ATSB TRANSPORT SAFETY INVESTIGATION REPORT

Aviation Safety Research and Analysis Report B2007/0191

Final

Aircraft Reciprocating-Engine Failure

An Analysis of Failure in a Complex Engineered System
 ATSB TRANSPORT SAFETY INVESTIGATION REPORT
Aviation Safety Research and Analysis Report
B2007/0191

Aircraft Reciprocating-Engine Failure

An Analysis of Failure in a Complex Engineered
System

Released in accordance with section 25 of the Transport Safety Investigation Act 2003

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Published by: Australian Transport Safety Bureau
Postal address: PO Box 967, Civic Square ACT 2608
Office location: 15 Mort Street, Canberra City, Australian Capital Territory
Telephone: 1 800 621 372; from overseas + 61 2 6274 6440
Accident and incident notification: 1 800 011 034 (24 hours)
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E-mail: atsbinfo@atsb.gov.au
Internet: www.atsb.gov.au

© Commonwealth of Australia 2007.

This work is copyright. In the interests of enhancing the value of the information contained in this
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Subject to the provisions of the Copyright Act 1968, you must not make any other use of the
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Please direct requests for further information or authorisation to:
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ISBN and formal report title: see ‘Document retrieval information’ on page ix.

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CONTENTS

THE AUSTRALIAN TRANSPORT SAFETY BUREAU ................................ XI

EXECUTIVE SUMMARY ................................................................................ XII

1 INTRODUCTION .......................................................................................... 1
1.1 References ............................................................................................ 3

2 AIRCRAFT SAFETY-CRITICAL SYSTEM RELIABILITY .................. 5

2.1 Introduction .......................................................................................... 5
2.2 Engineered systems .............................................................................. 5
2.3 Engineered system design..................................................................... 6
2.3.1 The effect of complexity..................................................... 6
2.3.2 Multiple goals ..................................................................... 7
2.3.3 Fine tuning goals................................................................. 7
2.3.4 Risk management................................................................ 8
2.3.5 Response to goal deviation ................................................. 8
2.4 Aircraft safety-critical subsystems ....................................................... 9
2.5 References .......................................................................................... 10

3 PROPULSION SYSTEM RELIABILITY ................................................. 13

3.1 Introduction ........................................................................................ 13
3.2 Reciprocating-engine systems ............................................................ 13
3.3 Reciprocating-engine reliability ......................................................... 14
3.3.1 The impact of structural efficiency ................................... 16
3.3.2 The impact of combustion abnormalities.......................... 16
3.4 Hazards created by reciprocating-engine failure ................................ 17
3.4.1 Pilot response.................................................................... 17
3.4.2 Engine structural failure.................................................... 18
3.5 Reliability measurement ..................................................................... 20
3.6 References .......................................................................................... 22

4 POWERTRAIN STRUCTURAL RELIABILITY .................................... 23

4.1 Introduction ........................................................................................ 23
4.2 Powertrain component design............................................................. 24
4.2.1 The relationships between engine parameters .................. 24
4.2.2 Effect of engine layout...................................................... 26
4.3 Powertrain component reliability ....................................................... 28
4.3.1 Safety factors .................................................................... 28

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 4.4 Powertrain component failure control plans....................................... 31
4.4.1 Component fracture control plans..................................... 31
4.4.2 Component melting control plan ...................................... 33
4.4.3 Bearing surface damage control plan................................ 33
4.5 References .......................................................................................... 34

5 FAILURE ANALYSIS METHODOLOGY ............................................... 35

5.1 Introduction ........................................................................................ 35
5.2 Methodology....................................................................................... 35
5.3 Information gathering ......................................................................... 36
5.3.1 Seeing ............................................................................... 36
5.3.2 Classifying ........................................................................ 36
5.3.3 Communicating................................................................. 37
5.3.4 Evaluating ......................................................................... 38
5.3.5 Analysing.......................................................................... 38
5.4 References .......................................................................................... 38

6 POWERTRAIN FAILURE OCCURRENCES – 2000-2005..................... 40

6.1 Introduction ........................................................................................ 40
6.2 Combustion chamber assembly failures ............................................. 42
6.2.1 Occurrence 2000/2157 VH-MZK (right engine) .............. 43
6.2.2 Occurrence 2000/3675 VH-NPA...................................... 50
6.2.3 Occurrence 2001/2885 VH-MJA...................................... 52
6.2.4 Occurrence 2001/3357 VH-RNG ..................................... 53
6.2.5 Occurrence 2001/3251 VH-FIA ....................................... 55
6.2.6 Occurrence 2002/2059 VH-LTW ..................................... 56
6.2.7 Occurrence 2002/5129 VH-TZY ...................................... 58
6.2.8 Occurrence 2003/3532 VH-HJS ....................................... 59
6.3 Connecting rod assembly failures....................................................... 60
6.3.1 Introduction....................................................................... 60
6.3.2 Occurrence 2000/90 VH-MZK (left engine) .................... 61
6.3.3 Occurrence 2000/1327 VH-BNN ..................................... 64
6.3.4 Occurrence 2001/1405 VH-LTW ..................................... 66
6.3.5 Occurrence 2002/3474 VH-ACZ...................................... 68
6.3.6 Occurrence 200303701 VH-OCF ..................................... 71
6.4 Crankshaft failures.............................................................................. 74
6.4.1 Introduction....................................................................... 74
6.4.2 Occurrence 2000/2157 VH-MZK (left engine) ................ 75
6.4.3 Occurrence 2000/2276 VH-ODE...................................... 83
6.4.4 Occurrence 2001/2544 VH-TTX ...................................... 85
6.4.5 Occurrence 2001/4799 VH-BEM ..................................... 88

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 6.4.6 Occurrence 2001/5866 VH-JCH....................................... 90
6.4.7 Occurrence 2004/2291 VH-VEC...................................... 98
6.4.8 Occurrence 2005/02231 VH-IGW.................................. 101
6.5 Crankshaft bearing, reported service difficulties and defects........... 105
6.6 References ........................................................................................ 108

7 EVALUATION OF POWERTRAIN COMPONENT FAILURES ....... 109

7.1 Introduction ...................................................................................... 109
7.2 Cylinder head fatigue fracture .......................................................... 111
7.2.1 Cylinder assembly design ............................................... 111
7.2.2 Cylinder stresses ............................................................. 111
7.2.3 Fatigue fracture control plan........................................... 112
7.3 Piston crown edge melting................................................................ 113
7.3.1 Piston design ................................................................... 113
7.3.2 Melting control plan........................................................ 114
7.4 Cylinder attachment fastener fatigue fracture................................... 115
7.4.1 Threaded fastener design ................................................ 115
7.4.2 Threaded fastener fracture control plan .......................... 115
7.5 Connecting rod bearing housing fatigue fracture ............................. 116
7.5.1 Connecting rod design .................................................... 116
7.5.2 Connecting rod little-end fatigue fracture control .......... 117
7.5.3 Connecting rod big-end fatigue fracture control............. 118
7.6 Crankshaft fatigue fracture ............................................................... 120
7.6.1 Crankshaft design ........................................................... 120
7.6.2 Crankshaft fatigue fracture control ................................. 121
7.7 Powertrain plain bearing failure ....................................................... 122
7.7.1 Plain bearing design........................................................ 122
7.7.2 Plain bearing failure control plan.................................... 124
7.8 References ........................................................................................ 126

8 ANALYSIS OF POWERTRAIN STRUCTURAL FAILURES ............. 127

8.1 Introduction ...................................................................................... 127
8.2 Factors associated with combustion ................................................. 128
8.2.1 Normal combustion......................................................... 128
8.2.2 Abnormal combustion – detonation................................ 128
8.2.3 The effect of combustion on engine roughness .............. 132
8.2.4 Combustion chamber condition - engines studied .......... 132
8.2.5 Engine control settings.................................................... 151
8.2.6 The effect of detonation – shockwave propagation ........ 154
8.2.7 Summary......................................................................... 155

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 8.3 Factors associated with bearing surface breakup.............................. 157
8.3.2 Connecting rod little-end bronze bush breakup .............. 157
8.3.3 Connecting rod big-end bearing boundary lubrication ... 158
8.3.4 Connecting rod big-end bearing breakup........................ 160
8.3.5 The effects of boundary lubrication on trimetal bearing
inserts manufactured with a copper-lead intermediate
layer ................................................................................ 173
8.4 Factors associated with the retention of bearing inserts in their
housings............................................................................................ 175
8.4.2 Connecting rod big-end bearing insert retention ............ 175
8.4.3 Crankshaft main-bearing retention ................................. 179
8.4.4 Summary......................................................................... 181
8.5 Factors associated with fatigue cracking in powertrain
components....................................................................................... 183
8.5.1 Cylinder head fatigue failure .......................................... 185
8.5.2 Cylinder attachment fastener fatigue failure................... 186
8.5.3 Connecting rod bearing housing fatigue failure.............. 187
8.5.4 Crankshaft fatigue failure ............................................... 189
8.5.5 Crankshaft fatigue failure – examples ............................ 193
8.5.6 Summary......................................................................... 226
8.6 Multiple event sequences.................................................................. 227
8.7 References ........................................................................................ 228

9 ANALYSIS OF AIRWORTHINESS ASSURANCE SYSTEM -

AIRCRAFT PROPULSION ...................................................................... 231
9.1 Introduction ...................................................................................... 231
9.2 Condition monitoring of propulsion systems.................................... 231
9.3 Corrective actions ............................................................................. 232
9.3.1 ATSB safety recommendations ...................................... 232
9.3.2 Lycoming mandatory service bulletins - crankshafts ..... 238
9.3.3 Airworthiness directives, Federal Aviation
Administration - crankshafts........................................... 241
9.3.4 Civil Aviation Safety Authority Australia
airworthiness directives - crankshafts............................. 244
9.3.5 Safety advisory publications – mixture control .............. 244
9.3.6 Safety advisory publications - bearings .......................... 245
9.4 Performance of the feedback process ............................................... 246
9.4.1 Feedback barriers............................................................ 248
9.5 References ........................................................................................ 250

10 CONCLUSIONS ......................................................................................... 251

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DOCUMENT RETRIEVAL INFORMATION
Report No. Publication date No. of pages ISBN
B2007/0191 22 November 2007 268 978-1-921165-48-1

Publication title
Aircraft Reciprocating-Engine Failure: An Analysis of Failure in a Complex Engineered System

Author
Dr Arjen Romeyn, Principal Failure Analyst - Engineered Systems

Prepared by Reference No.

Australian Transport Safety Bureau Nov2007/DOTARS50406
PO Box 967, Civic Square ACT 2608 Australia
www.atsb.gov.au
Abstract
Reciprocating-engine powered low-capacity transport aircraft (8 to 10 passengers) provide an
important public transport connection throughout regional Australia. In the period January 2000 to
December 2005, twenty powertrain structural failures of high-power (300 to 375 brake
horsepower) horizontally-opposed, reciprocating engines were associated with air safety
occurrences reported to the ATSB. These occurrences ranged in severity from; in-flight engine
shutdown; engine failure and forced landing; engine failure combined with in-flight fire and
fracture of both upper engine mounts; to the fatal accident of a regular public transport flight
following the structural failure of both engines to ditching at night. It is evident that the reliability
of high-power reciprocating engines is an important requirement for the safe operation of this
class of aircraft. This research investigation is a study of the factors that affect reciprocating
engine reliability.
The study found that powertrain structural failure was not restricted to one engine model, one
engine manufacturer, or one powertrain component. The events that initiated sequences that led to
engine in-flight failure could be grouped into three categories: combustion chamber component
melting; bearing breakup; and powertrain component fatigue cracking. Analysis of the factors that
were associated with each category of initiating event revealed that powertrain component
reliability is affected by the development of shockwaves during combustion, the response of
bearings to boundary lubrication and out-of-plane alternating loads, the increase in component
alternating stress magnitudes, and creation of stress-concentrating features in components during
engine operation. These factors may act singly, but on many occasions it is the synergistic effect
of the presence of multiple factors that result in a sequence of events ending with engine in-flight
failure.
The recurrence of powertrain component structural failure events suggests that the corrective
actions that are a part of the airworthiness assurance system may have been ineffective. Corrective
action is dependent on accurate analysis and feedback. It is evident that analysis is affected by the
complexity of reciprocating engine systems and feedback requires a broad view of the interaction
of systems and a detailed view of the components of a system.

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THE AUSTRALIAN TRANSPORT SAFETY
BUREAU
The Australian Transport Safety Bureau (ATSB) is an operationally independent
multi-modal Bureau within the Australian Government Department of Transport
and Regional Services. ATSB investigations are independent of regulatory, operator
or other external bodies.
The ATSB is responsible for investigating accidents and other transport safety
matters involving civil aviation, marine and rail operations in Australia that fall
within Commonwealth jurisdiction, as well as participating in overseas
investigations involving Australian registered aircraft and ships. A primary concern
is the safety of commercial transport, with particular regard to fare-paying
passenger operations.
The ATSB performs its functions in accordance with the provisions of the
Transport Safety Investigation Act 2003 and Regulations and, where applicable,
relevant international agreements.
Purpose of safety investigations
The object of a safety investigation is to enhance safety. To reduce safety-related
risk, ATSB investigations determine and communicate the safety factors related to
the transport safety matter being investigated.
It is not the object of an investigation to determine blame or liability. However, an
investigation report must include factual material of sufficient weight to support the
analysis and findings. At all times the ATSB endeavours to balance the use of
material that could imply adverse comment with the need to properly explain what
happened, and why, in a fair and unbiased manner.
Developing safety action
Central to the ATSB’s investigation of transport safety matters is the early
identification of safety issues in the transport environment. The ATSB prefers to
encourage the relevant organisation(s) to proactively initiate safety action rather
than release formal recommendations. However, depending on the level of risk
associated with a safety issue and the extent of corrective action undertaken by the
relevant organisation, a recommendation may be issued either during or at the end
of an investigation.
The ATSB has decided that when safety recommendations are issued, they will
focus on clearly describing the safety issue of concern, rather than providing
instructions or opinions on the method of corrective action. As with equivalent
overseas organisations, the ATSB has no power to implement its recommendations.
It is a matter for the body to which an ATSB recommendation is directed (for
example the relevant regulator in consultation with industry) to assess the costs and
benefits of any particular means of addressing a safety issue.
About ATSB investigation reports: How investigation reports are organised and
definitions of terms used in ATSB reports, such as safety factor, contributing safety
factor and safety issue, are provided on the ATSB web site www.atsb.gov.au

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EXECUTIVE SUMMARY
The safe operation of an aircraft depends on the reliable performance of systems
that provide thrust, lift, stability, control, collision avoidance, navigation, and cabin
environment. The wellbeing of crew, passengers, and bystanders may be threatened
by the failure of any one these systems to perform their designed function – they are
safety-critical systems.
The focus of this safety study is the reliability of propeller-based propulsion
systems that provide thrust for the operation of aircraft commonly used in low-
capacity public-transport operations during the period 2000 - 2005. In particular,
the study critically examines the issues arising from the in-flight failure of propeller
propulsion systems powered by reciprocating engines.
During the period 2000 - 2005 1,270 aircraft, powered by multiple reciprocating
engines, on the Australian register operated for a total of about 220,000 hours. Of
these aircraft around 200 were employed in low-capacity public transport with (8 to
10 passengers) providing an important public transport connection throughout
regional Australia.
In the period January 2000 to December 2005, twenty powertrain structural failure
events in high-power (300 to 375 brake horsepower) horizontally-opposed,
reciprocating engines were associated with air safety occurrences reported to the
ATSB. These occurrences range in severity from: in-flight engine shutdown to
engine failure and forced landing; engine failure combined with in-flight fire and
fracture of both upper engine mounts; and a fatal accident involving a regular
public transport flight following the structural failure of both engines. Powertrain
structural failure has the capability to create a threat to safe operation despite the
redundancy provided by twin propulsion systems and pilot training to respond to a
period of abnormal operation following the failure of one propulsion system.
This research investigation focuses on:
• developing an understanding of aircraft safety-critical systems and how
reliable propulsion system performance is achieved;
• evaluation of the available evidence associated with powertrain component
failures events, from the period 2000 to 2005, against a background of
component failure control plans;
• analysis of powertrain component failure events, individually and as a
group, to uncover the factors that initiate event sequences leading to
powertrain component failure; and
• analysis of the airworthiness assurance system to determine why there was a
reduction in high-power reciprocating-engine reliability over the period
2000 to 2005.
The powertrain structural failure events investigated in this study are dominated by
combustion chamber component melting, plain bearing breakup or movement, and
the initiation and growth of fatigue cracking in components that are designed to
have a life not limited by fatigue. Analysis of these events revealed that the
initiating factors are those that affect heat transfer to and from components, affect
bearing surface behaviour and bearing insert retention in their housing, and affect
the fatigue endurance strength of a component and the magnitude of alternating

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stresses in the component during engine operation. Failure events were not
restricted to one engine model, one engine manufacturer, or one component type.
A change in the combustion process – from flame propagation throughout the fuel-
air mixture to the auto-ignition of some part of the mixture – has the potential to
affect the reliability of powertrain components. The effect of detonation is related to
the intensity of detonation, which in turn, is dependent on the volume of end-gas
that undergoes auto-ignition. Light to medium detonation may result in some
mechanical damage. The actual nature of mechanical damage is dependent on the
robustness of powertrain components and assemblies to abnormal loading. Heavy
detonation results in the melting of aluminium alloy combustion chamber
components.
Detonation-free operation, for a fuel of known detonation resistance, is based on
limiting the operator-controlled engine parameters of manifold pressure (power),
speed, mixture, and engine load. Additionally, detonation-free operation is based on
designed limits for; combustion chamber surface temperatures (spark plugs, piston
crown and cylinder head inner surface, the presence of deposits), inlet air
temperature, and rate of pressure rise (spark ignition advance, ignition from sites
other than spark plugs). Variations in any of these factors, beyond designed limits,
will increase the likelihood of detonation during engine operation. In addition, the
cumulative effect of variations in a number of factors may also act to increase the
likelihood of detonation.
For the engine failure occurrences investigated in this study, it is clear that leaning
at climb power settings increases the likelihood of detonation. It is also evident that
the fuel-air mixture settings – lean climb and lean cruise, resulted in the deposition
of a non-volatile lead compound on combustion chamber surfaces. The presence of
non-volatile deposits also increases the likelihood of detonation.
With normal combustion, the pressure rise in a combustion chamber acts uniformly
on the piston. However, when detonation occurs, localised regions of high pressure
are created. As these regions of high pressure move, shockwaves are created. The
direction of shockwave propagation has an important effect on connecting rod
loading in horizontally-opposed engines. For the case of a horizontally-opposed
engine layout, end-gas detonation in horizontally-opposed engines will occur in the
regions over the piston pin ends, with shockwave propagation in a direction parallel
with the piston pin. The rocking of the piston pin in the plane of the little-end
bearing axis, and out-of-plane rocking of the big-end bearing, will affect the
integrity of the connecting rod assembly.
The rate of heat transfer from the combustion gas to the combustion chamber
(cylinder head and piston) is controlled, under normal combustion conditions, by
heat transfer across a gas boundary layer adjacent to the combustion chamber
surface. However, as the intensity of detonation and associated shockwave
propagation increases, the increasing turbulence in the combustion gases disrupts
the gas boundary layer. Once the gas boundary layer is disrupted, heat is transferred
rapidly to the combustion chamber components, leading to a rapid, large increase in
component temperature, and component failure when the incipient melting point is
reached.
For the engine failure occurrences investigated in this study, it is clear that leaning
at climb power settings increased the likelihood of detonation. It is also evident that
the fuel-air mixture settings – lean climb and lean cruise, resulted in the deposition

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of a non-volatile lead compound on combustion chamber surfaces. The presence of
non-volatile deposits also increases the likelihood of detonation.
The failure of bearings in aircraft horizontally-opposed engines can be related to
factors that: lead to a loss of hydrodynamic oil film stability or an increase in the
temperature of bearing materials or factors that control the magnitude of the bearing
insert retention force or the magnitude of forces which act to displace the bearing
insert. These factors are shaped by the functioning of other engine subsystems and
the actions of operators and maintainers.
Analysis revealed that events associated with the loss of oil film stability occurred
as a result of the development of high combustion gas pressures during high power
operation and, on other occasions, occurred as a result of inadequate bearing
clearance following maintenance actions performed to resize crankshaft journals.
Factors that were found to increase the temperature of bearings were: operation
under boundary lubrication conditions; the presence of an adherent nickel layer
between the lead-tin and aluminium-tin bearing layers exposed after bearing surface
wear; and the loss of metal-to-metal contact between the bearing insert and housing
through the inclusion of a lubricant.
The effect of increased bearing temperature during operation, on those bearing
inserts manufactured with an aluminium-tin intermediate layer, was the change in
the distribution of tin through diffusion. The formation of coarse tin particles at the
interface with the insert backing results, in a reduction of strength of the
intermediate layer and the breakaway of sections of the bearing.
The resistance of bearing inserts to movement in their housings is a function of the
magnitude of the friction force created by the interference fit and the magnitude of
forces acting to move the insert circumferentially and axially.
The magnitude of the forces acting to move an insert in its housing are affected by
increases in sliding surface friction (boundary lubrication and, in particular, the
sliding of a steel journal against an adherent nickel bearing surface) and the nature
of loading created by combustion. Combustion may have an effect through an
increased load on the bearing surface, increased bending moments on the main
bearings of crankshafts, and increased big-end bearing edge loads associated with
non-uniform gas loads on the piston created by the propagation of shock waves in
the combustion gases during combustion with light to medium detonation.
Powertrain components are designed to have a life not limited by fatigue crack
initiation and propagation to final fracture, within the bounds of specified
operational limits.
For the case of component designs that have passed certification testing and have
demonstrated fatigue-free operational performance, component failure analysis
indicates that:
• the component was subjected to alternating stresses that exceeded the
maximum design allowable value;
• a change in the distribution of component endurance strength from the
design state has occurred;
• a change in the component has occurred so that it is no longer bounded by
the component fatigue endurance strength distribution parameters; or

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• a combined reduction in component endurance strength and increase in
maximum alternating stress has occurred.
Crankshafts, regardless of the end application of the engine, are designed to have an
operational life not limited by fatigue. The complex interrelationships between
loads, geometric stress concentrators, residual stress, surface finish, surface
hardening, and material results in scatter in fatigue behaviour. Fatigue initiation at
the boundary between the surface hardened (nitrided) zone and core is a normal
location when bending or torsional loads just exceed the endurance strength of the
component.
The initiation of fatigue cracks in a powertrain component is not simply a matter
restricted to the material from which the component is manufactured. It is a matter
of all factors that affect the magnitude of component alternating stresses and the
component endurance strength. In addition to the complex interrelationships
between loads, preloads, geometric stress concentrators, residual stress, surface
finish, surface hardening, and material of an individual component, there are clear
interdependencies between the combustion process in individual and multiple
cylinders of a horizontally-opposed engine, the physics of plain bearing lubrication,
the mechanics of bearing insert retention, and the process of fatigue crack initiation.
The resolution of differences between reliability of propulsion systems achieved
during operation and the design level of reliability, is achieved by appropriate
adjustment or correction of the sub-systems and components that form the
propulsion system. Recurrent propulsion system failures suggests that system
adjustment or correction, through an effective feedback process, is not occurring.
Barriers to feedback may arise at various levels in a system hierarchy: individual
interactions, organisational goals and interactions, and societal influences. For
feedback in response to system malfunction to be effective, information must be
sensed, perceived, put into context, evaluated, analysed, and communicated.
Feedback in a complex engineered system is a function that relies on human
performance. Potential barriers to feedback may occur as a result of poor
communication, complacency, lack of knowledge, distraction, lack of teamwork,
fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness,
and accepted norms.
The complexity of systems has an important effect on the feedback process through
the inability to predict, with complete certainty, the consequences of interactions
between physical, chemical, mechanical and human processes.
The means of overcoming the barriers to effective feedback lies in developing an
awareness of the factors that: prevent the seeing of evidence clearly and in context,
result in incorrect classification, result in incorrect cause and effect linkages, and
interfere with communication at all levels. Feedback is highly dependent on
viewing the system in its entirety, and viewing its elements in detail. Feedback to
ensure continued safe operation should be based on the potential consequences of a
sequence of events.

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1 INTRODUCTION
Motion is fundamental to aircraft – without motion flight ceases. The safe operation
of an aircraft is based on the reliable performance of systems that provide motion –
systems that provide thrust.
This safety study is concerned with the performance of the propulsion systems that
provide thrust for aircraft commonly used in low-capacity public transport
operations. Typically, this class of operation utilises twin propeller propulsion
systems. While the engines that drive the propellers may be turbine or reciprocating
types, this study addresses the issue of reciprocating engine reliability.
The purpose of this study is to analyse the reported occurrences in order to identify
the factors affecting engine reliability. In doing so, it is intended that this report will
increase industry awareness of the identified factors and encourage safety action to
correct possible weaknesses or deficiencies in the system created to ensure engine
reliability. This study is an analysis of failures in a complex engineered system – an
aircraft reciprocating engine – it is not a treatise on engine design or operation.
However, a general understanding of engine design, manufacture, operation and
maintenance is necessary for effective analysis.
Reciprocating-engine powered low-capacity transport aircraft (8 to 10 passengers)
provide an important public transport connection throughout regional Australia. It
has been argued that these aircraft form the backbone of Australia’s rural and
regional air services (Swift, 2003). Around 1,270 multi reciprocating-engine
powered aircraft flying a total of around 220,000 hours for calendar years 2000 -
2005 are on the Australian register (BTRE, 2007 & CASA, 2007). Of these, about
200 reciprocating-engine powered aircraft were employed in the low-capacity
public transport operation (CASA, 2007).
The Piper Chieftain (PA-31-350) aircraft, is powered by two 350 brake horsepower
(bhp) Lycoming turbocharged six-cylinder horizontally-opposed engines, (L)TIO-
540-J2B(D). The Cessna Company has produced a series of 8 to 10 seat commuter
aircraft (models 401,402, 404, 411, 414, 421) powered by two Teledyne
Continental Motors turbocharged six-cylinder horizontally-opposed engines,
ranging from TSIO-520 (310 to 325 bhp) to GTSIO-520 (340 to 375 bhp) models.
These engines are very well-established designs with extensive demonstrated
reliable performance for their specified operational lives, in many countries, and
across many operators.
In the period January 2000 to December 2005, twenty powertrain structural failures
of high-power (300 to 375 bhp) horizontally-opposed, reciprocating engines were
associated with reported air safety occurrences. These occurrences range in severity
from: in-flight engine shutdown to engine failure and forced landing; engine failure
combined with in-flight fire and fracture of both upper engine mounts; to a fatal
accident of a regular public transport flight following the structural failure of both
engines and ditching at night, see figure 1.1.

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Figure 1.1: High-power reciprocating-engine structural failure occurrences,
2000 to 2005

–2–
 In addition to these reported air safety occurrences, several other structural issues
with this class of engine have been reported to the regulatory authority as major
defects 1 . In particular, there were a large number of reports of crankshaft bearing
failure (Sprigg, 2003).
While reciprocating engines have failed during service prior to January 2000, the
frequency of structural failure in the period 2000 to 2005 suggests that there was a
breakdown in the systems created to ensure engine reliability, in particular, the
systems created to ensure that structural failure of engine components does not
occur during flight.
The aim of this safety study is to examine the issue of high-power reciprocating
engine reliability in detail. The study is based on:
• developing an understanding of aircraft safety-critical systems and how
reliable propulsion system performance is achieved;
• evaluation of the available evidence associated with powertrain component
failures events, in the period 2000 to 2005, against a background of
component failure control plans;
• analysis of powertrain component failure events, individually and as a
group, to uncover the factors that initiate event sequences leading to
powertrain component failure; and
• analysis of the airworthiness assurance system to determine why there was a
reduction in high-power reciprocating-engine reliability over the period
January 2000 to December 2005.

1.1 References
Bureau of Transport and Regional Economics (BTRE), Regional Airline
Performance, 2007.
Civil Aviation Safety Authority (CASA), Civil Aircraft Register,
http://www.casa.gov.au/casadata/regsearch/findairs.as, May 2007.
Sprigg, DP 2003, Summary of Lycoming Engine Plain Bearing Failure Events in
Australia, 28 June 2003.
Swift, SJ 2003, Big Challenges for Little Airliners, 10th Australian International
Aerospace Congress, 29 July to 1 August 2003, paper number AIAC 2003-
1173.

1 Prior to June 2001 CASA operated the Major Defect Reporting (MDR) system. The system is now
known as Service Difficulty Reporting (SDR).
Major defects in relation to an aircraft, are defects that may affect the safe operation of an aircraft
or cause the aircraft to become a danger to person or property.

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–4–
2 AIRCRAFT SAFETY-CRITICAL SYSTEM
RELIABILITY

2.1 Introduction
The safe operation of an aircraft depends on the reliable performance of systems
that provide the fundamentals of flight: thrust, lift, stability and control. Safe
operation also depends on systems that maintain a habitable cabin environment,
assist navigation, and prevent collisions with the ground or other aircraft. These
systems are safety-critical systems
The success of a system, whether it be purely mechanical or human in nature, or a
combination of mechanical and human (socio-technical), is measured by its ability
to perform a designed function for a specified period of time. A successful system
is considered to be a reliable system. The study of system performance is also
known as the study of system reliability, where the term reliability relates to the
ability to provide a function for a defined period of time or the ability to prevent a
loss of function within the defined period of time. When a system loss of function
creates a threat to the wellbeing of operators, passengers and bystanders – a safety
hazard − the term system reliability may be translated to system safety. For the case
of aircraft, the term airworthy is used to encompass the issue of the reliable
performance of all systems that affect safe flight.
The analysis of the performance of a safety-critical system must be based on an
understanding of all facets of the system created to achieve safe operation. These
systems are engineered systems that rely on the ability of designers to predict future
system behaviour, and on feedback control to respond to threats to safe operation
encountered during continued operation.

2.2 Engineered systems

The systems that form the basis of public transport are engineered systems.
Engineered systems are socio-technical systems that are founded on the creation
and operation of man-made structures and machines. Engineered systems may be
broken down into a number of subsystems that may be divided further into system
elements that relate to technology and elements that relate to society.
The technological elements of engineered systems are based on our understanding
of the physical world (Ellis, 2004), a world of physical materials. The other element
of the technology framework is the set of physical laws that prescribe the
boundaries of what is possible, how objects are created and how machines are
operated. These laws are causally effective.
The societal elements of engineered systems are based on our understanding of
individual and communal consciousness – ideas, emotions and social constructions.
The structural hierarchy develops from the ideas and emotions through language,
individual knowledge and communal knowledge, to human goals and intentions.
Explicit social constructions such as language, customs, roles, and laws shape and
enable human social interaction. These social constructions have been developed
over time through conscious legislative and governmental processes. Each of these
elements is causally effective. Finally, there are societal elements that are derived

–5–
 from human behaviour and the behaviours of groups in society, people and their
customary attitudes, values, styles and relationships, reward systems, formal power
structures and informal power structures (from knowledge and personal power).
As socio-technical systems, engineered systems are not just simple relationships
between man and machine. The behaviour of an engineered system depends on the
relationships between all subsystems and system elements. System function is more
than the sum of individual elements, the interconnections between system elements,
more than each element, individually determines system performance.

2.3 Engineered system design

An underlying feature of engineering design is the need to predict the future
behaviour of structures, mechanisms, machines and operators. Will it work safely
and will it continue to work safely? In this less-than-perfect world our
understanding of materials, structures, mechanisms, machines and human behaviour
is not complete. System design requires human judgement and insight (especially in
decisions regarding safety). Structural analysis is done in support of, not in place of,
the creative process of design (Curtis, 1997). Mathematical models have limitations
— they are approximations of reality, the danger is that mathematical models can
hide a lack of knowledge.

2.3.1 The effect of complexity

Complexity affects the design of engineered systems. When the output of a system
is dependent on complex relationships between its component parts, our
understanding, and mastery, of system behaviour – to allow the prediction of future
behaviour of natural systems or the creation of man-made systems that achieve
specified goals – is based on decomposing the system into smaller and smaller parts
(modules), each of which may be refined or designed independently.
In addition to modularisation, the processes of abstraction and labelling in which
the system elements are reduced by ignoring their inessential details, forming an
idealised, labelled model of the element are used (Ellis, 2004). Elements are
simplified by encapsulation and information hiding. The system element is treated
as a black-box abstraction by specifying the expectation of the system element
while leaving the precise details of inner workings hidden. Each class of black-box
abstraction must have two parts, an interface – its exterior view that is common
with all other elements of the class of elements/objects, and an internal
representation and mechanism that achieves the desired behaviour/output. An
important property of classification is that each element class inherits all the
properties of its superclass.
Structural hierarchies define relationships between elements and further abstraction
through inheritance. Causal functioning within a hierarchy can occur from the
bottom up; what happens at a higher level depends on what happens at lower levels,
or top down; higher levels direct what happens at lower levels. Causal functioning
may also occur through less well defined interactions between system elements
regardless of their level.
The complexity of system element interaction leads to variations in output for the
same inputs. If there is a reliance on a particular output, then unexpected system
variation may result in an unanticipated output. Unexpected system element

–6–
 behaviours and/or interactions can cause new types of output that fail to meet
design expectations and affect system reliability. Faults can be propagated through
a system, through interdependencies between elements in unforeseen ways. It is
impossible to anticipate all possible relationships (Ellis, 2004).

2.3.2 Multiple goals

A characteristic of engineered systems is the presence of multiple and competing
goals. There will always be a tension between the desire for decreased threat to life
(safety) and the willingness to pay (cost to the user and profitability to the
operator). For the case of aircraft propulsion-system engines, there is competition
between the goals of economy, power, weight, bulk, and frontal area.
The state of balance between safety and profitability depends on the ability of the
creators, operators and regulators of an engineered system to learn. The rate at
which learning is achieved is dependent on the immediate goals of the various
players in the system, for example, driven by a need to satisfy a market, compete
with alternatives, or in reaction to an accident. Adjustments from learning in one
area may result in consequences that are not immediately apparent in another. The
connection between cause and effect in different areas may occur over widely
different time frames. Learning may also have to wait for developments in the
understanding of physical phenomena or human behaviour.

2.3.3 Fine tuning goals

The conflict that is created by the multiple goals of conservative system design for
system safety, cost, performance and profitability, results in the process of
subsystem and system element fine tuning. The danger of fine-tuning subsystems
and elements in a system that has multiple and conflicting goals is that changes can
always be justified and generate a benefit in one area while having an unrecognised
effect in another area.
System designers and operators are almost certain to reduce some safety factors
after creating a system, as continued successful system operation makes safety
factors look more and more wasteful (Starbuck and Milliken, 1998). Conservative
design with large safety factors, while ensuring safe operation in the face of
variations and uncertainties, may render projects prohibitively expensive or
technically impossible and thus prevent the solving of serious problems or the
attaining of important goals.

2.3.4 Risk management 1

A dilemma has been created by the need to quantify risk. The act of quantifying risk
results in the acknowledgment of a finite probability of failure. If failure occurs, is
this the failure predicted by statistics? If a predicted, extremely rare, event occurs
can it be argued that analysis to prevent recurrence is unnecessary because of the
small probability of recurrence?

1 Risk management is the human activity which integrates recognition of risk, risk assessment,
developing strategies to manage it, and mitigation of risk. The strategies include transferring the
risk to another party, avoiding the risk, reducing the negative effect of the risk, and accepting
some or all of the consequences of a particular risk.

–7–
 Risk in the context of public transport is not a simple technical matter of estimating
probability through mathematical calculation. Risk is also dependent on the
particular circumstances of the person who has to make a decision in the face of
uncertainty (Bernstein, 1998). Different people and different groups within society,
for example, those directly affected by a transport accident and those distant from
the accident, may ascribe different values to risk. These values may also change
with time. ‘Gut feeling’ is a significant factor in risk perception (Bernstein, 1998).

2.3.5 Response to goal deviation

Responses to system goal variation depend on the purposeful use of information
capture, storage, transmission, recall, and assessment to control subsystems and
system elements. Current information is filtered against a relevance pattern, the
irrelevant being discarded, the moderately relevant being averaged and stored in
compressed form, the most important being selectively amplified and used in
association with current expectations to assess and revise goals. Thus feedback
control systems based on sophisticated interpretation of present and past data
enables a purposeful response to goal deviations.

Figure 2.1: Schematic showing the relationship between system

elements, subsystems, and the goals (expectations) and
outcomes (reality) of a system

Feedback control loops operate at all levels within a system, the overall system,
subsystems and system elements. The linkages between the system goal comparison
function and the system adjustment function are information linkages. Feedback is a
necessary, widely called for, process in transport systems to ensure continued safe
operation.

–8–
 Feedback mechanisms are needed to ensure that the underlying assumptions
made during design and certification are continuously assessed in light of
operational experience, lessons-learned, and new knowledge. (National
Transportation Safety Board (NTSB) Safety Recommendation A-06-36
through A-06-38, May 17 2006)

The Society of Automotive Engineers (SAE) Aerospace Recommended Practice,

ARP5150, codifies the high level processes for conducting ongoing safety
assessments through a feedback mechanism.

2.4 Aircraft safety-critical subsystems

If the failure of a transport subsystem or system element creates a threat to the
wellbeing of operators, passengers and/or bystanders, then it is described as safety
critical.
During the design of transport systems, reviews are undertaken to identify safety-
critical subsystems and system elements. The reliable performance of a transport
system containing safety-critical subsystems is based, in the first instance, on the
provision of redundancy 2 for the safety-critical subsystems and system elements.
For instances where redundancy cannot be provided, actions including monitoring
of safety-critical subsystem/element performance combined with actions to restore
performance to design values, the limitation of operational time to a period in which
safety-critical subsystem/element deterioration does not exceed design values, and
the use of safety factors during safety-critical subsystem/element design, are
required to ensure safe operation (Civil Aviation Publication 418, 1990; FAA AC
120-17A, 1978).
The loss of function of a safety-critical subsystem or system element may not
always result in the loss of life through an accident. The complexity of transport
systems creates the possibility that the loss of function of a safety-critical subsystem
or system element may have a different outcome on different occasions – an
outcome that may be classified variously as; a reported difficulty, an incident, a
serious incident, or an accident.
Because of the number of people that may be affected by a system failure in a large
aircraft, a distinction is made for the purpose of airworthiness standards between
small and large aircraft. The dividing line between small and large aircraft is based
on a long-standing international agreement that large aircraft are those with a
maximum take-off weight exceeding 5700kg. Large aircraft are required to be
designed and operated in accordance with a fail-safe philosophy, which means that
a flight should be capable of being continued to a safe landing in the event of failure
of any of the various elements that go to make up the aircraft, other than those
justified on a safe-life 3 basis. To take account of a powerplant failure, for example,
a large aircraft must have more than one engine. The smaller aircraft are designed

2 Redundancy in engineering applications is the duplication of critical components of a system with

the intention of increasing reliability of the system, the duplicated system may operate in parallel,
sharing loads, but with sufficient capacity to maintain function in the event of one failure (fail
safe) or the duplicated system may operate in a standby mode.

3 Safe-life design philosophy may be used in situations where component properties or system
function degrade with continued operation. A specific component or system life, incorporating a
safety margin or reserve, is determined during design.

–9–
 and certificated against a simpler airworthiness code. The concept of fail safe is not
so rigorously applied; accordingly engine failure at a critical stage, during take-off,
may result in an accident (AAV Inquiry, 1980, p.325).

2.5 References
AAV Inquiry 1980, Report of Chairman of Board of Accident Inquiry on Accident
to Beech Super King Air 200 Aircraft VH-AAV at Mascot NSW on 21
February 1980, p. 325
Bernstein, PL 1998, Against the gods, the remarkable story of risk, John Wiley and
sons, New York
Civil Aviation Publication (CAP 418) 1990, Condition Monitored Maintenance: An
Explanatory Handbook, UK Civil Aviation Authority, Civil Aircraft
Airworthiness Information and Procedures, 1 July 1990
Curtis, HD 1997, Fundamentals of aircraft structural analysis, Irwin, Chicago
Ellis, GFR 2004, True complexity and its associated ontology, In Barrow JD,
Davies PCW, Harper CL, (Eds), Science and ultimate reality, quantum
theory, cosmology and complexity, Cambridge University Press,
Cambridge
FAA Advisory Circular 120-17A 1978, Maintenance Control by Reliability
Methods, 27 March 1978
National Transportation Safety Board (NTSB) Safety Recommendation A-06-36
through A-06-38, May 17 2006
Starbuck WH & Milliken FJ 1998, Challenger: Fine-tuning the odds until
something breaks, Journal of Management Studies, 25:4
The Society of Automotive Engineers (SAE) Aerospace Recommended Practice,
ARP5150, issued 2003-11

– 10 –
3 PROPULSION SYSTEM RELIABILITY

3.1 Introduction
Aircraft propulsion systems must have a high thrust-to-weight ratio. They must also
be economical, but above all, they must be reliable.
Propulsion systems that comprise of a reciprocating engine powered propeller
provide thrust for low-capacity public transport operations. These propulsion
systems are safety-critical systems and depend on the reliable operation of the
propeller and reciprocating engine.
The capability of a reciprocating engine to produce the power, specified by the
engine manufacturer, reliably throughout flight is a fundamental requirement of
safe operation. Conversely, the failure of engines to produce specified power levels
or the complete failure of an engine during flight is a threat to safe operation. The
expectation of safe operation is expressed, simply, in the design standard for aircraft
engines, Federal Aviation Regulations Part 33 Airworthiness Standards: Aircraft
Engines.
Engine design and construction must minimize the development of an unsafe
condition of the engine between overhaul periods.

In order to understand the factors that affect reciprocating-engine reliability, it is

necessary to develop an understanding of all of the sub-systems that combine to
produce the power specified by the engine manufacturer, for the duration of
planned flight. It is also necessary to develop an understanding of the hazards
created by engine failure and the methods used to prevent engine failure creating a
threat to safe aircraft operation.

3.2 Reciprocating-engine systems

It is important to recognise that, in reciprocating-engine installations, the engine
and propeller form an interdependent system. Constant-speed propellers are used in
conjunction with high-power reciprocating engines. This combination allows the
propeller speed and engine power to be set separately, to obtain the best
combination of performance and fuel economy, for all phases of flight.
Just as the engine and propeller form an interdependent system, the engine
subsystems (output power setting, structure, fuel/air mixture control, spark ignition,
lubrication, and cooling) and fuel consumed in the engine, form an interdependent
system. Engine performance and fuel properties are closely linked. The history of
spark-ignition engine development has been a process of mechanical refinement to
extract the available energy contained in gasoline under controlled combustion
conditions and a concurrent refinement of gasoline formulation to allow advantage
to be taken of mechanical refinements (Taylor, 1998, vol.1, p.425).

– 11 –
3.3 Reciprocating-engine reliability
Reliability is not a fundamental property of an engine. It is a result of the correct
performance of all subsystems through the phases of design, manufacture, operation
and maintenance, see figure 3.1.

Figure 3.1: Reciprocating-engine subsystems

The confidence that an aircraft engine will perform reliably and that risks are
managed is established by a certification process. The engine design, along with
approved instructions for operating limits, lubrication, inspection, component
replacement, and testing and adjustment, must pass an extensive testing program.
Reliability may be expressed in qualitative terms or quantitative terms. A
correlation between the qualitative and quantitative terms, along with descriptors of
failure severity and effect on aircraft and aircraft occupants, is shown in table 3.1. It
is normally accepted that a reliable system has a probability of failure of 1 in
10,000,000 (10-7) or that the probability of failure is extremely remote
(improbable).

– 12 –
Table 3.1: Relationships between qualitative and quantitative reliability
descriptors, severity descriptors, and effects on aircraft and
occupants (Smith, Cassell, and Cohen, 1999)

Probability -3 -5 -7 -9
1.0 10 10 10 10
(Quantitative)

Extremely
FAR Probable Improbable
Improbable
Probability
(Descriptive)
Reasonably Extremely Extremely
JAR Frequent Remote
Probable Remote Improbable

Failure FAR Minor Major Catastrophic

condition
severity
classification
JAR Minor Major Hazardous Catastrophic

Reduce capability of airplane or

crew to cope with adverse
Does not significantly operating conditions
reduce airplane safety Significant reduction in safety
(slight decrease in safety margins Conditions
margins)
Significant increase in crew which
Crew actions well within workload prevent
FAR
capabilities (slight continued
Severe Cases
increase in crew safe flight
workload) Large reduction in safety margins and landing
Some inconvenience to Higher workload or physical
Effect on occupants distress on crew, cannot be relied
aircraft upon to perform tasks accurately
and Adverse effects on occupants
occupants

Large reduction
Significant
in safety margins
reduction in
safety Crew extended
Operating margins because of Multiple
limitations workload or deaths,
Difficult for
JAR Nuisance environmental usually with
Emergency crew to cope
conditions loss of
procedures with adverse
aircraft
conditions Serious or fatal
injury to small
Passenger
number of
injuries
occupants

FAR; Federal Aviation Regulation (United States of America): JAR; Joint Aviation Regulation
(European).

– 13 –
3.3.1 The impact of structural efficiency
Structural efficiency in design is necessary to achieve high power-to-weight ratios.
The strength and robustness of engine components and mechanisms, within the
defined engine operating limits, is achieved by using materials that comply with
standard specifications (to guarantee that the properties of the materials used match
those assumed in design).
The engine must be designed and constructed to function throughout its normal
operating range of crankshaft rotational speeds and engine powers without inducing
excessive stress in any of the engine parts because of vibration and without
imparting excessive vibrational forces to the aircraft structure (FAR part 33, subpart
C, section 33.33).
A demonstration of the adequacy and robustness of the engine is provided by an
endurance test (FAR 33, subpart D, section 33.49). Engines are subjected to blocks
of engine operation under a variety of operating conditions to a total of 150 hours of
operation. At the conclusion of the endurance test, the condition of components and
mechanisms is assessed during a teardown inspection. Each component must retain
the functioning characteristics that were established at the beginning of the test.

3.3.2 The impact of combustion abnormalities

Combustion in spark-ignition engines is designed so that a flame front moves across
the premixed fuel-air charge in the combustion chamber resulting in a controlled
increase in gas pressure. Under certain conditions, rapid oxidation reactions occur
at many locations within the unburned charge, leading to very rapid combustion
throughout the volume. This essentially volumetric heat release in an engine is
called auto-ignition, and the very rapid pressure rise leads to the characteristic
sound of engine knock (Turns, 1996, p.6). Within the aviation industry this process
of auto-ignition or knock is referred to as ‘detonation’. Detonation can cause
mechanical damage through the creation of abnormal loads. It can also cause
component overheating and melting through its effect on the mechanism of heat
transfer.
Detonation of the fuel-air charge in a reciprocating engine is the principal factor
limiting the maximum power that can be produced by an engine. FAR 33, subpart
D, section 33.47 requires that:
Each aircraft engine type must be tested to establish that the engine can
function without detonation throughout its range of intended conditions of
operation.

Avoidance of detonation is achieved primarily by the use of fuel with a known

resistance to detonation (octane or performance number rating scales) and specified
engine operational limitations, which affect the combustion conditions in each
combustion chamber (a function of the engine design). Detonation-free operation is
not solely dependent on fuel properties. Factors such as charge temperature,
mixture strength, compression ratio and turbocharger boost pressure, ignition
timing and spark plug type can also affect the combustion process in an engine.
Detonation maps define the combinations of engine power and mixture strength for
a variety of limiting conditions (charge and combustion component temperatures)
that do not result in detonation.

– 14 –
3.4 Hazards created by reciprocating-engine failure
The failure of an engine powering an aircraft propulsion system can create a hazard
during aircraft operation by reducing aircraft performance, adversely affecting
aircraft control and stability, and exposing the flight crew to a period of abnormal
operation.

Figure 3.2: Engine failure consequence diagram

There are two possible defences for the hazard created by engine failure:
1. Pilot training to respond to the period of abnormal operation
2. Engine reliability.

