Reviewing the causes of loss of engine power in survivable CAPS saves - Pull early, pull often! - Safety and Training Programs - Cirrus Owners and Pilots Association

Reviewing the causes of loss of engine power in survivable CAPS saves

Reviewing the causes of loss of engine power in survivable CAPS saves

(updated with additional Probable Cause determinations by the NTSB; 2 July 2017)

Several recent conversations have highlighted the number of survivable CAPS deployments that involved loss of engine power scenarios. To help place these scenarios in context, here is a summary of the CAPS saves that involved loss of engine power since 1999 when the SR20 was introduced. Several of the more recent investigations have not yet published reasons for the loss of engine power and are noted as "cause TBD."

An important point to make about these investigations -- pilots chose to deploy CAPS rather than attempt a risky off-airport landing. Everyone on board these Cirrus aircraft survived. The same cannot be said about several COPA Pilots who did not deploy CAPS and died during an off-airport landing. And for other general aviation makes/models of aircraft, fatal off-airport landings are all too frequent despite the overwhelming success rate. In a Cirrus, the risks of a fatal outcome are not worth it. Pull early, pull often!

Note that engine problems that did not result in a CAPS deployment are not included in this review; that work is for someone else at another time.

2007, Sydney, Australia -- loss of engine power due to in-flight loss of blanking cap from the fuel pressure test port, hence maintenance induced failure (SR22 IO-550N)

2009, Elkin, NC -- total loss of engine power due to the failure of the No. 2 piston as a result of a fatigue crack of undetermined origin (SR22 IO-550N)

2009, Hamilton Island, Australia -- suspected fuel pump issue, but I don't have a copy of the ATSB report on this one (SR22 IO-550N)

2011, Cross City, FL -- loss of engine power due to a fractured camshaft due to a fatigue crack (SR22 IO-550N)

2011, New Orleans, LA -- loss of engine power due to detonation of the No.2 cylinder from a clogged fuel injector nozzle. (SR20 IO-360ES)

2012, Andros Island, Bahamas -- loss of engine power due to loss of oil pressure, as yet not reported, but suspected engine maintenance (SR22 IO-550N)

2012, Itu, Brazil -- loss of engine power due to failed fuel pump (SR20 IO-360ES)

2012, Pickens, SC -- loss of engine power due to fractured crankshaft, consistent with the application of insufficient torque on the cylinder through bolts by maintenance personnel. (SR22 IO-550N)

2012, Show Low, AZ -- loss of engine oil, likely due to loss of oil feeder line due to removal of the supercharger by maintenance personnel (SR22 IO-550N)

2012, Gilgandria, Australia -- loss of engine oil due to high oil consumption of about 0.5 quarts per hour (1 quart per 2 hours) (SR22 IO-550N)

2013, Tappahannock, VA -- loss of engine power due to failure of engine crankshaft top rear trailing forward counterweight retaining plate, consistent with service advisory about high-power low RPM operation below 2300 RPM (SR22 IO-550N)

2013, Texarkana, AR -- loss of engine power due to fuel exhaustion (SR22T IO-550K)

2014, Buckhannon, WV -- partial loss of engine power due to improper in-flight fuel mixture management (SR22 IO-550N)

2014, Fort Hall, ID -- loss of engine power due to dual magneto failure due to stripped gear teeth (SR22 IO-550N TN)

2014, Nogales, Mexico -- loss of engine power, cause TBD (SR20 IO-360ES)

2014, Louyang, China -- loss of engine power, cause TBD (SR22 IO-550N)

2014, Burlington, MA -- loss of engine power, cause maintenance improper tightening of engine through bolt (SR22 IO-550N)

2014, Nishikata, Japan -- loss of engine power due to fuel exhaustion (SR20 IO-360ES)

2014, Lexington, NC -- loss of engine power, cause maintenance improper tightening of engine through bolt (SR22 IO-550N)

2014, Hampton, SC  -- loss of engine power, cause faulty oil pressure transducer led to pilot reducing engine power  (SR22 IO-550N)

2015, Maui, HI  -- loss of engine power, cause fuel exhaustion due to failure to transfer from ferry tanks to wing tanks (SR22 IO-550N)

2015, Lake Wales, FL  -- loss of engine power, cause oil starvation likely due to stuck oil control rings(SR20 IO-360ES)

2015, Fayetteville, AR -- loss of engine power, cause fatigue failure of cross fitting from oil cooler (SR22 IO-550K)

2015,  Jefferson, NC -- loss of engine power, cause undetermined after successful test run of engine (SR22 IO-550N)

2015, Watertown, WI  -- loss of engine power, cause fuel starvation (SR22 IO-550N)

2016, Laguna Pueblo, NM -- loss of engine power, cause fuel exhaustion (SR22 IO-550N)

 

As mentioned above, more recent events are too new to have reliable data published.

Cheers
Rick

Comments
  • I think it think is useful to separate the data into broad categories by root cause:,

    I find it useful to divide this into category based on how they might be prevented.

    Fuel Exhaustion:  2

    MIF:                      3, 1 suspected.

    Other:                   7 (the oil consumption and clogged injector look potentially preventable by pilot)

    TBD:                     5

  • See the follow-up blog entry: Turning Fatals into CAPS Saves and Avoiding CAPS Deployments

  • Hi Rick, during my (very recent) Private Pilot test, the examiner said something like "You've lost engine power and need to land..."

