Aircraft Accident/Incident Report

Edgewater, Florida 32132
Saturday, April 10, 2004 12:06 EDT

NTSB Narrative Summary Released at Completion of Accident

The single-engine experimental airplane was the lead airplane in a formation with three other airplanes, in cruise flight at 1,500 feet above the ground, when it suddenly experienced a catastrophic engine failure and began to veer to the left toward one of the other airplanes. The pilot of the other airplane turned to avoid the accident airplane, and noticed that the accident airplane's cockpit was filling with smoke. Oil was also seen streaming back onto the canopy. The accident pilot requested help, and one of the other pilots attempted to guide him to a safe off-field landing. The accident pilot was then observed to open the cockpit canopy. Smoke and oil were seen pouring onto the pilot's face. The accident airplane then continued to descend until impacting trees and terrain. Examination of the wreckage revealed that the engine's no. 2 connecting rod had separated and punched a hole in the crankcase. A detailed engine exam revealed that the no. 2 connecting rod bearing substrate had delaminated from the steel backing of the bearing, thus allowing excessive bearing clearance. This led to a failure of the rod cap bolts (due to overstress) and separation of the connecting rod from the crankshaft. The separated rod punctured a hole in the engine crankcase, allowing oil to escape and mechanical seizure of the engine. No materials deficiencies of any engine part were noted. The bearing type was the subject of a Lycoming Special Advisory (no. 59-800) in 2000, a Mandatory Service Bulletin (no. 547) in 2001, and another Mandatory Service Bulletin (no. 561) in 2004 which discussed delamination of the bearings for undetermined reasons, and recommended replacement of them with bearings that had "increased durability." These bulletins addressed a higher powered engine (TIO-540), and not the accident engine; however, two other instances of delaminated bearing failures from lower-powered engines (including one similar to the accident engine) were noted. The accident airplane had a propeller installed that was not the one required for normal certification. Additionally, the pilot frequently flew the airplane in formation, thus requiring frequent power changes (with a geared engine). Records indicate that all 6 cylinders were overhauled and sent back to the pilot's mechanic about 6 months before the accident. About 4 months before the accident, the mechanic changed the oil and oil filter about 20 operating hours after the cylinders were replaced. This entry (as well as a previous oil change entry 8 months prior) did not indicate that the oil filters and screens were opened and inspected for metal debris; however, the mechanic stated that he always checked for debris. The airplane had flown an additional 14 flights since the last oil change. The pilot's log indicated that 7 quarts of oil were added to the engine during that time. The final pilot logbook entry was dated one week before the accident and indicated that one quart of oil was added to the engine, at an engine time of 326.2 hours. The logs did not reveal any unresolved discrepancies.

NTSB Probable Cause Narrative

The delamination of the no. 2 connecting rod bearing for undetermined reasons, resulting in a total loss of engine power. A factor in the accident was the pilot's inability to complete a successful forced landing due to oil on the windscreen, and smoke and oil in the cockpit as a result of the mechanical failure of the engine.

Event Information

Type of Event Accident
Event Date 4/10/2004
Event Day of the Week Saturday
Time of Event 1206
Event Time Zone Eastern Daylight Time
Event City Edgewater
Event State FLORIDA
Event Country --
Zipcode of the event site 32132
Event Date Year 2004
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 290440N
Event Location Longitude 0810240W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1200 Eastern Daylight Time
Direction of event from weather observation facility (degrees) 10
Weather Observation Facility ID DAB
Elevation of weather observation facility 23
Distance of event from weather observation facility (units?) 10
Time Zone of the weather observation EDT
Lighting Conditions Day
Lowest Ceiling Height --
Lowest Non-Ceiling Height 5500
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 26
Dew Point at event time (in degress fahrenheit) 17
Wind Direction (degrees magnetic) 50
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 8
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.92
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 2
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 18794
NTSB Notification Source
NTSB Notification Date Apr 10 2004 12:00AM
NTSB Notification Time 1215
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Dec 20 2005 6:27AM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office Orlando, Florida

Aircraft Involved

Aircraft #1

Aircraft Registration Number N860MK
NTSB Number IAD04LA016
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire Ground
Aircraft Explosion None
Aircraft Manufacturer's Full Name Pilatus
Aircraft Model P3-05
Aircraft Series Identifier --
Aircraft Serial Number 498-47
Certified Max Gross Weight 3465
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 2
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Conditional
Date of Last Inspection Jun 10 2003 12:00AM
Airframe hours since last inspection 55
Airframe Hours 3564
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name Michael J. Keemar
Aircraft Owner Street Address 1720 Baron Court
Aircraft Owner City Daytona Beach
Aircraft Owner State FL
Aircraft Owner Country USA
Aircraft Owner Zipcode 32124
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 1720 Baron Court
Operator City Daytona Beach
Operator State FL
Operator Country USA
Operator Zip code 32124
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code TIX
Departure City Titusville
Departure State FL
Departure Country USA
Departure Time 1145
Departure Time Zone EDT
Destination Same as Local Flt --
Destination Airport Code 7FL6
Destination City Daytona Beach
Destination State FL
Destination Country USA
Specific Phase of Flight Emergency descent/landing
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Sep 29 2005 10:42AM
User who most recently changed record MUZD
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --