N561TUCostruzioni Aeronautiche Tecna P92 EAGLET · 2017

On July 15, 2017, about 1615 eastern daylight time, a Costruzioni Aeronautiche Tecnam P92 airplane, N561TU, was substantially damaged when it was involved in an accident near Stevensville, Maryland. The two private pilots were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The airplane had recently been purchased by the owner and placed on a lease-back operation with the operator. Two days before the accident, the owner, along with the pilot who was in the right seat during the accident flight, took delivery of the airplane in Apopka, Florida, and flew it to Bay Bridge Airport (W29), Stevensville, Maryland.

On the day of the accident, the airplane was fueled to about 16 gallons (8 gallons per side) for a roundtrip flight to Shoestring Aviation Airfield (OP2), Stewartstown, Pennsylvania.

Before departing on the return flight, the left seat pilot checked the oil, coolant, and fuel. The oil and coolant levels were normal, and the airplane contained about 12 gallons of fuel. Upon arrival in the area of W29, the pilots obtained the current conditions from the automated weather observation and entered the traffic pattern for runway 29 on the crosswind leg. They observed no other traffic in the pattern at the time, and due to noise-abatement rules, they conducted the runway 29 downwind leg about 2 miles south of the airport.

The left seat pilot, who was flying the airplane, reduced engine power and began to configure the airplane for landing abeam "the 29 numbers." Several seconds after the power reduction, the engine abruptly started to run rough. At this time, the right seat pilot took the controls. Both pilots scanned the engine indications but did not observe any anomalous readings. The right seat pilot turned onto the base leg of the traffic pattern, but did not turn directly toward the runway out of concern for arriving too high at the threshold and a flightpath that would have resulted in overflight of a densely-populated townhouse community. The pilots increased the flaps setting to correct for the high glidepath, and about 20 seconds later, the engine abruptly stopped.

The right seat pilot turned directly toward the runway threshold, and both pilots determined that the airplane would not reach the runway. After considering their forced landing options, the right seat pilot turned the airplane toward a cleared but rough area of open ground about 45° left of their flightpath. The airplane "firmly" glanced off the top of an earthen berm and settled onto the rough ground beyond it. During the landing roll, about 150 ft from the touchdown point, the airplane struck a second berm, the right main landing gear and nose gear separated from their mounting points, and the airplane came to rest about 20 to 30 ft beyond the second berm. The pilots shut off both fuel valves and the master switch and then egressed.

The airplane was equipped with a Garmin G3X electronic flight instrument system (EFIS), which provided full primary flight display attitude and directional guidance along with electronic engine information. Review of data downloaded from the G3X indicated that fuel pressure, cylinder head temperature, and oil temperature all remained relatively steady until the loss of power occurred.

On September 9, 2017 and April 12, 2018, the airplane and engine were examined by the NTSB.

The airframe was substantially damaged. During the impact sequence, the nose landing gear separated from its mounting location, the right main landing gear bent back and toward the left main landing gear, and the left main landing gear was damaged. One blade of the two-bladed propeller was broken off, the engine had been pushed back toward the firewall, the engine mounts were bent, the firewall was buckled, and the fuselage and wings displayed multiple areas of crush and compression damage.

External examination of the engine revealed that the air filter was clean and the exhaust system was damaged, but no anomalies were noted. The cooling system was intact. The oil line between the oil cooler and oil thermostat was kinked during the impact sequence, and the Nos. 2/4 (left side) carburetor had been displaced from its intake socket. The propeller gearbox rotated smoothly with no binding noted.

The sparkplug electrodes appeared normal and the spark plug gaps were all 0.19 inches. Both the Nos. 2/4 (left side) and Nos. 1/3 (right side) carburetor float bowls contained automotive gasoline. No anomalies were noted with the carburetors. Both the mechanical and electric fuel pump were functional.

No oil was found in the oil line between the oil thermostat and oil pump. The oil pump drive pin displayed excessive wear in relation to the operating hours of the engine. The oil cooler appeared to be undamaged. The magnetic plug was covered in metallic particles. The oil filter was clean.