    So my training kicked in, and after quick run-through of the items I could control (switching fuel tanks, etc.), I said, "I'm getting ready to pull the chute and now am looking for best place to deploy (we were close to water)."

    He said, "NO, you've GOT TO LAND."

    Mentally I was still optimizing for chute pull, and he wanted to see me land the plane, which meant it didn't go smoothly.  Later in the test, he pulled power back again, and said, "you've lost power, you don't have a chute, what do you do?"  

    I was able to land the plane smoothly, because the scenario was set up in a situation where a pilot COULD land safely.  But, if I really do lose power, I'm also certainly pulling that chute.  Why?  Because rarely does an engine quit under circumstances where a flight examiner has done the calculus to determine a pilot should be able to land the plane and I've had good training (thanks Flight Academy) that says when bad stuff happens, #1 on the checklist is always "Consider a chute pull." And items #3 and #4 are "Hey, remember you've got a parachute!"

  • First off Rick. Thank you for your tireless efforts in keeping us informed through your prolific work on this subject.

    Interesting that 1/2 of the known conditions above that caused failure could be classified as maintenance induced or potentially maintenance discoverable. For most of us on this site who aren't mechanics, we leave a lot of trust in what the shop does in diagnosing or repairing a problem area. But while I always ask the person working on my bird "what was done and why", I can never determine if something was done exactly correct (e.g. "is 'torqued' right"). I see a lot use services like Savvy but not sure even they could detect if it was properly repaired to spec.

  •  Your comment touches on a vital part of auditioning examiners for Cirrus pilots. The Flight Academy interviews the examiner for their private pilot candidates. They inform the examiner that the pilot flies with an airframe parachute system and has been trained to use it when faced with an off-airport landing. They query the examiner on how they would handle that scenario. In particular, TFA insists that the examiner not do what yours did -- not press on regardless after a stated intention to pull the CAPS handle. Instead, if the examiner wants to see you set up for an emergency off-airport landing, then complete the first task at the declared CAPS pull, go onto other tasks, and then come back to the emergency landing task with a preamble that requires demonstration with use of CAPS. The goal is to avoid cross-training a candidate to not trust or complete the CAPS pull. If the examiner does not agree, then TFA will not use that examiner.

    Cheers

    Rick

  • The issue of maintenance issues seems to be getting increased attention. Certainly, it helps to have owners discuss work with the maintenance shop, querying the inspection process and who signs off on repairs, and exploring what procedures were used. Any indication that the work was not done according to the Cirrus maintenance manual (usually phrased as "IAW AMM") should be cause for concern.

    As for SavvyMX oversight, indeed, that is not something that goes into the detail of how procedures are completed and inspected. Actually, that is an FAA oversight role for Part 145 repair shops. If we find a problem at such a shop (and not all maintenance facilities are Part 145), then the FAA is our consumer protection branch.

    Cheers

    Rick

  • Rick, is it really true that the first CAPS deployment for loss of power was in 2007?

  • @Jeff Price: Yes, the first 10 CAPS deployments were for other reasons, such as disorientation, high altitude loss of control, and a maintenance induced failure of safety wiring an aileron hinge, etc. The 11th was a maintenance induced failure of the fuel system, and the first loss of engine power resulting in a CAPS deployment.

    Cheers

    Rick

  • That's amazing.  I wonder how many loss of power incidents resulted in off airport landings instead of CAPS pulls?

    Thanks to you for pushing the "Pull early Pull often" mantra. I'm a believer!

    jp

  • @jdprice: Regrettably, too many off-airport landings happened prior to 2007 and that 11th CAPS deployment. One of the first at St. Boniface, MN in 2001 paralyzed the pilot and seriously injured the passenger due to the lack of a safety wire on the oil drain plug. They landed hard in a frozen corn field. As we know now, they would likely have survived uninjured if they deployed CAPS. Hence the mantra of "Pull Early, Pull Often!" -- before you get too low or too fast, and in more scenarios where others have survived.

    Cheers

    Rick

  • I looked at the article Cirrus CAPS History.  Looks like of the 65 CAPS events 23 were due to engine failure/loss of power.  This seems like a highh percentage.  Can one draw the conclusion that Cirrus has an engine issue?

  • @Dan Elkins: Does the Cirrus have an engine issue? Of course it does. Does the Cirrus have a high percentage? Who knows?

    Any time that the airplane loses engine power, it has an engine issue. One might ask if this is more or less likely that other engines or other models of aircraft. Sorry, but we don't have good data on engine failures in the single-engine piston marketplace. They are not reportable events, so no one has the data.

    What the Cirrus has that differentiates it from other aircraft is the opportunity to lower the risks of an off airport landing by deploying the parachute. That action generates greater interest, news coverage, and speculation on aviation forums.

    Cheers

    Rick

  • Rick :  Aren't we missing Danbury CT?  Fuel Exhaustion

  • @Scott Philiben: Yup, forgot that one:

    2013, Danbury, CT -- loss of engine power due to fuel exhaustion (SR20 IO-360)

  • What is the fleet ratio of SR22's vs SR20's?  Seems like the incidents favor SR22's but that could just be due to usage statistics. :-)

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