ERA12LA219

The inadequate servicing and maintenance of the engine and the airplane owner and maintenance personnel's disregard of the manufacturer's recommended engine overhaul schedule and service bulletins, which resulted in an in-flight internal failure and seizure of the engine.

During cruise flight at 6,000 feet mean sea level (msl), the airplane's engine incurred a total loss of power. The flight instructor and the private pilot looked for a suitable place to land. Their first choice was an airport, but due to the prevailing wind, they were unable to make it to the airport. Their second choice was a highway, but it also proved to be unsuitable due to the amount of automobile traffic. As they descended through 2,000 feet msl, they considered deploying the Cirrus Aircraft Parachute System (CAPS) but noticed a light colored patch of ground, which appeared to be a hard dirt surface; they thought landing there would be a better option than deploying the CAPS. During the final approach, while in ground effect, the flight instructor observed a mound of dirt that was directly in front of the airplane, and he deployed 50-percent wing flaps to "balloon" the airplane over the obstacle. The wheels touched down on a water-filled marshy area, and the airplane slid over a mound of dirt and came to rest in the marshy area. A review of onboard recorded data showed that fluctuations of the No. 2 cylinder's exhaust gas temperature were present beginning at engine start. Examination of the engine revealed that the engine had a hole in the top of the crankcase and that both magnetos had separated from their mounting locations. Further examination of the engine revealed that the No. 2 connecting rod bearing had been starved of oil and released from the crankshaft. The No. 2 main bearing had shifted and the lock slot in the crankcase was damaged, which indicated that the crankcase through bolts were not properly torqued. The No. 2 main bearing was fractured, and portions were missing from the steel backing, and the No. 2 and No. 3 piston pin bushings were also missing bushing material, which indicated that, during maintenance, a service bulletin had not been complied with. Review of the manufacturer's overhaul schedule also revealed that the recommended time between overhauls was 2,000 hours. At the time of the accident, the engine had accrued 2,978.1 total hours of operation without overhaul. Review of the airplane and engine manufacturers guidance also revealed that because engine cooling was accomplished by discharging heat to the oil in the engine the engine should not be operated with less than 6 quarts of oil. The flight instructor however, stated that he added oil to the engine during the preflight to bring it up to 5 quarts. He also advised that was the level they always serviced it to, which indicated that in addition to the engine having been inadequately maintained, the engine was also continuously operated below the minimum specified oil level.