Cylinder No. 1 displayed substantial damage and evidence of bluing was present. The exhaust valve spring retainer was fractured in half, and one half of the cotter was fractured. A small ridge could be felt on the exhaust valve spring retainer, and galling (a rough surface) was visible on the exhaust valve bore in the cylinder head. The hydraulic lifter (tappet) for the exhaust valve displayed a small indentation on the edge of the lifter, and when the hydraulic lifters were manually depressed, the lifter for the exhaust valve was easier to depress than the lifter for the intake valve. The pushrod for the exhaust valve was straight, but displayed a ridge on the rocker arm side of the pushrod, and the rocker arm displayed impact damage on the valve connection face. The exhaust valve was found in the combustion chamber. It was chipped, and bent, and deformed into an “S” shape. A hole was visible in the piston. No unusual marks were seen on the intake valve rocker arm, valve keeper retainer, valve or valve stem, or valve keepers. Cylinder Nos. 2, 3, and 4 did not display any anomalies. The crankshaft was twisted and would not rotate within the crankcase; the camshaft displayed no visible anomalies.

The internal configurations of the oil system thermostat and associated oil system hoses were documented using radiographic images, and there were no indications of blockages, broken components, or hose breaches.

On November 13, 2018 in the presence of the Austrian Federal Safety Investigation Authority (BMK), the No. 1 cylinder head assembly, cylinder, oil pump assembly, oil tank assembly, and oil cooler were examined at Rotax Aircraft Engines in Gunskirchen, Austria.

Examination of the fractured surface on the valve spring retainer by electron microscope revealed the presence of fatigue with pronounced vibration stripes. The heat treatment, however, corresponded to the target specifications, as did the statistical process control value.

Examination of the cylinder head revealed that the shim from the intake valve and exhaust valve showed unusual wear on the spring contact surface, indicative of increased spring movement. A hardness test of the shim indicated that it corresponded to the drawing specifications. No deviation from the drawing specifications was discovered.

Examination of both hydraulic valve tappets revealed that the oil control plates showed noticeable wear. Examination of the oil pump showed no indication of malfunction. The housing, suction inner and outer rotor showed no abnormalities. Examination of the oil tank showed no abnormalities. No indication of a malfunction was visible. Examination of the oil cooler did not reveal any abnormalities and a leak check revealed no indication of a leak or visible malfunction.

A small amount of oil from the hydraulic tappets was captured and sent to an independent laboratory for analysis.

According to the analysis report:

The lead content in this sample is an indication of the usage of leaded fuel. Nickel is significantly elevated. Could come from manganese-containing alloys, as they occur in high-alloy hardened steels, e.g. for camshafts, valves, or valve shafts. Because of the very low sample volume, we could not undertake all requested tests. The determined additive elements fit well to the requested type of oil. However, molybdenum and barium are unusual for this. Silicon is increased which is mostly an indicator for dust. Sometimes it can also be the result of non-abrasive silicone-containing materials such as assembly aids, silicone-based greases or flexible seals.

Additional Valve Spring Retainer Fractures

In 2019 and 2020, another four valve spring retainer fractures occurred in the United States involving the following aircraft: N1PJ, N204BF (NTSB Case No. WPR20LA012), N117BF, and N562TU (NTSB Case No. ERA20LA341).

Examinations of the damaged engines revealed:

o S/N 4421750 (N1PJ), intake valve failure, broken valve spring retainer cylinder No. 2

o S/N 9569290 (N204BF), intake valve failure, broken valve spring retainer, cylinder No. 2

o S/N 9569271 (N117BF), intake valve failure, broken valve spring retainer, cylinder No. 2

o S/N 9569181 (N562TU), exhaust valve failure, broken valve spring retainer, cylinder No. 1

All the engines had differing hours of operation; however, all experienced a valve spring retainer failure during engine operation. At the request of the NTSB, numerous components from the four engines were shipped by Rotech Flight Safety to the Austrian Federal Safety Investigations Authority (BMK) for examination and testing at the engine manufacturer’s factory in Gunskirchen, Austria. Extensive metallurgical examination of the intake and exhaust valves, valve spring retainers, valve springs, valve tappets, pushrod assemblies, pistons, cylinder heads, valve cotters, and camshafts was conducted. The results of the examinations were similar to those from the examination of the engine components from this accident. All the parts met their specifications, and the fractured surfaces on the exhaust valve spring retainers revealed the presence of fatigue with pronounced vibration stripes.