3.4.1 Pilot response

The UK AAIB investigation of a fatal accident in which a Cessna 404 crashed
shortly after takeoff during an attempt to return to the airfield following responses
to a set of confusing signs and symptoms related to engine malfunction, discusses
the issue of pilot response to engine failure in this class of aircraft (UK AAIB report
2/2001).
The investigation established that accessory gear-train damage in the left engine
resulted in the progressive loss of all thrust from the left engine. The right engine
showed no evidence of mechanical malfunction, however, the right propeller had
been feathered.
The response to an engine failure in a twin-engine aircraft is based on correctly
identifying the failed engine, securing it, climbing away if necessary and flying a
single-engine approach and landing to a runway. Further, an engine failure after
takeoff in a twin-engine aircraft requires immediate, prioritised and accurate
corrective action from the handling pilot because of limitations in climb
performance.
The affect of an unexpected, complete, engine failure on aircraft behaviour and
pilot response is different to the affect of a progressive loss of power and final
engine failure.
The AAIB concluded that the handling skills required to successfully overcome an
unexpected engine failure, shortly after takeoff, in a twin-engine, aircraft are among
the most demanding of skills required by any aircraft pilot and that mishandled turn
backs are often fatal (UK AAIB report 2/2001).
A review of accident data for twin reciprocating-engine powered aircraft provides
further evidence demonstrating the critical nature of engine failures in this class of
aircraft (AVweb, 2003).

– 15 –
 Between 1972 and 1976, the NTSB investigated the outcome of twin engine
crashes and concluded that in the event of an engine failure that resulted in a
crash, the likelihood of it being fatal was four times greater than a crash in a
single.
Our most recent review of twin accident data tends to support this finding in
general, if not to the same decimal point. Typically, in crashes where an
engine failed in a twin, the accident was fatal between 20 and 50 percent of
the time; in singles, the fatal rate for powerplant failure is lower, on the order
of 10 percent, somewhat variable with model.

In light of the potential effect of engine failure on twin-engine, passenger-carrying,

aircraft and the lack of thrust-system redundancy for all phases of flight, engine
reliability is a critical issue and an important defence for safe operation.

3.4.2 Engine structural failure

The failure of the structure of a reciprocating engine may create additional hazards,
increased asymmetric drag and airframe failure. There are no effective defences to
these hazards.

Figure 3.3: Engine structural failure consequence diagram

The creation of drag through engine failure is the most critical factor influencing
the performance of 8 to 10 seat twin reciprocating-engine air transport aircraft.
The UK AAIB investigation of the Cessna 404 accident states that many aircraft of
this class will not sustain a single-engine climb at maximum take-off weight unless
the landing gear and flaps are retracted. In the period between takeoff and achieving
a suitable climb speed, a forced landing is the only outcome. An unexpected and
complete engine failure results in the propeller changing very rapidly from
producing thrust to producing drag – it takes time (up to 15 seconds) for a propeller
to move to the feather position after the feathering controls have been operated. The
reduction in forward thrust for the aircraft is significantly more than 50%. The
sudden change in thrust also tends to cause a loss in airspeed while the pilot
responds to the problem and takes corrective action. The single-engine rate of climb
is highly dependent on airspeed. If, after an unexpected failure, the airspeed drops

– 16 –
below the best rate of climb airspeed ‘blue line’, the aircraft may not climb despite
it being correctly configured (UK AAIB report 2/2001).
A greater effect on aircraft performance is the drag created when the engine
cowlings are disrupted by the forceful ejection of engine parts or fracture of engine
mounts. In this case forced landing is likely to be the only outcome.

Figure 3.4: The effect of the forceful separation of the No.1 cylinder
assembly on the engine cowling (occurrence 2000/90)

Examples of accidents and forced landings resulting from the disruption of engine
cowlings are present in the literature.
In 1995 a Piper Navajo was forced to ditch near Kennedy Airport following the
failure of the left engine while descending into Farmingdale, N.Y.
The pilot reported that the cowling was open – probably from the departing
cylinder that cratered the engine – and the best he could do was a 300 fpm
descent into the water. All six exited safely but one passenger died from
cardiac arrest. (AVweb, 2003)

The Transportation Safety Board of Canada Aviation Investigation Report

A99C0208 details the outcome of the forceful separation of the No. 2 cylinder from
the left engine of a Piper Chieftain.
The Piper PA-31-350 Navajo, C-GHMK, departed from St. Andrews,
Manitoba, on a visual flight rules charter flight to Berens River. One pilot and
ten passengers, including one infant, were on board, and a dog was stowed in
the baggage compartment behind the right, rear seat. At approximately 1530
central daylight saving time (CDT), while the aircraft was at an altitude of
about 2500 feet and about 30 nautical miles south of Berens River, the pilot
heard a loud sound from the left engine. He saw deformation of the left engine
cowling and smoke coming from the engine, and the aircraft yawed to the left.
Part of the engine cowling departed in flight. The pilot could not pull the left
propeller lever beyond half of its normal travel, nor could he move it into the

– 17 –
 feather position. He set maximum power on the right engine, but the aircraft
did not maintain altitude. The pilot advised company dispatch over the radio
that he would attempt a forced landing, then force landed in a mossy marsh
area. Everybody on board, including the dog, deplaned. Five of the passengers
sustained minor injuries during the evacuation. A fire ensued, completely
destroying the aircraft except for the empennage aft of the horizontal
stabilizers. (TSB Report A99C0208)

Fire created by the failure of engine structures represents an extreme hazard if it

exists for a period of time. The reduction of the structural strength of the airframe
can result in a catastrophic collapse of a wing. No fire extinguishing systems are
provided in this class of aircraft.
The fracture of a connecting rod little end resulted in the forceful separation of a
cylinder from the rear of an engine and the fracture of both upper engine mounts.
The disruption of the engine mounting system can allow the engine to droop in the
airframe and create a high drag condition.

Figure 3.5: The effect of No.6 connecting rod little end fracture on the
engine structure (occurrence 2003/2701)

3.5 Reliability measurement

In reality, components of reciprocating-engine systems do fail and flight safety may
be threatened by the total loss of thrust, partial loss of thrust, or damage to other
structures and systems by the effects of fire or physical impact. Because of the
complexity of the systems, the consequences of a component failure may be benign
or they may be catastrophic.
While reciprocating-engine reliability is an important factor in flight safety, it is
apparent that there is no hard measure of the reliability of these engines, in
particular, the horizontally-opposed engines in the 300 to 375 HP class that power
the 8 to 10 seat twin-engine air transport aircraft.

– 18 –
The UK AAIB, in the course of its investigation of the Cessna 404 Titan G-ILGW
accident (UK AAIB report 2/2001), raised the issue of engine reliability with
several regulatory agencies and asked for data on in-flight shut-downs by different
models of reciprocating engines. The response from the FAA, and other agencies,
was that no reliable data exist for this kind of comparison, largely due to ‘gross
under-reporting’ of in-flight shutdown of general aviation piston engines. The FAA
assessed the rate as ‘between 1 per 1,000 and 1 per 10,000 flight hours’. This failure
rate, qualitatively described as ‘probable’ or ‘reasonably probable’, is well in excess
of the ‘improbable’ or ‘extremely remote’ reliability goals expressed in design
standards.
Airsafety.Com provided another measure of reciprocating engine reliability in their
Information report, December 1, 2002.
The FAA’s accident/incident data base of 168,272 records was reviewed in
order to determine how often a mechanical or system failure was found to be
the causal factor in an accident.
Of 34,406 accidents since 1973 involving horizontally-opposed reciprocating
engines;
9,170 (27%) involved a system or mechanical factor (non-operational -
something broke or failed).
5,506 (16%) involved the engine or an engine system (ATA codes 7100 to
8597) (engine fuel, ignition, controls, exhaust, oil, starting, turbocharging).
1,315 (4% of the accidents, 14% of the mechanical failures, 24% of the
engine failures) involved either the engine power sectio (ATA 8520) or the
engine cylinder section (ATA 8530).
Considering that there are nearly 500 different ATA codes, ATA codes
8520/30 (engine power and cylinder sections) seem to be disproportionately
represented.
A comparison was made between several of the high performance
horizontally-opposed reciprocating engine models.
Teledyne Continental Motors (TCM) TSIO-360, 968 accidents
492 (51%) system or mechanical factor
266 (27%) engine or engine system
103 (11%) of the accidents, 21% of the mechanical failures, 39% of the
engine failures) ATA 8520/30
TCM GTSIO-520, 478 accidents
295 (62%) system or mechanical factor
174 (36%) engine or engine system

62 (13% of the accidents, 15% of the mechanical failures, 25% of the

engine failures) ATA 8520/30
Lycoming TIO-540, 944 accidents
512 (54%) system or mechanical factor
319 (34%) engine or engine system

– 19 –
 79 (8% of the accidents, 15% of the mechanical failures, 25% of the engine
failures) ATA 8520/30

3.6 References
Airsafety.Com Information report, December 1, 2002
AVweb 2003, Why twins crash, Aviation Consumer, December 2001. Reprinted by
AVweb, July 6, 2003, http://www.avweb.com/news/safety
FAR part 33, Federal Aviation Regulations part 33, Airworthiness Standards:
Aircraft Engines
FAR part 23, Federal Aviation Regulations part 23 Airworthiness Standards:
Normal, Utility, Acrobatic and Commuter Category Airplanes
FAR part 25, Federal Aviation Regulations part 25 Airworthiness Standards:
Transport Category Airplanes
Smith A, Cassell R, Cohen B, ‘An Approach to Aircraft Performance Risk
Assessment Modelling – final report March 31, 1999’, Rannoch
Corporation, Federal Aviation Administration Contract No. DTFA01-98-P-
01243
TSB Report A99C0208, Engine power loss/forced landing, Sowind Air Ltd., Piper
PA-31-350, C-GHMK, Princess Harbour, Manitoba, 29 August 1999,
Transportation Safety Board of Canada Aviation Investigation Report
A99C0208
Turns, SR, 1996, An Introduction to Combustion – Concepts and Applications,
McGraw-Hill Inc., New York
UK AAIB report 2/2001, Air Accidents Investigation Branch United Kingdom,
Accident Report No: 2/2001 (EW/C99/9/01), Report on the accident to
Cessna 404 Titan, G-ILGW, Near Glasgow Airport on 3 September 1999

– 20 –
4 POWERTRAIN STRUCTURAL RELIABILITY

4.1 Introduction
The structural core of a reciprocating engine is known as the powertrain. The
powertrain comprises of the assembly of cylinders, pistons, connecting rods,
crankshaft, crankcase, supporting structure, and bearings.
Of all the problems involved in engine design, that of securing a reliable
structure to withstand the heavy loads imposed by gas pressure, inertia forces
and thermal expansion, without excessive weight, bulk or cost is the most
difficult and basically the most important. Without a sound, reliable and
durable structure no amount of refinement of other aspects of design is of any
value. (Taylor, 1999, vol.2, p.425)

The dominant design issue for aircraft propulsion systems is the need to minimise
bulk, weight and cost for a given power output. The pursuit of high power brings
with it the need to, firstly manage the impact of high temperatures developed by the
combustion of fuel and, secondly, in concert with the pursuit of minimal weight,
manage the impact of high stresses in components of the engine.
Aircraft reciprocating engines have different requirements to automobile
reciprocating engines.

Table 4.1: Comparison of the requirements of aircraft and automotive

reciprocating engines (Taylor, 1999, vol.2, p.353)

Application Most Important Requirement Moderately Less Important

Important Requirement
Requirement

Passenger Automobile Low noise and vibration, reliability, Fuel economy, Long life
flexibility (smooth and efficient weight, bulk
operation over a wide range of
engine speeds and loads, low
maintenance

Aircraft Propulsion Light weight, small bulk, high power Low vibration, Initial cost, long
for takeoff, reliability, fuel economy low life, noise
(brake specific fuel consumption, the maintenance
mass of fuel an engine uses per
horsepower per operating hour),
operation over a small engine speed
range

The principal issues of aircraft reciprocating-engine reliability centre on the

management of component strength, component stress, and component temperature.
Excessive component stress and insufficient component strength can threaten
reliable operation through component fracture. Excessive component temperature
can threaten reliable operation through a loss of strength (softening) or component
melting. These threats are addressed through the development and implementation
of component failure control plans.
The objective in the design of engine powertrain components is to optimise the
desired performance requirements of safe efficient operation relative to cost
considerations (cost of materials, design, fabrication, operation and maintenance).

– 21 –
4.2 Powertrain component design
An internal combustion reciprocating engine is an energy conversion machine. The
potential chemical energy in the hydrocarbon fuel is converted to a rotational force
(turning moment or torque). In the case of an aircraft propulsion system, the torque
created by the engine is used to turn a propeller.
The output power of a spark ignition reciprocating engine is controlled by
throttling the air supply. The immediate purpose of opening the throttle is to
secure an increase in torque, whether or not an increase in speed follows
depends on the nature of the load. With governed engines, the throttle is
opened in response to a demand for increased torque, and little change in
speed occurs. On the other hand, engines driving fixed pitch propellers or
driving vehicles on a level road will respond to opening the throttle with an
increase in speed. (Taylor, 1999, vol.2, p.188)

Constant speed propellers act to govern the engine speed by varying the load on the
engine. Engine power can be set independently of engine speed.

4.2.1 The relationships between engine parameters

When a gas expands in a cylinder fitted with a moveable piston, work is done by
the gas on the piston (Ivanoff, 1994). The relationships between gas pressure,
engine capacity, engine speed, engine torque, engine power are summarised in the
following mathematical expressions.

W = p (V2 − V1 ) W work done by the gas at constant pressure

P the actual constant pressure or mean effective
pressure
V1 the initial volume of the gas
V2 the final volume of the gas
When the piston is connected to a crankshaft, as is the case in a reciprocating
engine, the movement of the piston causes the crankshaft to rotate. This turning
force is known as torque (T) and the distance the shaft is rotated is known as
angular displacement (θ). The work done by torque on a rotating object is a simple
function of torque and angular displacement.
W = T ×θ
When work is being done continuously over a period of time, the rate of doing work
per unit time is known as power. Power (P) produced by a torque in rotational
motion is a simple function of torque (T) and angular velocity (ω).
P = T ×ω
In the metric system of measurement, the unit of power is a Watt and the unit of
torque is a Newton-metre. In the imperial measurement system, the unit of power is
horse power and the unit of torque is foot pound. Angular velocity is commonly
measured as revolutions per minute. When power is measured at the output shaft of
an engine by a brake dynamometer, it is known as brake horse power (bhp).
For a spark-ignition engine, power has been found to be proportional to the engine’s
air capacity, provided the fuel-air ratio, compression ratio and spark timing are
constant (Taylor, 1998, vol.1, p.147). Power is controlled by varying the mass flow
of air – throttling the air supply.

– 22 –
P = JM& a ( FQcη ) P power developed
J mechanical equivalent of heat
M& a mass flow of dry air per unit time, or air capacity
Qc heat of combustion per unit mass of fuel
η thermal efficiency
F fuel-air ratio
The air capacity of an engine is commonly described by the parameter known as the
volumetric efficiency. This parameter is independent of cylinder size and is a
measure of the mass of fresh mixture which passes into the cylinder in one suction
stroke, divided by the mass of the mixture which would fill the displacement
volume of the cylinder.

2 M& i
ev = M& i mass of fresh mixture per unit time
NV d ρ i
N number of revolutions per minute
Vd total displacement volume of the engine
ρi inlet density

The volumetric efficiency of naturally aspirated engines is in the range 0.8 to 0.9.
Supercharging or turbo-supercharging is a means augmenting the air pumping
capacity of an engine by the use of an external compressor to increase the mass of
air inducted into the combustion chamber.
The rating of engines, that is, the specification of rated power, indicates the highest
power that is consistent with the specified engine reliability and durability. The
rated power of an engine is not the maximum power that may be produced by the
engine. The brake mean effective pressure (bmep) and piston speed are normally
used in the determination of the operating limits of an engine and assessment of the
capabilities of various design options. Brake mean effective pressure (bmep) is a
hypothetical quantity that is a measure of the mean pressure in the combustion
chamber during the engine cycle without considering the pressure needed to
overcome pumping and frictional losses (Repco, 1980, p.5).
Brake horsepower, torque and brake mean effective pressure are related to each
other as shown in the following expression (Repco, 1980, p.3).