The accident airplane did not have a flight recorder installed nor was one required to be installed under the applicable CFRs. It did however have data recording capability incorporated in the Primary Flight Display and Multi Function Display. The Primary Flight Display (PFD) The PFD unit included a solid state Air Data and Attitude Heading Reference System (ADAHRS) and displayed aircraft parameter data including altitude, airspeed, attitude, vertical speed, and heading. The PFD unit had external pitot/static inputs for altitude, airspeed, and vertical speed information. The PFD contained two flash memory devices mounted on a riser card. The flash memory stored information the PFD unit used to generate the various PFD displays. Additionally, the PFD had a data logging function, which was used by the manufacturer for maintenance and diagnostics. Maintenance and diagnostic information recording consisted of system information, event data and flight data. The PFD recording contained records of 20 power cycles and approximately 16 hours of data. The accident flight was associated with the 16th power cycle. The duration of the 16th power cycle was approximately 45 minutes. The Multi Function Display (MFD) The MFD unit was able to display the pilot checklist, terrain/map information, approach chart information and other aircraft/operational information depending on the specific configuration and options that were installed. One of the options that were available was a display of comprehensive engine monitoring and performance data. The MFD contained a CF memory card located in a slot on the side of the unit. This memory card contained all of the software that the MFD needed to operate. Additionally, this card contained all of the checklist, approach charts, and map information that the unit used to generate the various cockpit displays. During operation, the MFD received information from several other units that were installed on the aircraft. Specifically, the MFD received GPS position, time and track data from the aircraft's GPS receiver. The MFD also received information from the aircraft concerning altitude, engine and electrical system parameters, and outside air temperature. This data was also stored on the unit's CF memory card. The MFD CF card contained 103 data files. One data file was identified as being recorded during the accident flight. The data file was approximately 39 minutes in duration. Review of PFD and MFD Data Review of the recorded data indicated that the airplane was initially powered up at 09:41:30 and departed OPF at 09:54:36. The airplane then climbed in an easterly direction passing north of North Miami Beach, Florida and out over the Atlantic Ocean, before turning southbound. At 10:13:36 the airplane reached a cruise altitude of 6,000 feet. Then approximately 5 minutes later at 10:18:29, while passing just to the west of Key Largo, Florida, a drop in engine rpm and an oscillation in lateral acceleration was recorded. The airplane then began to descend, turned approximately 180 degrees to the right until it was on a northeasterly heading. Moments later it turned left to a northwesterly heading while still descending, then turned right until it was above the remains of an old drainage canal and touched down with the last recorded position information occurring at 10:25:18. Exhaust Gas Temperature (EGT) Data Examination of the data revealed that from the time that power up occurred at 09:41:30 until the last position information was recorded at 10:25:18 that fluctuations of the No. 2 cylinder's EGT were present with fluctuations reaching a peak of approximately 1600 degrees Fahrenheit. Piston Pin Bushings According to the owner of a local engine overhaul facility, about 6 weeks prior to the accident, the mechanic who maintained the airplane found a piece of connecting rod bushing (piston pin bushing) in the engine oil sump. When the piece was shown to personnel at the engine overhaul facility, the airplane owner and the mechanic were advised that there was a service bulletin concerning connecting rod bearings and that the engine case should be split for repair. Then when the owner of the engine overhaul shop was advised of the total time of operation that the engine had accrued, he recommended that the owner either get a major overhaul or purchase a new engine. He was then advised by the mechanic that the airplane was expected to be sold as is. Neither the mechanic, nor owner returned to the overhaul shop prior to the accident. Service Bulletin (SB) 96-7C According to Continental Motors Incorporated (CMI) SB96-7C, failure to torque through bolt nuts on both sides of the engine can result in a loss of main bearing "crush" with main bearing shift and subsequent engine failure. Service Bulletin (SB) 07-1 According to Continental Motors Incorporated (CMI) SB07-1, which provided instructions for inspection of the connecting rod piston pin bushing installation, Continental had received reports of piston pin bushing material being found in the sump or oil filter. If piston pin bushing material was recovered from an engine, all of the cylinders, pistons, and piston pins must be removed to allow access for inspection of the connecting rod piston pin bushing. Additionally the piston pin bushing must be inspected for condition each time a cylinder was removed for any reason. Review of Maintenance Records Review of maintenance records revealed that on December 1, 2006, the engine had received a propeller strike inspection at 927. 8 hours, and that on September 25, 2008 the engine had received a "top overhaul" utilizing CMI EQ7369 Cylinder kits. The last annual inspection was completed on December 20, 2011. At the time of the inspection, the airplane had accrued 2,888 total hours of operation. The last logbook entry was dated February 2, 2012, when an overhauled starter was installed at 2930.8 hours. No record any other maintenance, or evidence of SB07-1 being complied with, was discovered. Total time in service for the failed engine was 2,978.1 hours. According to the information contained in CMI SIL98-9A, time between overhauls was 2,000 hours. During an interview with the flight instructor, he advised that during the preflight he discovered that the oil level was at 3 and ¾ quarts, so prior to departure, he added oil to the engine to bring it up to 5 quarts. He also advised that was the level they always serviced it to. He stated that this was based on his experience, and recommendations from the Cirrus Owners and Pilot Association (COPA), that anything over 5 quarts would blow out the breather. The Cirrus Design SR22 Pilot's Operating Handbook and FAA Approved Airplane Flight Manual Section 4 (Normal Procedures), stated in part however; "Engine Oil ……… Check 6-8 quarts". Section 7 (Airplane Description), also contained a "Caution" which stated, "The engine should not be operated with less than six quarts of oil. Seven quarts (dipstick indication) is recommended for extended flights". Further review of section 7 also revealed that "Engine cooling is accomplished by discharging heat to the oil and then to the air passing through the oil cooler". Review of the CMI, IO-550 Permold Series Engine Maintenance and Overhaul Manual also revealed that, with an 8 quart fill, when the airplane was in a 16 degree nose up attitude, usable oil with an 8 quart fill was 5 quarts. When the airplane was in a 10 degree nose down attitude, usable oil with an 8 quart fill was 4.5 quarts. Supplemental instructions for normal operation in the manual under "Pre-operational Requirements" also advised to; "check the oil level and verify quantity is within specified limits". The recorded weather at Homestead Air Reserve Base (KHST), Homestead, Florida, approximately 10 nautical miles northwest of the accident site, at 1455, included: wind 110 degrees at 12 knots gusting to 15 knots, visib