N562TU is a 2017 Costruzioni Aeronautiche Tecna P92 EAGLET. It is a fixed-wing single-engine aircraft with 2 seats, powered by a Rotax 912UL2 rated at 80 horsepower. The registration is active, with the registrant based in Annapolis, MD. Its light-sport airworthiness certificate was issued in Jul 2017. It has been registered to its current owner since Oct 2017. This page also carries 2 NTSB events.
2017
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The flight instructor reported that his student began the transition to flare on a normal, full stop landing. During the flare, the airplane’s nose yawed to the left. The instructor added right rudder to correct; however, the left wing pitched up. The instructor attempted to correct by applying left aileron to level the wings. He encountered resistance from the student’s flight control inputs, and the airplane touched down on the right main gear, putting a side load on it. The instructor announced that he had taken control of the airplane and initiated a go-around. The pitch trim was set to full nose up, and the instructor could not reduce the trim forces since the trim switch was set to the student’s side. The airplane pitched up and out of ground effect, and the right wing stalled and struck the ground, resulting in the nose and left wing also striking the ground. There were no injuries. An inspector with the Federal Aviation Administration examined the wreckage and determined that the damage to the fuselage and both wings was substantial. The flight instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation.
On September 28, 2020, about 1800 eastern daylight time, a Tecnam P92 airplane, N562TU, was substantially damaged when it was involved in an accident near Centerville, Maryland. The flight instructor and student pilot were not injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight.
The airplane was being operated by Chesapeake Sport Pilot, a 14 CFR Part 91 flight school based at Bay Bridge Airport (W29), Stevensville, Maryland. According to the flight instructor, he and a student pilot were returning to W29 when the airplane suddenly began to vibrate severely. This was followed by a reduction in engine rpm from about 5,100 rpm to 4,500 rpm. Review of onboard recorded data indicated that the fuel pressure, cylinder head temperature, and oil temperature remained relatively steady until the loss of power occurred.
The flight instructor took over the flight controls from the student pilot and manipulated the throttle control to see if a different power setting would reduce the vibrations. Movement of the throttle control did not elicit a corresponding response from the engine. The flight instructor then ensured that the fuel valves were all on and turned on the electric fuel pump. There were no changes to the vibrations or power.
Assessing the situation as an impending engine failure, the flight instructor configured the airplane for best glide speed, turned towards the nearest field for a potential forced landing, and made a “Mayday” transmission. About 1 minute later, the engine lost total power. He attempted to restart the engine, but the engine would not crank when the starter was engaged, and all the avionics in the airplane shutdown. About 30 seconds later, all the displays came back on, and the flight instructor configured the airplane for landing and touched down uneventfully in the soybean field he had selected.
As the airplane slowed, the airplane’s nose dropped to the ground, and the nose landing gear dug into the soft earth. The nose landing gear separated, and the airplane nosed over.
The strut-braced, high-wing, two-seat, airplane was made of sheet and tubular aluminum. The design complied with Federation Aeronautique Internationale microlight rules and Federal Aviation Administration (FAA) light sport aircraft rules.
It was equipped with an American Society for Testing and Materials compliant, 4-cylinder, horizontally-opposed, 100-horsepower, Rotax 912 ULS 2 engine. The engine used a single central camshaft with hydraulic tappets. The cylinder heads were liquid cooled, and the cylinders were ram air cooled. The oil system was a dry sump, forced lubrication system. The engine used a reduction gearbox to drive the two-bladed, fixed-pitch Sensenich propeller.
According to FAA and airplane maintenance records, the airplane was manufactured in 2017. The airplane's most recent condition inspection was completed on March 3, 2020. At the time of the inspection, the airplane had accrued about 1,081 hours of operation, and the engine had accrued about 734 hours of operation.
The airplane was not equipped with a flight data recorder nor was it required to be under CFR Part 91. It was equipped with two Garmin G3X flight displays that recorded historical information at a variable rate of about 10 Hertz to internal non-volatile memory.
Review of the data revealed a noticeable gap in the data toward the end of the flight. This was indicative of the power interruption to the displays as described by the flight instructor and resulted in the displays writing the remaining flight data to a separate file. This process resulted in a gap in the recorded data.
Postaccident examination revealed that the airplane had sustained substantial damage to the fuselage and both wings.