PLAN 2π .n.T
= b.h. p = P bmep, pounds per square inch
33,000 33,000
L stroke, feet
A area of cylinder, square inches
n total number of firing strokes per minute
N revolutions per minute
T torque, pound-feet
This relationship was originally applied to steam engines. When units that are more
appropriate to high-speed reciprocating engines are used; cylinder diameter (D) –
inches, stroke (S) – inches, piston area (A) – square inches, number of working
strokes per minute (N), engine speed (n) in revolutions per minute, mean piston
speed (K) – feet per minute, brake mean effective pressure (P), horsepower (bhp),
torque (T) – pounds-feet, the relationships are shown in the following expressions:

– 23 –
 T .n P.D.2 K .N P.D.2 n.S .N P. A.S .n.N
bhp = = = =
5252 84,000 505,000 396,000

The reciprocating motion of a piston results in cyclic variations in piston velocity

and in acceleration. A parameter known as mean piston speed is used as a
parameter to evaluate design options. The limiting piston speed is determined by
the ability of the reciprocating structure to cope with the mechanical stresses
created by inertia (inertia stress increases with the square of piston speed). Limiting
piston speed is also determined by the desired fuel economy (Taylor, 1999 vol.2,
p378).

n.S
Mean Piston Speed = n number of revolutions per minute
6
S stroke, inches

4.2.2 Effect of engine layout

Various arrangements of cylinders around a crankshaft have been used in engine
design. These layouts include, inline, vee, horizontally-opposed and radial. The
radial layout gives the lowest weight-per-unit displacement because the material in
the crankshaft and crankcase is minimised for a given number of cylinders. The
ability to maximise power-to-weight resulted in the dominance of this type in large
propeller-driven transport aircraft. The horizontally-opposed engine layout gives
particular advantages through being short in length, light weight and having a small
frontal area for engine powers up to 375 bhp. The horizontally-opposed layout also
provides sufficient space between the cylinders for cooling fins and is suited for air
cooling, in particular air-cooled installations in smaller aircraft.
A comparison of the key engine parameters of power (bhp), engine speed (rpm),
combustion gas pressure (bmep), and piston speed (ft/min) between various aircraft
reciprocating engines, automotive engines and a marine engine is presented in table
4.2.

– 24 –
Table 4.2: Comparison of key engine parameters, aircraft, automotive
and marine reciprocating engine (Taylor, 1999, vol.2, pp. 410-
421)

Engine Layout Engine Model bhp rpm bmep, piston propeller Power/
psi speed, reduction weight,
ft/min gear ratio lb/bhp

Aircraft HO-6 IO-360D 210 2800 165 1760 1 1.4

Continental

Aircraft HO-6 TSIO-520-E 300 2700 169 1800 1

Continental

Aircraft HO-6 GTSIO-520-C 340 3200 162 2140 0.75 1.6

Continental

Aircraft HO-6 GTSIO-520-M 375 3350 171 2233 1

Continental

Aircraft HO-6 IO-540-D 260 2700 141 1969 1

Lycoming

Aircraft HO-6 IGSO-480 340 3400 165 2200 0.58 1.5

Lycoming

Aircraft HO-6 TIO-540-V2AD 350 2600 197 1896 1 1.6

Lycoming

Aircraft HO-6 TIO-540-J 350 2575 200 1878 1

Lycoming

Aircraft Radial Wright R1820-82A 1525 2800 236 3220 0.563 0.97

Automobile V-8 Mercedes380 SE 155 4750 110 2454

Automobile V-6 Nissan VG30E 160 5200 135 2834

turbocharged
200 168

Automobile V-8 Chevrolet 390 5200 139 3260

Automobile V-8 Ford 5L 134 3400 103 1700

Marine diesel Sulzer RTA84 48,360 87 223 1370 74

supercharged
I-12

Engine layout abbreviations: HO-6, six cylinders horizontally-opposed; V-8, eight cylinders in
a vee layout; V-6, six cylinders in a vee layout; I-12, twelve cylinders inline.

Engine model abbreviations: IO, injected opposed; T–turbocharged; TS–turbosupercharged,

R–radial; 540 etc., engine capacity in cubic inches.

This comparison shows that more power is produced from the same engine (same
capacity) at the same or reduced engine speed when the engine air supply is boosted
(turbocharged or supercharged) – compare the Lycoming IO-540-D engine with the
Lycoming TIO-540-J. It is also clear that a similar power can be obtained from a
turbocharged engine operating at different engine speeds by varying the combustion
gas pressure (bmep) – compare the Continental GTSIO-520 engines with the
Lycoming TIO-540-J engine.
The differences in engine/piston speed and combustion gas pressure between
various engine models, is reflected in the criticality of various powertrain
components. Higher combustion gas pressures will impose greater stresses on those

– 25 –
 powertrain components affected by combustion gas pressures, for example, cylinder
assemblies, pistons, connecting rods, crankshafts and bearings. Similarly, higher
engine/piston speeds will impose greater stresses on those powertrain components
affected by inertia loads and friction, for example, bearings, pistons, connecting
rods, and crankshafts.

4.3 Powertrain component reliability

Each type of aircraft operation, from recreational using single-engine fixed-gear
aircraft to low-capacity regular public transport using multiengine aircraft, imposes
special requirements on reciprocating engine design. Typically, the issues of power-
to-weight, reliability, simplicity of operation, initial cost and cost of operation, and
maintainability, determine the selection of design options. Aircraft performance,
through the use of high power-to-weight engines, is important in public transport.
Simplicity of operation and ease of maintenance are important for recreation
aviation. Engine reliability is important for all types of operation.
The failure of powertrain components has a direct effect on engine reliability, as
elements of the propulsion system, they are safety-critical. It is in the nature of
reciprocating engines that redundancy cannot be provided for powertrain
components.
When considering maintenance requirements for reciprocating engines, it is
important to realise that a reduction in failure resistance of powertrain components
usually cannot be detected by routine flight crew monitoring or by in-situ
maintenance or test. The function of powertrain components is hidden from view. It
is also important to realise that there may be an inverse relationship between
component age and component reliability.
Powertrain component reliability is achieved by a combination of hard time
maintenance actions such as replacement, measurement and overhaul at specified
intervals. Powertrain component reliability is not based on the principle of ‘run to
failure’ or ‘fit and forget’.

4.3.1 Safety factors

In the most general sense a mechanical system will fail when the stress imposed on
the system exceeds the strength of the system. If the system strength is known, then
the range of stress that can be applied to the system without resulting in failure is
clearly defined.
In reality, system failure stresses and operational stresses cannot be predicted for
each component during each moment of operation. Strength can only be determined
accurately by testing to destruction and operational stresses can only be determined
by continuous measurement. The consequence of uncertainty created by variations
in stress and strength is the need to apply safety factors to design values – a design
is an approximation, hopefully a conservative approximation, to an effective
structure or system.
The effect of uncertainty in operational stress and strength (failure stress) can be
shown diagrammatically, see figures 4.1 to 4.5. Structural failure occurs when the
operational stress exceeds the failure stress. The probability of failure can be
defined as the overlap of the distributions of operational stress and failure stress. It
is important to remember that because stress and failure stress are random variables,

– 26 –
the identity of particular components that lie in the overlap of the stress and strength
distributions, cannot be determined beforehand.
Safety factors are applied to some measure of the distribution of operational stress
and failure stress, for example, the mean or either an upper or lower tolerance limit.
Variations in the nature of the distributions; from component batch to batch, or
between different types of engine operation, may affect the ability of the safety
factor to achieve the desired level of component reliability.

Figure 4.1: Schematic illustration of the probability of failure under

conditions of variable operational stress and failure stress –
no failure condition.

If the distributions of operational stress and failure stress do not overlap, the probability of
failure is zero.

Figure 4.2: Schematic illustration of the probability of failure under

conditions of variable operational stress and failure stress –
failure condition

The area of overlap (coloured red) represents the probability of system failure.

– 27 –
Figure 4.3: Schematic illustration of the probability of failure under
conditions of variable operational stress and failure stress –
failure condition, the effect of distribution change

Changes in the nature of distributions, for example, skewing the distribution toward the lower
end of the failure stress distribution, will increase the probability of failure – everything else
being equal. Similarly, skewing the operational stress distribution toward the higher end of
the distribution will also increase the probability of failure.

For the case of components that deteriorate with operational usage, hard time
maintenance actions, such as, component replacement are based on a knowledge of
the distribution of component failure times and an adequate safety factor

Figure 4.4: The desired relationship between retirement time and

component failure time

– 28 –
 Figure 4.5: The relationship between retirement time and failure time that
results in a number of component failures

4.4 Powertrain component failure control plans 1

One of the key questions in developing a failure control plan for any particular
component of a machine or structure is determining the magnitude of the margin of
safety. The degree of safety and reliability needed (factor of safety) is often
specified by code. However, the degree of safety depends on many additional
factors such as consequences of failure or loss of redundancy, so it may vary within
a generic class of structures or machines. Accordingly, a component failure control
plan is developed only for the specific structure or machine under consideration and
can vary from one which, in essence, provides assurance of very low probability of
service failures, to one which may allow for occasional failures during service.
Structural reliability is a function of the effective operation of structural reliability
systems through all phases of the life of a structure - design, manufacture, operation
and maintenance. These systems minimise the probability and/or minimise the
consequences of component failure.

4.4.1 Component fracture control plans

When loads are applied to a component, fracture may occur through; yielding and
plastic collapse or unstable crack propagation from a site of stress concentration
(geometric feature or a region of pre-existing crack growth).
The essence of fracture control is ensuring that the mechanical strength of a
component is greater than the stress imposed on the component during operation,
throughout its designed lifetime (Rolf and Barsom, 1977). While the terms strength
and stress may be used in a general manner, the development of a fracture control
plan requires the identification of the most critical fracture mechanism or
mechanisms and the factors that need to be limited or controlled so that fracture
does not occur during operation. It is in the nature of components and applied loads

1 Risk assessment methodology used to limit catastrophic failure of an individual component, sub-
system or system. Generally, this involves varying degrees of inspection and monitoring, repair,
maintenance and eventual retirement. The concept is often initialised early on in the design stage
by the manufacturer, but may change depending on experiences encountered during actual service.

– 29 –
that variations from a norm do occur. The success of a fracture control plan depends
on the prediction of variation and the development of strategies to cope with
uncertainty in prediction.
For the case of yielding and plastic collapse, the critical factors are:
• material properties such as yield and ultimate tensile strengths (tensile,
compressive, shear, torsion);
• component stress as determined by component dimension and the nature and
magnitude of applied loads;
• potential reduction in material properties due to exposure to the operating
environment (e.g. softening resulting from exposure to elevated temperatures);
and
• potential increase in component stress due to exposure to the operating
environment (e.g. loss of cross-sectional area due to aqueous corrosion).
For the case of unstable crack propagation from a site of stress concentration the
critical factors are:
• the critical stress intensity for fracture of the material under the prevailing stress
state (plane stress or plane strain) and rate of loading; and
• the stress intensity at the site of stress concentrating features (this is a function
of geometric detail and the nature of applied loading).
For the case of unstable extension of a pre-existing crack the critical factors are:
• the critical stress intensity for fracture of the material under the prevailing stress
state and rate of loading;
• the nature of subcritical crack growth (e.g. fatigue cracking or stress corrosion
cracking) and the operating parameters that affect the initiation of crack growth
and the rate of crack growth; and
• the residual strength of the component as a function of crack size.
When fracture from fatigue crack growth is considered to be a threat to the integrity
of a component or structure, two options may be considered during design; the
specification of component strength and the control of operational stresses to avoid
crack initiation (infinite fatigue life), or the development of a plan to retire the
component from service after a period of operation (finite life).
A number of strategies have been developed to ensure structural integrity when a
component is expected to have a finite life. A component may be removed from
service after a predetermined ‘hard time’ period, known as its ‘safe life’. Structural
redundancy may be provided in a manner that allows load sharing in the event of
component fracture. Note: it is important that redundancy is coupled with repeated
inspection for component failure as cracking may initiate and grow in the other
elements of the redundant design. Finally, in the damage tolerance approach, the
choice of material and design allows non-destructive inspections, at repeated
intervals, to detect cracks before they reach a critical size. The component is
replaced when a crack is detected.
The nature of reciprocating engines determines that those components subjected to
alternating stresses are designed on the basis that their operational life is not limited
by fatigue fracture – they are retired from service as a result of wear.

– 30 –
4.4.2 Component melting control plan
Simply, a melting control plan is based on preventing the temperature of a
component reaching the melting point of the material. It should be noted that alloys
melt over a range of temperatures. The critical temperature from a structural point
of view is the incipient melting point.
Control of component temperature requires control of the magnitude of heat energy
liberated by a process, the control of heat transfer to the component, and the control
of heat removed from the component.
For an air-cooled engine, heat energy is removal from the combustion chamber by
air flowing over the exterior of each cylinder head. It is important to note that the
cooling system consists of the cylinder-head cooling fins, inter-cylinder baffles and
engine cowling. The variable in the cooling system is the air pressure in the cowling
– a function of airspeed and cowl flap position, if cowl flaps are fitted.

4.4.3 Bearing surface damage control plan

Plain bearings are used to transmit loads between rotating crankshafts, connecting
rods and crankcases. These bearings operate under a hydrodynamic lubrication
regime – a high-pressure oil film supports the shaft in the bearing and transmits the
applied loads. Hydrodynamic lubrication is created by the slight eccentric rotation
of a shaft in the bearing; a converging gap traps oil and results in the development
of a localised high-pressure oil film. The critical features for successful bearing
operation are; the dimensions and geometry of the shaft and bearing, the surface
roughness of the shaft and bearing, and the rotational speed of the shaft in the
bearing.
It is common practice for bearings to be created by assembling precision bearing
inserts into a bearing housing; this practice allows the bearing surface to be
replaced easily following wear.
The nature of hydrodynamic lubrication places two demands on the bearing. Firstly,
surface roughness needs to be controlled to prevent oil film disruption. Secondly, a
suitable metal surface needs to be provided to minimise friction and wear between
the shaft and bearing for the short periods of operation when the rotational speed of
the shaft is below the minima for hydrodynamic film formation (boundary
lubrication regime). These periods occur at engine start-up and shutdown.
Bearing design and manufacture is governed by the requirements to provide the best
bearing surface to cope with short periods of boundary lubrication and
contaminants in the oil, while having sufficient strength (load endurance factor) to
avoid the break-up of the surface by fatigue cracking. These requirements are met
by the creation of multilayer bearing inserts, control of bearing loads, control of
bearing temperatures, control of oil temperatures, and control of bearing
dimensions.
The load that may be carried by a plain bearing depends on many factors, including
the characteristics of the lubricant as well as the bearing. Theoretically, the oil film
will not fail if the product of oil viscosity and rotational speed divided the oil film
pressure does not fall below a critical value (Taylor, 1999, vol.2, p.513).

– 31 –
4.5 References
Repco 1980, Repco Engine Service Manual, Repco Limited, Melbourne, 1980
Rolfe ST, Barsom JM 1977, Fracture and fatigue control in structures, applications
of fracture mechanics, Prentice-Hall New Jersey, pp. 414-440
Taylor CF 1998, The internal combustion engine in theory and practice, Volume 1:
thermodynamics, fluid flow, performance, second edition revised, The
M.I.T. press, Cambridge Massachusetts
Taylor CF 1999, The internal combustion engine in theory and practice, volume 2:
combustion, fuels, materials, design, second edition revised, The MIT
Press, Cambridge Massachusetts
V Ivanoff 1994, Mechanical engineering science an introduction, McGraw-Hill,
Sydney, p.401

– 32 –
5 FAILURE ANALYSIS METHODOLOGY

5.1 Introduction
The task of analysing engineered-system failure is, essentially, one of
reconstructing an event sequence against a background of system design,
manufacture, assembly, operation and maintenance (Romeyn, 2002, 2004, 2006).
Traditionally, investigations of engineered-system failure have involved the
gathering of facts; what happened, what failed, how did it happen, how did it fail?
More recently, there has been a greater emphasis placed on determining why
failures occur. The issue of determining why is easy to say but is it easy to do?
What do we need to learn and how do we learn it? How do we know when we have
learnt it? How do we achieve system correction? Finally, why do failures continue
to occur?
Failure analysis, in the context of transport systems, is the descriptive term for the
process of feedback that aims to correct safety-critical subsystems and system
elements to achieve the system goal of safe operation. In keeping with all other
feedback processes, it operates through information linkages. These linkages are
human-based and involve the processes of information capture, information
processing, and interaction with others who may be required to change subsystems
or system elements.

5.2 Methodology
In keeping with many other fields of study and pursuits of learning, a method is
used to provide the framework for failure analysis.
For occasions where learning is initiated by a past event, analysis begins with
observations (physical, recorded and reported evidence), followed by the
development of more general statements regarding patterns of behaviour or
classification of events into groups that have similar characteristics and mechanisms
of behaviour, before developing a hypothesis and drawing conclusions. This
method is commonly used in science and employs inductive reasoning in the initial
stages. It is different to another research method that seeks to establish if a theory
applies to a particular circumstance or behaviour through a process of hypothesis
development and testing.

Figure 5.1: Relationships between observation and reasoning

– 33 –
5.3 Information gathering
Information gathering (information capture and processing) can be divided further
into the processes of seeing, classifying, communicating, evaluating, and analysing.

5.3.1 Seeing
The most important features of seeing are the mental images created in response to
sensory input. Seeing is much more than the physical process of image formation.
Features in our environment are brought to our sense of sight for recognition and
quantification through a variety of tools; simple lens, electron microscope,
thermometer, and all manner of instrumentation.
All day and every day we are receiving information from our sensory organs. The
decisions and judgements we make are based on the information received and the
ways in which we adapt to, and deal with, new information. Some information is
sensed as immediately useful and is acted on. Much is sensed as not immediately
useful; we are aware of receiving it but we do nothing about it. Other information is
received without any conscious awareness. Successful detectives differ from less
successful ones in their ability to perceive the relevance of information, which the
rest of us ignore, regard as irrelevant, or do not see, to the solution of their problem
(Johnson Abercrombie, 1969). It is important to be able to see the detail of system
element construction and behaviour as well as the construction and behaviour of
subsystems in the context of an overview of system expectations and reality; goal –
output matching.
The process of seeing is dependent on individual traits and abilities. These traits and
abilities give rise to variability in information gathering that extends to variability in
the effectiveness of feedback control. The success of analyses depends on the
mental processes and knowledge of the analyst.
What one sees or observes depends on what one knows and understands
(Hull, 1999).
And the new object presented to Sense, or a new idea presented to Thought,
must also be soluble in old experiences, be re-cognized as like them,
otherwise it will be unperceived, uncomprehended (Lewes, 1879).

5.3.2 Classifying
Every person has a store of information. As a result of seeing, listening, reading,
reflecting on our experiences, and reasoning, we acquire both information and
misinformation. Every person also has persistent deep-rooted ways of classifying
information, thinking, perceiving, and behaving. The process of classifying is the
process of matching observations with our prior store of information. The effect of
personal assumptions, bias, and preconceptions can lead to classifications that differ
from those made by others.
The strength of the process of classification is in its ability to tap into knowledge
developed in other places and at other times. It also allows logically valid
inferences to be made on the basis of experiences from the operation of other
systems and the conduct of prior, controlled, experiments.
Classification of event significance is a process that creates a dilemma.
Classification for significance is conducted against a relevance pattern that may be

– 34 –
 an individual norm, an industry norm, or a societal norm. If an event is considered
to be of low significance, the information is discarded. If an event is considered to
be of moderate significance, the information is averaged and stored in compressed
form. If an event is considered to be of high significance, the information is
selectively amplified and used immediately to assess and revise subsystem and
system element performance.
In a complex system, such as a transport system, the presence of redundancy and
other strategies to minimise the effect of critical subsystem or system element
failure on system safety, creates a dilemma of significance. Subsystem or system
element failure with no catastrophic outcome may be viewed as a measure of the
robustness of the system, or it may be viewed as an example that the system is
operating in ways not anticipated during its creation. Additionally, in a complex
system with multiple strategies to minimise the effect of safety-critical subsystem
system or system element failure, an immediate threat to wellbeing is not always
created through subsystem or system element failure. However, it has been well
recognised that lesser events can, in combination with other events and
circumstances that may be extremely difficult to predict, create a threat to wellbeing
at some other time (O’Hara, 2004). There is value in acting to prevent system
failure through correcting subsystem and system element failure rather than reacting
to system failure.
In judging the severity of the event, it is important to understand the actual
consequences that the observed event had on airplane operation. It is even
more important, however, to understand the potential consequences if the
event had occurred in more vulnerable circumstances. (SAE ARP5150)

The classification of solid rocket booster O-ring erosion and external fuel tank foam
strike damage as nagging issues, of seeming little consequence, was initially taken
as evidence that the Space Shuttle design was capable of operating successfully
with these design deviations. They were not taken as signals of potential danger.
The significance of O-ring erosion, and 17 years later, foam debris strikes, became
clear in retrospect, after lives had been lost (Columbia Accident Investigation
Board, 2003).

5.3.3 Communicating
Knowledge and understanding are gained through interactions between other
analysts, designers and operators of systems, and other members of society with
specialised knowledge. The critical issue is about gathering proper answers to the
right questions. Formulating the right questions requires a broad knowledge of
system structures, interactions and control hierarchies, and a common technical
language. The use of technical descriptors can be a source of confusion when
different meanings are attached to the same descriptor.
Effective feedback is dependent on the creation of an information linkage, through
oral and written communication between the analysts, designers, and operators of
engineered systems. The dependence on oral and written communication is a
potential barrier to effective feedback. Communication across professional
groupings and disciplines is affected by the culture, preconceptions and, possibly
bias, of each grouping.

– 35 –
5.3.4 Evaluating
Evidence associated with an event needs to be evaluated from the viewpoint of the
system structural and control hierarchies in order to resolve what subsystem or
system element failure led to the threat to safe operation.
Successful evaluation comes from the conscious consideration of many possible
cause and effect linkages rather than jumping to a conclusion without considering
the evidence for alternate cause and effect linkages. Important discoveries in
science provide clear examples of making use of information that had previously
been regarded as unimportant or useless. The ability to address new problems
depends on the ability to make new associations between information where,
previously, there have been no conventional or traditional relationships.

5.3.5 Analysing
Cause and effect linkages associated with an event need to be analysed to determine
what designed subsystem or system element controls and limits were ineffective,
inoperative, or not present. Analysis requires knowledge of the normally hidden
internal variables within a system and a deeper knowledge of subsystem and system
element behaviours that are normally treated as black-box abstractions.
Analysis is a process of learning. Learning implies the gaining of knowledge; in the
case of failure analysis, the gaining of knowledge that allows a system to continue
to achieve the goal of safe operation. The process of learning is a key variable in
achieving effective feedback control.

5.4 References
Aerospace Recommended Practice, ARP5150 (2003). Safety assessment of
transport airplanes in commercial service, SAE International, Warrendale
Bernstein, PL 1998, Against the gods, the remarkable story of risk, John Wiley and
Sons, New York
Columbia Accident Investigation Board 2003, Columbia investigation board report
volume 1. Washington, National Aeronautics and Space Administration and the
Government Printing Office
Curtis HD 1997, Fundamentals of Aircraft Structural Analysis, Irwin, Chicago
Ellis GFR 2004, True complexity and its associated ontolog, In Barrow JD, Davies
PCW & Harper CL (Eds), Science and ultimate reality, quantum theory, cosmology
and complexity, Cambridge University Press, Cambridge
Hull, D 1999, Fractography: observing, measuring and interpreting fracture
surface topography, Cambridge University Press, Cambridge
Johnson Abercrombie, ML 1969, The Anatomy of Judgement, Penguin Books,
Harmondsworth
Lewes, GH 1879, Problems of life and mind, In Johnson Abercrombie ML 1969,
The Anatomy of Judgement, Penguin Books, Harmondsworth
O’Hara, K 2004, Trust, from Socrates to spin, Icon Books, Cambridge

– 36 –
Romeyn A 2002, Analysis of failures in complex systems, International Failure
Analysis Conference 20-22 November 2002, Melbourne, The Institute of Materials
Engineering Australasia Ltd
Romeyn A 2004, Transport safety investigations – engineering failure analysis
methodology, International Failure analysis And Maintenance Technologies
conference 29-30 April 2004, Brisbane, The Institute of Materials Engineering
Australasia Ltd
Romeyn A 2006, When something breaks – the anatomy of failure analysis,
Evolving System Safety 2006, 7th International Symposium of the Australian
Aviation Psychology Association, Manly, Australia, 9-12 November 2006
Starbuck, WH, Milliken, FJ 1988, Challenger: fine-tuning the odds until something
break, Journal of Management Studies, 25: 4

– 37 –
– 38 –
6 POWERTRAIN FAILURE OCCURRENCES –
2000-2005

6.1 Introduction
During the period, January 2000 to December 2005, 20 in-flight engine failures
occurred in Australia. Each in-flight engine failure was caused by the structural
failure of a powertrain component. An overview of both the frequency and nature of
these occurrences is shown in figure 6.1.
The distribution of reported powertrain failure occurrences over the six-year period
was not uniform. There were five occurrences in 2000 (one involved the structural
failure of both engines), seven occurrences in 2001, three occurrences in 2002, two
occurrences in 2003, one occurrence in 2004, and one occurrence in 2005.
Sixteen of the 20 failures involved Lycoming TIO-540-J2B(D) engines fitted to
Piper Chieftain aircraft, two failures involved Lycoming IO-540 engines, one fitted
to an Aero Commander and one fitted to a Piper PA32, one failure involved a
Teledyne Continental Motors TSIO-520-E engine fitted to a Cessna 402B, and one
failure involved a Teledyne Continental Motors GTSIO-520-M engine fitted to a
Cessna 404.
It is also evident from the reported occurrences that structural failure was not
restricted to a particular powertrain component. The failures involved cylinder head
fracture, piston edge melting, connecting rod little-end fracture, connecting rod big-
end fracture, cylinder attachment stud fracture, bearing failure, and crankshaft
fracture.
For each reported occurrence of powertrain structural failure, the available evidence
is examined to identify the key event in the failure sequence and classify the
structural failure mechanism. The occurrences are grouped according to the
structural subsystems affected, combustion chamber, connecting rod, crankshaft,
bearings. The evidence examined for each occurrence consists of; reported evidence
(pilot statements, witness reports and maintenance records), physical evidence (an
examination of engine components), and where available, data relating to engine
and aircraft performance that had been recorded electronically.

– 39 –
Figure 6.1: Timeline of powertrain structural failure occurrences for the
period January 2000 to December 2005

– 40 –
6.2 Combustion chamber assembly failures
The typical form of combustion chamber structures for air-cooled aircraft
reciprocating engines is a cast aluminium alloy cylinder head connected to a steel
barrel, with an aluminium alloy piston. The cylinder barrel is attached to the
crankcase by a number of threaded fasteners.
The discontinuous nature of combustion in a reciprocating engine and the heating
and cooling that accompanies each period of engine operation (start/stop cycle),
creates cyclic stresses in various elements of the combustion chamber structure.
Cyclic stresses, developed through cyclic pressures and cyclic, differential,
expansion and contraction, create a threat to structural integrity through the
possibility of fatigue crack initiation and propagation.
Because heat is liberated during combustion, a mechanism to transfer heat away
from the combustion chamber is required in order to maintain the temperature of
structural elements to design-allowable temperatures. The failure to transfer heat
effectively creates a risk of material softening or melting.

Table 6.1: Combustion chamber failure occurrences, period 2000 to

2005

Occurrence Occurrence Aircraft Component Failure

Number Date Registration
(Engine type)

2000/2157 31 May 2000 VH-MZK (right) No.6 Cylinder head and piston
Lyc LTIO-540-J2B melting
2000/3675 10 Aug 2000 VH-NPA No.6 Piston melting
Lyc LTIO-540-J2B
2001/2885 17 Jun 2001 VH-MJA No.1 Cylinder head fracture
Lyc TIO-540-J2B
2001/3357 5 Jul 2001 VH-RNG No.4 Cylinder attachment stud
Lyc LTIO-540-J2B fracture
2001/3251 25 Jul 2001 VH-FIA No.2 Cylinder attachment stud
Lyc TIO-540-J2B fracture
2002/2059 12 Apr 2002 VH-LTW No.3 Piston melting
Lyc LTIO-540-J2B
2002/5129 5 Nov 2002 VH-TZY No.4 Cylinder attachment stud
Lyc LTIO-540-J2B fracture
2003/3532 4 Aug 2003 VH-HJS No.5 piston melting
Lyc LTIO-540-J2B

– 41 –
6.2.1 Occurrence 2000/2157 VH-MZK (right engine)

Reported evidence
VH-MZK was forced to land on water, at night, following the failure of both
engines. All passengers and crew were fatally injured.
Time since overhaul: 1,395 hours

Physical evidence
Examination of the right engine revealed that melting of a region of the No.6 piston
edge allowed combustion gases to bypass the piston rings, see figure 6.2.

Figure 6.2: No.6 piston, MZK right, overview of the piston crown and a
detailed view of the region of localised melting

– 42 –
In addition to the melting of the piston edge, localised melting had affected a
localised region of the cylinder head, see figure 6.3. Melting occurred in the region
between the upper spark plug hole and the edge of the exhaust valve. Heat transfer
from this region is affected by the presence of the port between the exhaust valve
and cylinder head exhaust flange. The separation of this region from the air-cooled
surfaces of the remainder of the cylinder head, results in a higher temperature in
this region of the cylinder head. When cylinder head temperatures are increased
generally, the region between the upper spark plug and exhaust valve will be first to
reach the melting point of the cylinder head alloy.

Figure 6.3: No.6 cylinder head, MZK right, overview of the combustion
chamber surface and a detailed view of the region of
localised melting

– 43 –
Examination of the remaining five pistons from the engine revealed that the No.5
piston displayed evidence of piston edge distress from exposure to high
temperatures, see figure 6.4.

Figure 6.4: No.5 piston, MZK right, region of edge distress (arrowed) and
a metallographic section taken through the piston edge

The metallographic section is oriented with the piston crown to the right and the piston side
to the top. The microstructural features indicate that material is breaking away from the
piston edge as a result of extensive softening of the edge and the forces developed during
engine operation.

Recorded evidence
Evidence of aircraft performance was limited to that derived from recorded radar
data and recorded voice transmissions between the pilot and ground stations. This
class of aircraft is not required to be fitted with a flight data recorder or a cockpit
voice recorder. While the data relating to aircraft operation and flight performance
is limited, useful data on the performance of the aircraft propulsion system was
obtained.
The takeoff, climb, and the cruise phases of flight were recorded by two radar
sensors – Adelaide and Summertown. Altitude, aircraft heading and groundspeed
data was recorded every 3.6 seconds – the period relates to the period of radar
sensor rotation. This frequency of data collection is sufficient to establish
performance trends, such as, rate of climb, but insufficient to detect changes in
performance parameters over periods of less than, approximately, 12 seconds.
During radio transmissions between the pilot and ground stations, other sounds in
the cockpit will be transmitted when the pilot’s microphone is keyed. One
background sound that is of use to the investigation of propulsion system
performance, is the sound created by the aircraft’s propellers. The sound created by
propellers is characterised by discrete frequencies occurring at harmonics of the
blade passing frequency, a function of the number of blades and the propeller speed
(Lan and Roskam, 1988). The sound level, for a particular propeller design,
increases with absorbed power and increased tip speed. Data on propeller/engine

– 44 –
speed obtained from audio analysis relates, only, to the period that the pilot’s
microphone is open – the data relates to short intervals of flight.
A comparison was made between the flight performance, as recorded by radar, of
several Piper Chieftain (PA 31-350) aircraft, departing Adelaide airport, prior to
and following the flight where both propulsion systems failed on MZK.
A plot of altitude versus flight time is shown in figure 6.5. The ground track of each
aircraft is shown in figure 6.6. The details of each flight are:
• MZK departing Adelaide at 0530 UTC, 31 May 2000, for Port Pirie – VH-MZK
YPAD-YPIR
• MZK departing Adelaide at 0850 UTC, 31 May 2000, for Whyalla (accident
flight) – VH-MZK YPAD-YWHA
• NPB departing Adelaide at 1030 UTC, 31 May 2000, for Port Pirie – VH-NPB
YPAD-YPIR
• AZJ departing Adelaide at 2140 UTC, 31 May 2000, for Leigh Creek – VH-AZJ
YPAD-YLEC
Note: local time in Adelaide was Australian Central Standard time (Australian
Central Standard time is 0930 hours ahead of Coordinated Universal time, UTC).
It is evident that the takeoff and climb phase of flight for the accident flight (MZK
YAD-YWHA) was normal and comparable to climb phases for the other flights,
given variations in aircraft weight. The rate of climb was constant to cruising
altitude. Climb performance is a direct function of propulsion system performance.
Any pilot-commanded change in propulsion system settings or any propulsion
subsystem/component loss of function will be reflected by a change in the rate of
climb.

