident Report was not generated for this event.

The accident airplane was manufactured in 2007 and was equipped with a Continental Motors IO-360-ES reciprocating engine which was rated to produce 210 horsepower. The airplane's most recent 100 hour inspection was completed on October 27, 2011. At that time the airframe had accumulated 3788.5 hours since new. The factory rebuilt engine was installed on the airframe on July 22, 2009 when total accumulated airframe time was 2177 hours. Since that time the engine had accumulated 1652 hours.

The weather conditions reported at CRG at 2153 located 10 nautical miles south of the off airport landing included wind from 030 degrees at 6 knots, visibility 9 statute miles with clear skies. The temperature was 17 degrees C, dew point 15 degrees C, and the altimeter setting was 30.37 inches of mercury.

The accident airplane was manufactured in 2007 and was equipped with a Continental Motors IO-360-ES reciprocating engine which was rated to produce 210 horsepower. The airplane's most recent 100 hour inspection was completed on October 27, 2011. At that time the airframe had accumulated 3788.5 hours since new. The factory rebuilt engine was installed on the airframe on July 22, 2009 when total accumulated airframe time was 2177 hours. Since that time the engine had accumulated 1652 hours.

The airplane was not damaged during the off airport landing. Despite several attempts following the accident, the operator was unable to restart the airplane's engine.

The engine was subsequently removed from the airplane and returned to the manufacturer for evaluation. It was shipped as removed with no disassembly other than required for removal. The manufacturer conducted an engine teardown overseen by an NTSB investigator.

An engine examination was completed by the manufacturer who provided a detailed report. The manufacturers report summarized that the engine revealed the crankshaft gear was mechanically damaged and that missing gear teeth and damaged teeth were contained in the engine oil sump. The camshaft gear was damaged and the teeth were worn away. The crankshaft gear with bolts, camshaft gear with bolts, oil pump drive gear and driveshaft, and oil sump debris were sent to the NTSB materials laboratory in Washington DC for further inspection and analysis.

The NTSB materials laboratory staff examined the crankshaft gears with bolts, the camshaft gear with bolts, the oil pump drive gear and driveshaft and the oil sump debris and concluded that the engine failure was a result of fatigue failure of a tooth on the crankshaft gear that led to failure of multiple teeth on the camshaft timing gear and subsequent loss of correct valve timing in the engine. No obvious defects were visually apparent on the failed gear. The fracture appeared typical of tooth bending from normal gear tooth meshing. Damage to the oil pump drive gear was secondary as a result of ingestion of gear teeth pieces from the crank and cam gears. Metallurgical properties of the crankshaft gear were not evaluated.

The engine, s/n1000738 IO360ES, was installed in the airframe as a rebuilt engine on July 22, 2009. Total time on the airframe at the time of this engine installation was 2177.7 hours. Total time on the airframe at the time of the incident on December 3, 2011 was 3830 hours. Total engine time at time of failure was 1652.3 hours.

According to the manufacturer the crankshaft gear would be inspected during an engine overhaul that normally occurs at the 2000 hour time between overhaul (TBO), and longer under certain circumstances on the IO360ES engine. The manufacturer was familiar with gear tooth failures on other models of Continental engines but not with this type of tooth failure on the IO360ES.