Review of Published Guidance

Review of Rotax 900 series operators’ manuals indicated that the dry sump lubrication system would provide sufficient lubrication up to a maximum bank angle of 40°. The engines were also limited to a maximum of 5 seconds of operation at -0.5 G.

A limited review revealed that about 463 aircraft models used Rotax 900 series engines. These included plans-built aircraft, kit aircraft, and certificated manufactured aircraft. Review of published guidance materials from some of these manufacturers revealed that the Rotax engine bank angle G limitations were not published in the flight manuals or pilot’s operating handbooks, and in many cases, the maximum published bank angle limitation for the aircraft was 60°, which exceeded the Rotax published limitation.

Rotax 912 Heavy Maintenance Manual 72-00-00, Edition 1, Revision 4, page 69, stated that wear of “the valve spring support [shim] can indicate a malfunction of the valve train as a result of badly or insufficiently vented hydraulic valve tappets.”

Review of Rotax Service Instruction SI-916 i B-003 / SI-915 i-003R1 / SI-912 i-004R2 / SI-912-018R3 / SI-914-020R3, issued on November 4, 2020, revealed that it provided instructions on purging of lubrication systems for Rotax 900 series engines. The reason listed for the service instructions was:

Rotax was informed of a limited number of engine failures in the field resulting from a lack of proper oil purging after the engine had been first installed and /or the engine had been re-worked. This Service Instruction should help to make sure that the engines do not suffer such engine failure in the field. As air can be trapped in the valve tappets and cause valve train failure it is very important to complete these instructions in their entirety.

The compliance section of the service instructions stated, in part:

These inspections have to be performed

-before first engine run,

-after re-installation (e.g. after overhaul),

-after lubrication system opened and drained during maintenance work (e.g. removal of oil pump, oil cooler or suction line).

NOTE: Not affected are the removal and replacement of components that do not drain the oil pressure galleries.

WARNING: Non-compliance with these instructions could result in engine damages, personal injuries or death.

Review of Rotax Service Bulletin SB-912 i-008 R1 / SB-912-070 R1 / SB-914-052 R1, issued on October 12, 2017, revealed that in section 3.1.3, the second step of the procedure instructed the person performing the work to “turn crankshaft so that the respective piston is exactly on ignition top dead center,” but the direction of rotation of the crankshaft was not defined or specified.

Rotax Service Instruction SI-04-1997 R3, issued on September 2002, (cancelled and superseded by SI-912-018 / SI-914-020, issued on January 23, 2017), stated that the following as the reason it was published:

ROTAX was informed of a limited number of engine failures in the field resulting to a lack of proper oil venting after the engine had been first installed, after the engine had been reworked and/or have had the prop spun in reverse direction allowing air to be ingested into the valve train. This Service Instruction should help to make sure that the engines do not suffer such engine failures in the field.

The compliance section of SI-04-1997-R3 stated:

These inspections have to be performed

- before first engine run,

- after re-installation (e.g., after overhaul),

- after lubrication system opened or drained during maintenance work (e.g., removal of oil pump, oil cooler or suction line) or

- after unintentional turning of engine in the wrong direction of rotation.

The Rotax 912 Operators Manual, Edition 4 /Rev. 0, Page 3-5, November 01/2016, stated:

Propeller shouldn't be turned excessively reverse

the normal direction of engine rotation.

Remove bayonet cap, turn the propeller slowly by hand

in direction of engine rotation several times to pump oil

from the engine into the oil tank.

The Rotax 912 Operators Manual did not refer to a purging of the oil system as was described in Service Instruction SI-916 i B-003/ SI-915 i-003R1/ SI-912 i-004R2/ SI-912-018R3/ SI-914- 020R3.

In summary, review of the published guidance documents indicated that air could possibly enter the oil system in the following ways and lead to valve train failure:

1. By exceeding the maximum bank angle of 40°

2. By poorly or insufficiently vented hydraulic valve tappets

3. By lack of proper oil system purging

4. By spinning the propeller in the reverse direction from normal rotation

5. By opening portions of the oil system during maintenance or servicing.

Engine Test Run

As a result of the review of published guidance, during the examinations that occurred at BRP Rotax, a Rotax 914 engine was test run to determine how long it would take for intentionally trapped air to vent from the hydraulic valve tappets. During this test run, it took about 6.5 minutes at 2,538 rpm for the trapped air to vent and all hydraulic tappets to work as designed.