Figure 6.5: Altitude versus flight time profiles to the limit of radar
coverage, radar data recorded for Piper PA31-350 aircraft
operating out of Adelaide (31 May 2000)

11500
11000
10500
10000
9500
Barometric corrected Mode C Altitude (feet)

9000
8500
8000
7500
7000
6500
6000
5500
5000
4500
4000
3500
3000 VH-AZJ YPAD-YLEC
2500 VH-NPB YPAD-YPIR
2000 VH-MZK YPAD-YPIR
1500 VH-MZK YPAD-YWHA
1000
500
0
0 200 400 600 800 1000 1200 1400 1600 1800 2000 2200 2400 2600 2800 3000 3200
Elapsed Time (sec)

– 45 –
Figure 6.6: Ground tracks, radar data recorded for Piper PA31-350
aircraft operating out of Adelaide (31 May 2000)

95

85

75

65

55
Y (n a u tic a l m ile s )

45

35

25

VH-AZJ YPAD-YLEC

VH-NPB YPAD-YPIR 15

VH-MZK YPAD-YPIR

VH-MZK YPAD-YWHA 5

-5
-50 -40 -30 -20 -10 0 10
X (nautical miles)

A detailed examination of the parameters of altitude, ground speed and heading for
the accident flight (MZK) indicated that the initial section of the cruise phase of
flight was normal. However, it is evident that, 17 minutes after top-of-climb, there
was a short-term deviation in heading (approximately two minutes) accompanied by
a sustained drop in ground speed. The event responsible for the deviation in heading
and reduction in ground speed may have been the sudden failure of one engine. It is
important to note that the deviation in heading does not represent the direction of
aircraft yaw that would be expected to accompany a sudden engine failure in a
twin-engine aircraft. The deviation in heading may be a consequence of a control
response to an engine failure, and may be an under or over correction.
Analysis of the available audio transmissions indicated that during climb the
propeller speed was 2,400 rpm, the normal propeller speed for climb. During cruise
four minutes after the top-of-climb, the propeller speed was 2,200 rpm, the normal
propeller speed setting for cruise. However, eight minutes after the event that
initiated the heading deviation and ground speed decrease, audio analysis indicated
that the propeller speed was 2,400 rpm, an abnormal propeller speed for the cruise
phase of flight.

– 46 –
Figure 6.7: Altitude, ground speed, and heading for VH-MZK, accident
flight

PA31-350 Chieftan VH-MZK

6000 210

200
5500
190
TOP of CLIMB TOP of DESCENT
5000 180

170
4500 160

EVENT 150
4000
140
Altitude (feet) / Heading (degT)

3500 130

Groundspeed (knots)
120
3000
110

100
2500
90
2000 80

70
1500
SYTR.HEADING 0.1DEG 60

1000 SYTR.ALTITUDE FEET 50

SYTR.SPEED_MOD KTS 40
500
30

20
0
10

-500 0
8:50:00 8:55:00 9:00:00 9:05:00 9:10:00 9:15:00 9:20:00 9:25:00 9:30:00
Time (UTC)

Figure 6.8: Ground track for VH-MZK, accident flight, polar plot

Track of VH-MZK

100
north

90

80

70

60

event
50

40

30

20

10

0
-75 -65 -55 -45 -35 -25 -15 -5 5

-10

Fourteen minutes after the event that resulted in a deviation in heading and a
reduction in groundspeed, the pilot made a Mayday transmission – ‘both engines
failed’.
The failure of the left engine involved:

– 47 –
• the separation of the destruction of the No. 6 connecting rod big-end bearing
inserts;
• the fatigue fracture of the No. 6 connecting rod big-end bearing housing;
• a forceful collision between the No. 6 piston and the cylinder head;
• the collision between the No. 6 connecting rod and the camshaft leading to the
fracture of the pneumatic pump drive coupling and holing of the crankcase; and
• the fatigue fracture of the No. 6 connecting rod crankshaft journal.
See pages 78-85 of this report.

– 48 –
6.2.2 Occurrence 2000/3675 VH-NPA

Reported evidence
The pilot noted that the right-engine oil pressure was low and decreasing, the
engine oil temperature had increased during the course of recording engine
instrument readings for trend monitoring (cruise phase of flight). Oil was observed
to be streaming from the engine nacelle skin joints and vent. The right propeller
was feathered and the engine shutdown.

Physical evidence
Examination of the engine revealed that the engine had malfunctioned and lost
power because of the loss of piston sealing through the melting of a section of the
No.3 piston edge, see figure 6.9. In addition, localised melting of the cylinder head
had occurred in the region between the upper spark plug and exhaust valve.

Figure 6.9: No.3 Piston and cylinder head, NPA, showing the regions of
localised melting

During an inspection of the remaining components of the engine, the presence of

cracking in the No.4 main bearing journal fillet radius of the crankshaft was
discovered. The cracking comprised of a series of short cracks, oriented parallel
with the journal axis, in the fillet between the journal and the No.4 main/No.5
connecting rod web, see figure 6.10. Cracking of this nature occurs as a result of
sliding contact between the main bearing inserts and the journal fillet radius,
following the displacement of the inserts from their normal position in the main
bearing housing during engine operation.

– 49 –
Figure 6.10: Cracking in the fillet between the No.4 main bearing journal
and the No.4 main/No.5 connecting rod web

The location of cracking is arrowed. The nature of cracking is shown in the inset.

– 50 –
6.2.3 Occurrence 2001/2885 VH-MJA

Reported evidence
The left engine of a Piper Chieftain malfunctioned approximately 4 minutes after
takeoff. The pilot heard a ‘thud’ from the left engine and sensed a slight yaw to the
left. A reduction in manifold pressure was observed. However, no signs of smoke or
oil loss were observed. The engine was not shutdown following the malfunction or
during the return to the airfield.
Time since overhaul: 1,352 hours

Physical Evidence
Inspection of the engine revealed that the head of the No.1 cylinder had separated
from the cylinder barrel, figure 6.11. The fracture of the cylinder head occurred as a
result of fatigue crack propagation through the cylinder head wall from the location
of the threaded connection between the head and barrel on the exhaust valve side of
the cylinder.

Figure 6.11: The fractured No.1 cylinder, the site of fatigue crack initiation
is arrowed

– 51 –
6.2.4 Occurrence 2001/3357 VH-RNG

Reported evidence
Shortly after takeoff, the right engine of a Piper Chieftain malfunctioned. The pilot
observed a drop in the manifold pressure in the right engine and oil streaking on the
engine cowl. The engine was shutdown and the aircraft returned to land at the
airfield.
Time since overhaul: 623 hours

Physical evidence
Examination of the engine revealed that the No.4 cylinder had partially separated
from the crankcase following the fracture of seven of the cylinder hold down
fasteners, see figure 6.12. The sequence of fastener fracture commenced with the
initiation and propagation of fatigue cracks in one of the two ½ inch studs. Fatigue
cracking initiated at the root of the first thread in from the face of the nut and,
subsequently, at the root of the thread adjacent to the face of the nut, figure 6.12.

Figure 6.12: The two fractured ½-inch studs and the fractured through-
bolt

Secondary fracture Secondary fracture

½-inch stud through bolt

Primary fatigue fracture,

½ inch stud

The remaining ½-inch stud and, one of the two ½-inch through bolts, fractured as a
result of fatigue crack growth and fastener load redistribution following the initial
½-inch stud fracture. The smaller, ⅜-inch, studs fractured as a result of fastener
load redistribution, figure 6.13. The second through-bolt remained intact.

– 52 –
Figure 6.13: General view of the recovered cylinder base attachment
fasteners

– 53 –
6.2.5 Occurrence 2001/3251 VH-FIA

Reported evidence
During climb through 1,200 ft, the pilot noticed a reduction in power in the left
engine. A visual inspection of the left engine from the cockpit revealed oil streaking
on the engine cowl. The engine was shutdown and the aircraft returned to the
airfield.

Physical evidence
Examination of the engine revealed that the No.2 cylinder assembly had become
detached from the crankcase following the initiation and propagation of fatigue
cracking in both ½-inch studs. Fatigue cracking was extensive, extending to
approximately 80% of the diameter of each stud, figure 6.14. The four ⅜-inch studs
fractured as a result of fastener load redistribution following the fracture of the ½-
inch studs.

Figure 6.14: The two fractured ½ inch studs

Figure 6.15: The four fractured ⅜ inch studs

– 54 –
6.2.6 Occurrence 2002/2059 VH-LTW

Reported evidence
The pilot of a Piper Chieftain became aware of a slight engine vibration during
climb, passing through 2,500 ft. The engine instruments were checked and readings
were found to be within the normal operating range. Approximately one minute
later the right engine surged and the manifold pressure decreased to approximately
26 inches of mercury. No change in engine performance occurred when the throttle
was opened fully, the mixture adjusted to rich and the propeller speed increased to
give a fine pitch. A decision was made to return to the airport (seven minutes flight
time by GPS). On descent, the right engine manifold pressure fluctuated between 26
and 31 inches of mercury. During the completion of pre-landing checks it was noted
that the right engine oil temperature was above the maximum allowed and the oil
pressure below minimum allowed. The right engine cylinder head temperature was
normal. The propellers could not be synchronised. After landing, the smell of
burning oil was noted and oil staining on the right engine cowls was observed.
Once clear of the runway, both engines were shutdown following the normal
checklist procedures.

Physical evidence
Examination of the engine revealed that the edge of the No.3 piston crown had
melted and the piston rings had fractured into many small pieces, figure 6.16.
Approximately 1 litre (1.06 US Quarts) of engine oil remained in the engine sump –
the maximum capacity of the engine is 11.4 litres (12 US quarts) and the minimum
safe quantity is 2.6 litres (2.75 US quarts). The No.3 fuel injector nozzle was
examined and found to be free of any obstruction.

Figure 6.16: The No.3 piston, as removed from the engine

– 55 –
Figure 6.17: The No.3 piston and cylinder head showing the extent of
damage created by the fragmented piston rings

– 56 –
6.2.7 Occurrence 2002/5129 VH-TZY

Reported evidence
The pilot of a Piper Chieftain observed a small drop in manifold pressure in the
right engine during climb. Visual inspection of the engine from the cockpit revealed
oil streaking on the engine cowl.
Time since overhaul: 1699 hours

Physical evidence
Examination of the engine revealed that seven of the eight cylinder base attachment
fasteners on the No.4 cylinder had fractured. The primary fracture was caused by
the initiation and growth of a fatigue crack in one of the two ½-inch studs (upper
left figure 6.18) Fatigue propagated to approximately 80% of the stud diameter. The
remaining ½-stud and one through bolt fractured as a result of fatigue cracking
under conditions of increased alternating stress developed by load redistribution
after the primary fracture.

Figure 6.18: The fractured ½ inch studs (top – the primary fatigue fracture
is on the left) and the fractured through bolt (bottom)

– 57 –
6.2.8 Occurrence 2003/3532 VH-HJS

Reported evidence
The pilot of a Piper Chieftain observed that, while leaning in cruise, the right engine
manifold pressure and oil pressure dropped accompanied by increase in the exhaust
gas temperature. The pilot also noticed that the engine was ‘smoking’. The engine
was shutdown.
Time since overhaul: 1,135 hours

Physical evidence
Examination of the engine revealed that the edge of the No. 5 piston had melted to
an extent that combustion gases could bypass the piston seal, figure 6.19. No
localised melting of the cylinder head in the region between the upper spark plug
and exhaust valve had occurred.

Figure 6.19: The No. 5 piston and cylinder head

– 58 –
6.3 Connecting rod assembly failures

6.3.1 Introduction
Connecting rods provide the means of transferring the reciprocating motion of the
pistons to the rotary motion of a crankshaft. The primary loads imposed on a
connecting rod during engine operation are related to combustion gas pressures and
inertia forces.
Because loads are being transferred between components moving relative to each
other – the connecting rod little-end oscillates about the piston pin, and the
crankshaft journal rotates within the connecting rod big-end – bearings are needed
at both ends of the connecting rod.
The bearings used in aircraft reciprocating engines are plain bearings. Two types of
plain bearing are used in engines with a horizontally-opposed cylinder layout. A
bronze bush is used to provide the bearing surface between the piston pin and the
connecting rod. A precision insert, comprising of a number of bonded metallic
layers, is used to provide the bearing surface between the connecting rod and the
crankshaft. The differences in bearing type and size relate to the differences in
sliding speed and the constraints imposed by engine assembly.

Table 6.2: Summary of occurrences involving connecting rod failure

Occurrence Date of Occurrence Aircraft registration Component

Number and Engine Type Failure

2000/90 7 Jan 2000 VH-MZK No.1 con rod little-

Lyc TIO-540-J2B end fracture
2000/1327 8 Apr 2000 VH-BNN No.4 con rod big-
Lyc IO-540 end fracture
2001/1405 26 Mar 2001 VH-LTW No.2 con rod big-
Lyc TIO-540-J2B end fracture
2002/3474 14 Jul 2002 VH-ACZ No.4 con rod big-
Lyc IO-540-E135 end fracture
2003/2701 21 Aug 2003 VH-OCF No.6 con rod little-
Lyc TIO-540-J2B end fracture

– 59 –
6.3.2 Occurrence 2000/90 VH-MZK (left engine)

Reported evidence
During the cruise phase of flight, the pilot heard a bang from the left engine. The
left engine then stopped and the propeller feathered. A visual inspection of the
engine from the cockpit revealed that the engine cowling had been damaged. The
aircraft was forced to land.
Time since overhaul: 1,673 hours

Figure 6.20: The extent of damage to the engine cowling caused by the
forceful separation of the No.1 cylinder assembly

Physical evidence
Examination of the engine revealed that the No.1 cylinder had separated from the
crankcase. An internal examination revealed that the No.1 connecting rod little-end
had fractured.

Figure 6.21: The No.1 cylinder ‘as recovered’

– 60 –
Figure 6.22: The No.1 connecting rod showing the fractured little-end
housing

While the remnant of the little-end housing had been damaged extensively and the
rest of the housing was lost during the engine failure, it is evident that the nature of
the failure is consistent with the development of fatigue in the housing.
It is unlikely that the failure of the little-end housing was the result of a single load
application. The fracture occurred during cruise, a phase of flight during which the
inertia forces imposed on the little-end housing are lowed through the reduction in
engine speed from the engine speeds used during takeoff and climb.
There is evidence that the little-end bearing had been destroyed during a period of
engine operation prior to the fracture of the housing. Galling (adhesive wear) was
present on the surface of the No.1 piston pin in the region where it bears against the
little-end bearing. Galling occurs when the steel piston pin bears against the steel
inner surface of the housing. The surface damage created by galling is known to be
a potent initiator of fatigue cracking.

– 61 –
Figure 6.23: Galling (adhesive wear) on the No.1 piston pin

An overview of piston pin wear, with the piston in situ in the No.1 piston, is shown at the top
of the figure. Detailed views of two regions of galling are shown at the bottom of the figure.

– 62 –
6.3.3 Occurrence 2000/1327 VH-BNN

Reported evidence
During the cruise phase of flight, the pilot of the single-engine aircraft (Piper
Lance) noticed that the vacuum pump warning light had illuminated and the
vacuum gauge reading had dropped to zero. The pilot also reported that the engine
started to vibrate. While completing troubleshooting checks the propeller stopped.
The aircraft was forced to land on a suburban beach.
Time since overhaul: 1,300 hours

Physical evidence
Examination of the engine revealed that the No.5 connecting rod big-end had
fractured.