Examination of the engine, serial number (S/N) 9569181, revealed that there were no anomalies with the oil system and that there was oil throughout the engine. Aluminum debris and engine oil were found in the carburetor for Nos. 1 and 3 cylinders.
The No. 1 cylinder’s exhaust valve spring retainer was broken, and the exhaust valve had fallen into the cylinder’s combustion chamber. A buildup of metallic material was found in the No. 1 intake manifold. The stem of the No. 1 exhaust valve was in place; however, the head of the exhaust valve was no longer attached.
After removal of the No. 1 cylinder head, damage to the cylinder head, piston, and valves was discovered. The No. 1 exhaust valve head was found imbedded in the No. 1 intake valve. The No. 1 piston had a large hole in the crown of the piston; the No. 1 cylinder displayed damage; and the No. 1 connecting rod was bent and twisted.
Additionally, the No. 3 cylinder head was removed, and metallic material was found in the No. 3 combustion chamber. The No. 3 piston displayed damage, and the No. 3 cylinder was damaged and displayed multiple impact marks.
Accident with N561TU
The National Transportation Safety Board (NTSB) first became aware of valve spring retainer fracturing issues with Rotax 900 series engines in 2017 due to an accident that occurred in Stevensville, Maryland, with another Tecnam P92 airplane, N561TU, that was also operated by Chesapeake Sport Pilot. (NTSB Case No. ERA17LA246). The airplane was powered by a Rotax 912 ULS2-01 engine, S/N 9569084. In this accident, the airplane experienced a total loss of engine power at the end of a cross country flight, and the pilot performed a forced landing during which the airplane sustained substantial damage.
The airplane had recently been purchased, and the engine had 13.2 hours total operating time. Review of onboard data indicated that the fuel pressure, cylinder head temperature, and oil temperature remained relatively steady until the loss of power occurred, which indicated that the engine failure likely did not involve the fuel system, cooling system, or lubrication system.
Examination of the engine revealed that there was no oil in the oil line between the oil thermostat and oil pump. The oil pump drive pin also displayed excessive wear in relation to the operating hours of the engine, and the magnetic plug was covered in metallic particles, although the oil filter was clean. Further examination of the engine revealed that the No. 1 cylinder was damaged, and evidence of bluing was present. The cylinder’s 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.
Examination of the fractured surface on the exhaust valve spring retainer revealed the presence of fatigue with pronounced vibration stripes when viewed with an electron microscope; however, the heat treatment corresponded to the target specifications, as did the statistical process control value. According to the NTSB’s final report on the accident, the root cause of the failure could not be determined based on the available information.
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 (this case).
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 the 2017 accident with N561TU. All of 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 however that the Rotax engine bank angle and 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.
Review of the Rotax 912 Heavy Maintenance Manual 72-00-00, Edition 1, Revision 4, page 69, revealed that wear of “the valve spring support can indicate a malfunction of the valve train as a result of badly or insufficiently vented hydraulic valve tappets.” Figure 1 shows the components of the engine valvetrain.
Figure 1. Illustration of components of the engine valvetrain.
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 instruction 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
o before first engine run,
o after re-installation (e.g. after overhaul),
o 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 in September 2002 (cancelled and superseded by SI-912-018 / SI-914-020), issued on January 23 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 re-worked 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
o before first engine run,
o after re-installation (e.g., after overhaul),
o after lubrication system opened or drained during maintenance work (e.g., removal of oil pump, oil cooler or suction line) or
o 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 40º
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.
At the request of the NTSB, BRP Rotax reviewed its records and advised that they had identified a total of 18 production engine failures due to broken valve spring retainers for 900 series engines produced between February 2015 and February 2019 . The failures occurred with engines installed on multiple types of aircraft, and the failures occurred over a large spread in operating hours from as low as 7 hours to as high as 1,936.6 hours. All components examined at the Rotax factory met their specifications. Not all the engines were affected by or complied with Service Bulletin SB-912 i-008 R1 / SB-912-070-R1 / SB-914-052 R1, which was originally issued due to deviations in the manufacturing process of the valve push-rod assembly that could result in partial wear on the rocker arm ball socket. This wear could lead to rocker arm cracking / fracture and subsequent malfunction of the valve train.
Icon Airplane Valve Spring Retainer Failure
On August 10, 2021, the NTSB was notified of another valve spring retainer failure on a Rotax 912S engine (S/N 7705135) that was installed in an Icon A5 airplane, N639BA. The engine was manufactured in 2021 and should have had all changes that were addressed in previous Rotax guidance materials complied with before being placed into service.
The airplane was in cruise flight at a power setting of about 5,350 rpm when the pilot felt the engine vibrating. The exhaust gas temperature (EGT) for cylinder No. 1 began to steeply drop, and the engine rpm dropped to 4,820 rpm without throttle reduction by the pilot. About 2 seconds later, the EGTs for cylinders Nos. 2 and 4 began to drop. Shortly thereafter, the engine lost total power. The pilot then tried twice to restart the engine without success. The pilot made an uneventful forced landing.
Postincident examination revealed that the No. 1 cylinder exhaust valve spring retainer was broken in half. Half of the valve spring retainer was discovered in the rocker box cover, and the other half was found jammed between the cylinder head and the exhaust rocker arm. The No.1 exhaust valve was found severed, and the No.1 piston was impact-damaged.
Corrective Actions
As a result of these occurrences, to increase safety, these organizations took the following actions:
BRP Rotax
o Revised Service Bulletin SB-912 i-008 R1 / SB-912-070 R1 / SB-914-052 R1 to include a specific venting procedure for the oil system. (Now SB-912 i-008 R2 / SB-912-070 R2 / SB-914-052 R2.)
o Revised Service Instruction SI-915 i-003 / SI-912 i-004R1 / SI-912-018R2 / SI-914-020R2 to help preclude lack of proper oil purging after an engine had been first installed and/or an engine had been re-worked, and to help to prevent engine failures in the field, as air could be trapped in the valve tappets and cause valve train failure. (Now SI-916 i B-003 / SI-915 i-003R1 / SI-912 i-004R2 / SI-912-018R3 / SI-914-020R3.)
o All future instructions for continued airworthiness (service bulletins, service instructions, and alert service bulletins) will provide direct references to instructions found in other documents that pertain to the required procedures.
o Notified their distributers of the publication of Service Instruction SI-916 i B-003 / SI-915 i-003R1 / SI-912 i-004R2 / SI-912-018R3 / SI-914-020R3 and encouraged them to inform their customers proactively and to encourage original equipment manufacturers (OEMs) to also distribute the information relating to air in the lubrication system in documents issued by the OEM to significantly improve the chance to reach the end customer with the information. They also asked that their distributors ensure that all OEMs in their regions understand the importance of the revised service instructions, check their relevant instructions for continued airworthiness (ICAs) for possible checks and required changes, and have their aircraft customers, operators, and maintenance technicians made aware and informed about it. Additionally, they further asked their distributers to transmit the relevant ICAs to all their service centers, OEMs, retail sellers, flying schools, flying clubs, authorities, and press, for accomplishment or information.
o Developed new valve spring retainers with improved materials to make them more resistant to breakage if they are exposed to significantly higher stress loads due to insufficient purging/venting of the lubrication system.
Rotech Flight Safety
o Distributed Service Bulletin SB-912 i-008R2 / SB-912-070R2 / SB-914-052R2 on the Rotax-owner website, advising that the new revisions included instructions on purging the oil system after the work was completed. A video clarifying purging of the lubrication system was also included.
o Distributed Service Instruction SI-916 i-003R1 / SI-915 i-003R2 / SI-912 i-004R3 / SI-912-018R4 / SI-914-020R4 on the Rotax-owner website to provide further guidance for the lubrication system with respect to purging and venting and to avoid air in the lubrication system. They also advised that the service instruction should help to avoid engine failures in the field, as air can be trapped in the valve tappets and cause valve train failure, and it is very important to complete these instructions in their entirety.
Icon Aircraft
Issued Service Letter SL-081221-A to provide awareness that air entering the engine lubrication system could lead to potential failure of valvetrain components and that following the correct procedures when performing any installation, maintenance, repair, and overhaul activities on the engine has been shown to minimize the occurrence of this situation. Additionally, the service letter advised that certain uncoordinated or unloaded flight maneuvers should be avoided as they can lead to air entering the lubrication system and that one such incident in an Ion A5 resulted in loss of engine power inflight and an emergency landing.
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