ASN Wikibase Occurrence # 282615
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| Date: | Tuesday 22 October 2019 |
| Time: | 19:50 LT |
| Type: |  CSA SportCruiser |
| Owner/operator: | Bountiful Flight LLC. |
| Registration: | N204BF |
| MSN: | C0610 |
| Year of manufacture: | 2017 |
| Total airframe hrs: | 2192 hours |
| Engine model: | Rotax 912 ULS |
| Fatalities: | Fatalities: 0 / Occupants: 1 |
| Aircraft damage: | Substantial |
| Category: | Accident |
| Location: | Holden, Utah -
 United States of America
|
| Phase: | En route |
| Nature: | Private |
| Departure airport: | Provo Airport, UT (PVU/KPVU) |
| Holden, UT | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
During a night flight, the airplane was at 11,000 ft mean sea level when the engine sputtered and lost total power. The propeller would not windmill, and the engine would not restart. Due to the dark night conditions, the pilot could not identify a safe forced landing area, so she deployed the ballistic recovery system (BRS) about 700 ft above ground level. The left-rear steel suspension cable, one of the two cables and two fabric straps attaching the BRS parachute to the airplane, separated in overload when it caught on a bolt during the BRS deployment. This resulted in an improper deployment of the BRS before the airplane touched down in a left-wing low attitude which substantially damaged the wing.
Examination of the engine revealed the No. 2 intake valve spring retainer was broken, and the intake valve had fallen into the No. 2 combustion chamber, which resulted in the loss of power. The No. 2 valve spring shim exhibited a worn appearance with a groove visible around the shim. According to the engine manufacturer, worn valve spring shims are a clear sign of an engine operating with air in the oil system.
This valve spring retainer failure was not the first one with a Rotax 900 series engine; in 2017, at the end of a cross-country flight, an airplane powered with the same series engine experienced a total loss of engine power, and the pilot performed a forced landing during which the airplane sustained substantial damage. Examination of that engine revealed the presence of a broken valve spring retainer that had resulted in the loss of power. Additionally, it was discovered that the valve spring retainer displayed evidence of metal fatigue.
During 2019 and 2020, in addition to this accident, four more cases of broken valve spring retainers on the Rotax 900 engine series occurred in the United States. All the engines had differing hours of operation. Extensive metallurgical examination of the engine components from these five engines revealed that they met their specifications, and the fractured surfaces on the valve spring retainers revealed the presence of fatigue with pronounced vibration stripes, which was the same pattern that was observed on the valve spring retainer from the 2017 accident.
Review of the engine manufacturer's published guidance revealed that air could be introduced into the oil lubrication system through several means, including exceedance of the recommended maximum bank angle of 40º, poorly or insufficiently vented hydraulic valve tappets, lack of proper oil system purging, spinning the propeller in the reverse direction from normal rotation, or opening portions of the oil system during maintenance or servicing. Testing of an exemplar engine with air introduced into the lubrication system revealed that with air trapped in the hydraulic tappets, it took about 6.5 minutes of engine operation at 2,538 rpm for air to be purged from the tappets allowing them to work as designed. This indicated that with air trapped in the hydraulic tappets, the valve train could be overloaded, which could lead to a fatigue crack and breakage of a valve spring retainer; this was likely the reason for the fatigue cracking of the valve spring retainers in the 2017 accident, in this accident, and in the other four 2019-2020 engine failures.
During the investigation, the engine manufacturer reviewed its records and found a total of 18 production engine failures due to broken valve spring retainers. The engines were installed on multiple types of aircraft with a large spread in operating hours from as low as 7 hours to as high as 1,936.6 hours. All the components examined met their specifications, and not all the engines were affected by service bulletins that had been issued due to deviations in the manufacturing process of the valve push-rod assembly, which could result in partial wear on the rocker arm ball socket and lead to rocker arm cracking leading to a malfunction of the valve train. These engine failures indicated that valve train failure could occur for reasons other than the push-rod manufacturing issue such as air being introduced into the lubrication system. Additionally, after the engine manufacturer's record review, an engine in an airplane that was produced in 2021, which should have had all changes included in Rotax guidance materials incorporated before it was placed into service, experienced a valve spring retainer failure, confirming that valve train failure could occur for reasons such as air being introduced into the lubrication system.
Probable Cause: The fatigue failure of the No. 2 cylinder intake valve spring retainer due to air trapped in the lubrication system, which resulted in a total loss of engine power. Contributing to the severity of the damage was the improper deployment of the ballistic recovery system.
Accident investigation:
 |
|
Sources:
NTSB WPR20LA012
Location
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 09-Sep-2022 12:43 | ASN Update Bot | Added |
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