Figure 6.24: The remnants of the No.5 connecting rod recovered form the
engine

The recovered fragments of the big housing (top left), some of the larger fragments of the
bearing inserts (top right), detailed view of both housing fractures at the transition to the rod
‘I’ beam (bottom). The sites of fatigue initiation are arrowed.

It is evident that the initial fracture of the big-end housing occurred as a result of
fatigue crack growth from the outer surface to the inner surface of the housing. The
sites of fatigue crack initiation are associated with the regions of reduced cross-
section created by the counterbore at the transition between the housing and the
connecting rod ‘I’ beam.
It is also evident that the big-end bearing inserts had been destroyed prior to the
fracture of the housing. There are two significant features of the bearing insert
destruction. Firstly, the separation and fragmentation of the aluminium-tin/lead-tin

– 63 –
bearing alloy layer from the steel backing. Secondly, the steel backing of the inserts
had been uniformly reduced in thickness through a process that involved the
extrusion of the steel backing through the gap between the big-end housing and
crankshaft journal.

– 64 –
6.3.4 Occurrence 2001/1405 VH-LTW

Reported evidence
The pilot became aware that the left engine was running ‘roughly’ at the top-of-
descent. An initial check of the engine instruments showed no abnormal readings,
however, within 30 seconds of the indication of rough running, the engine failed.
The engine was shutdown and the propeller feathered in accordance with
emergency procedures.
Time since overhaul: 1,035 hours

Physical evidence
Examination of the engine revealed that the No.2 connecting rod big-end had
fractured.

Figure 6.25: The recovered No.2 connecting rod and piston

Detailed views of both fractures in the big-end housing, at the transition between the housing
and rod ‘I’ section (bottom). The sites of fatigue crack initiation are arrowed.

– 65 –
It is evident that the initial fracture of the big-end housing occurred as a result of
fatigue crack growth from the outer surface to the inner surface of the housing. The
sites of fatigue crack initiation are associated with the regions of reduced cross-
section created by the counterbore at the transition between the housing and the
connecting rod ‘I’ beam.
It is also evident that the big-end bearing inserts had been destroyed prior to the
fracture of the housing. The aluminium-tin/lead-tin bearing alloy layer had
separated from the steel backing. The steel backing of the inserts had been
uniformly reduced in thickness through a process that involved the extrusion of the
steel layer through the gap between the big-end housing and crankshaft journal.

– 66 –
6.3.5 Occurrence 2002/3474 VH-ACZ

Reported evidence
The pilot noticed that the left engine was vibrating with increasing intensity during
cruise. The engine malfunction culminated in a loss of power and yaw, at which
point, the pilot shutdown and secured the left engine.
Time since overhaul: 157 hours

Physical evidence
Examination of the engine revealed that the No.4 connecting rod big-end had
fractured.

Figure 6.26: The No.5 connecting rod recovered from the engine

Some of the larger fragments of bearing inserts recovered from the debris in the engine
sump are shown (bottom right).

– 67 –
Figure 6.27: Detailed views of the fractures in the big-end housing at the
transition between the housing and rod ‘I’ section

It is evident that the initial fracture of the big-end housing occurred as a result of
fatigue crack growth from the outer surface to the inner surface of the housing. The
sites of fatigue crack initiation are associated with the regions of reduced cross-
section created by the counterbore at the transition between the housing and the
connecting rod ‘I’ beam.
It is also evident that the big-end bearing inserts had been destroyed prior to the
fracture of the housing. The aluminium-tin/lead-tin bearing alloy layer had
separated from the steel backing. The steel backing of the inserts had been
uniformly reduced in thickness through a process that involved the extrusion of the
steel layer through the gap between the big-end housing and crankshaft journal.

– 68 –
Figure 6.28: Detailed views of the crankshaft, No.5 connecting rod journal
and debris recovered from the sump

– 69 –
6.3.6 Occurrence 200303701 VH-OCF

Reported evidence
The pilot first became aware of a malfunction in the left engine through a series of
‘explosions’ followed by severe vibrations and flames, during an approach to land.
The engine was shut down immediately and the propeller was feathered. The fire
went out after the engine was shutdown.
Time since overhaul: 1,640 hours

Physical evidence
Examination of the engine revealed that the little end of the No.6 connecting rod
had fractured. The separated end of the connecting rod had collided with the
underside of the No.6 piston resulting in the fracture of the No.6 cylinder
attachment fasteners, the separation of the No.6 cylinder from the crankcase. In
addition, the crankcase structure surrounding both upper engine mount attachment
points was fractured during the forceful separation of the cylinder and by the
flailing of the connecting rod. The engine remained supported only by the two
lower mounts.

Figure 6.29: The damage to the crankcase and upper mounts

– 70 –
Figure 6.30: The fractured little-end housing of the No.6 connecting rod

A sample of debris from the little-end bearing, recovered from the sump and filters is shown
bottom left.

It is evident from the nature of the little-end bearing remnants recovered from the
engine sump and oil filters that the little-end bearing had been destroyed during a
period of engine operation prior to the fracture of the housing. Galling (adhesive
wear) and surface cracking were present on the inner surface of the housing. This
type of surface damage occurs when the steel piston pin bears against the steel inner
surface of the housing in the absence of the leaded bronze bearing.
Examination of other connecting rods from the left engine revealed that the process
of little-end bush destruction was not restricted to the No.6 connecting rod, figure
6.31.

– 71 –
Figure 6.31: The condition of little-end bearings from other connecting
rods from the left engine

Cracking and edge breakaway is evident at both ends of the No.1 rod little end bearing (top),
cracking is evident in the bearings from the No.2 and No.3 connecting rods.

Similar connecting rod little-end bearing deterioration was discovered during the
disassembly of the right engine at a later time, figure 6.32.

Figure 6.32: Cracking and edge breakaway in the No.1 connecting rod
little bearing, VH-OCF right engine

– 72 –
6.4 Crankshaft failures

6.4.1 Introduction
The crankshaft is the component that converts the reciprocating action of the
piston/connecting rod into rotational power – for a direct drive engine, the
rotational power is provided at the end flange of the crankshaft. In a multi-cylinder
engine, the crankshaft combines the combustion forces created in each cylinder
assembly. While the crank form (a short section of the shaft displaced parallel to the
main axis of the shaft) is common to all crankshafts, the overall form of the shaft
depends on the layout of the cylinders, for example, inline, vee, horizontally
opposed, or radial.
During engine operation, the crankshaft is subjected to alternating stresses created
by the discontinuous gas pressure loads from each cylinder and the inertia loads
associated with the reciprocating action of the pistons and rotation of unbalanced
masses. Because the crankshaft is an elastic member, these alternating stresses
create deflections in the plane of rotation, giving rise to torsional vibrations, and in
the plane of the axis of the crankshaft, giving rise to longitudinal vibrations.
The crankshaft is supported in the engine crankcase by several main bearings. For
six-cylinder horizontally-opposed aircraft engines, the crankshaft is supported by a
main bearing at each end of the shaft and two intermediate main bearings, one
between each of the two connecting-rod journals.

Table 6.3: Summary of occurrences involving crankshaft fracture

Occurrence Date of Occurrence Aircraft registration Component Failure

Number and Engine Type

2000/2157 31 May 2000 VH-MZK left No.6 con-rod journal

Lyc TIO-540-J2B fracture plus big-end
housing fracture
2000/2276 20 May 2000 VH-ODE No.1 con-rod bearing
Lyc TIO-540-J2B breakdown
2001/2544 9 Jun 2001 VH-TTX Main bearing crankweb
Lyc TIO-540-J2B fracture No.4 main/No.4
rod
2001/4799 4 Oct 2001 VH-BEM Main bearing crankweb
TCM TSIO-520-E fracture
2001/5866 14 Dec 2001 VH-JCH No.6 con-rod journal
Lyc LTIO-540-J2B fracture plus big-end
housing separation
2004/2291 22 Jun 2004 VH-VEC No.3 con-rod bearing
TCM GTSIO-520-M breakdown
2005/02231 18 May 2005 VH-IGW Main bearing crankweb
Lyc TIO-540-V2AD fracture, No.4 main/
No.4 rod journal

– 73 –
6.4.2 Occurrence 2000/2157 VH-MZK (left engine)

Reported evidence
VH-MZK was involved in a fatal accident following the failure of both engines and
a ditching at night.
Time since overhaul: 262 hours

Physical evidence
The engine was recovered with the aircraft wreckage from the bottom of Spencer
Gulf. It had been immersed in seawater for several days.
During the initial examination of the engine, it was apparent that the No.6
connecting rod had separated from the crankshaft journal, collided with the
camshaft, and collided with the top of the left crankcase half. The collision with the
crankcase ruptured a major oil gallery, see figure 6.33. The impulse transmitted
through the camshaft to the accessory drive train, resulted in the fracture of the
pneumatic pump drive coupling, see figure 6.34.

Figure 6.33: The left engine, MZK, as recovered

The site of crankcase rupture is arrowed.

– 74 –
Figure 6.34: Pneumatic pump coupling fracture, left engine, MZK

The fractured pneumatic pump drive coupling is arrowed.

Detailed examination of the No.6 connecting rod revealed that the fracture of the
big-end housing did not occur as the result of a single load application. The big-end
housing fractured as a result of fatigue cracking that initiated on the outside of the
big-end cap at the regions of reduced cross-section created by the counterbore,
figures 6.35 and 6.36. When final fracture of the big end occurred, the piston was
released with sufficient speed to impact the cylinder head and deform the edge of
the piston, figure 6.37. This type of damage is an indicator that the big-end housing
fractured while the engine was operating in its normal speed range.

– 75 –
Figure 6.35: The No.6 connecting rod, as recovered

Several fragments of the big end bearing inserts are shown at the bottom of the figure.

Figure 6.36: The location and extent of fatigue cracking in the No.6
connecting rod cap

The sites of fatigue crack initiation are arrowed. Fatigue crack growth, in the region identified
as ‘fracture 1’, extended over the full extent of the cross-section.

– 76 –
Figure 6.37: The nature of piston edge deformation created by the impact
of the No.6 piston against the No.6 cylinder head

The deformation of the edge of the piston and the region of contact between the piston and
cylinder head are arrowed.

The No.6 big-end bearing inserts had been reduced to fragments of insert steel
backing that had been reduced uniformly in thickness while lubricating oil was
supplied to the bearing, figure 6.38. There was no evidence of overheating of the
big-end bearing associated with a loss of lubrication. It is evident from wear
between the crankshaft journal and the inner surface of the big-end housing, and the
guide section of the housing bolts, that the crankshaft continued to rotate with an
intact housing for a period of time following the destruction of the bearing inserts,
see figure 6.39.

Figure 6.38: Fragments of the No.6 big end bearing inserts recovered from
the engine sump

A fragment of the steel backing from the No.6 connecting rod bearing insert remained in the
sump, arrowed left.

– 77 –
Figure 6.39: No.6 connecting rod, big end housing bolt. Bolt guide section
wear

The design of the connecting rods fitted to Lycoming TIO-540-J2B engines is such that the
guide section, (the increased diameter at the centre of the bolt), protrudes beyond the
housing inner surface into a recess machined in the rear surface of the bearing inserts.

Upon disassembly of the engine, it was clear that the crankshaft had fractured at the
No.6 connecting rod journal, figure 6.40.

Figure 6.40: The fractured No.6 connecting journal, in situ

Fracture was caused by fatigue crack initiation and growth. Fatigue cracking
initiated at the transition between the journal and the crankweb fillet, figure 6.41.
Distinctive fatigue ‘progression’ marks were present on the fatigue fracture surface.
These marks are created by major changes in the alternating loading spectrum.
Typically, for engine crankshafts, they are associated with engine start/stop cycles.
It was estimated that fatigue crack growth had occurred over a period of at least
fifty engine start/stop cycles.

– 78 –
Figure 6.41: Detailed views of the No.6 connecting rod journal

The lower two photographs show the fracture surface of the rear crankshaft section in the ‘as
received’ condition (left) and after some of the deformed material had been broken away to
reveal the initiation site of fatigue cracking.

Because the plane of fatigue cracking was inclined at an angle to the axis of the
journal and crack growth extended into the crankweb, rotational forces could be
transmitted between the two halves of the crankshaft for a period of time after the
final fracture of the journal.
It is evident that with continued engine operation and crankshaft rotation, that
deformation of the interlocking parts of the crankshaft halves occurred
progressively. Continued operation with progressive deformation of the fracture
surfaces will have an effect on engine timing, and as such, engine performance. It is
a design feature of the horizontally-opposed engine that ignition and valve timing
for all cylinders is indexed to the position of the crankshaft through a gear train
driven from the rear of the crankshaft. Correct ignition timing for each cylinder
relies on the location of the connecting-rod journal with respect to the ignition
timing gear train.
Fatigue cracking initiated at a site below the journal surface. This region of the
fatigue fracture surface had been affected by heating and localised deformation. It is
noticeable that a ‘steplike’ feature extended from the site of initiation to the surface.

– 79 –
Figure 6.42: The initiation site of fatigue cracking

Further evidence, that the engine had continued to operate and the crankshaft had
continued to rotate, is provided by the presence of fatigue cracking in the fillet of
the No.5 connecting rod journal and the fillet of the No.4 main journal.

Figure 6.43: Magnetic particle inspection indication of fatigue cracking in

the No.5 connecting rod journal and the No.4 main journal

No.4 main journal is shown on the left, No.5 connecting rod journal is shown on the right.
Examples of fatigue crack growth extending from the surface of the journals, associated with
magnetic particle indications are shown below the photographs of the journals. The extent of
fatigue cracking from the journal surface is arrowed.

– 80 –
The failure of the left engine of VH-MZK is characterised by several processes of
wear, crack growth, progressive deformation, affecting a number of components
over varying periods of operational time before the final engine stoppage.

Recorded evidence
Detailed analysis of recorded radar data and voice transmissions between the pilot
and ground stations, indicated that the performance of the propulsion systems were
normal until 17 minutes into the cruise phase of flight, see pages 48-52.

– 81 –
6.4.3 Occurrence 2000/2276 VH-ODE

Reported evidence
During cruise, the pilot noticed a loss of propeller synchronisation. A short time
later it was noticed that the left engine manifold and oil pressures were decreasing
while the oil temperature was increasing. The engine was shutdown.
Time since overhaul: 835 hours

Physical evidence
Examination of the engine revealed that the big-end bearing inserts in the No.1
connecting rod were in state of partial destruction.

Figure 6.44: The extent of damage to the No.1 connecting rod big end
bearing inserts

Bearing breakdown was characterised by the separation of the aluminium-tin and

lead-tin bearing alloy layers. The steel backing was in various states of destruction:

– 82 –
generally, the backing had been reduced in thickness and broken up through
rotation against the section of the housing bolts that protrude into the housing; some
of the backing had been extruded through the gap between the housing and
crankshaft journal. The bearing inserts, p/n 74309-M03, were 0.003 of an inch
oversize to allow for a reduction in journal diameter following maintenance actions
designed to restore the condition of worn crankshaft journals. The crankshaft was
identified as p/n 13F27735, s/n V53794017 M03P (M03P refers to the reduction in
the diameter of the connecting-rod journals of 0.003 of an inch).
During engine disassembly, it was found that small sections of the bearing alloy
layers had broken away from other big-end bearing inserts, see figure 6.71.

Figure 6.45: The condition of the No.1 crankshaft journal and surface of the
big end housing

Extensive ‘thermal’ surface cracking of the journal is evident in the magnetic particle
inspection indications (top left).

– 83 –
6.4.4 Occurrence 2001/2544 VH-TTX

Reported evidence
The left engine failed during climb at approximately 600 feet. The pilot completed
the engine failure checklist and returned to land.
Time since overhaul: 1,300 hours

Physical evidence
Examination of the engine revealed that the crankshaft had fractured in two
locations between the two centre main-bearing journals as a result of fatigue
cracking. The primary fatigue fracture was located at the forward fillet radius of the
No.4 main bearing journal, figure 6.46.

Figure 6.46: The primary fatigue fracture, No.4 main bearing/No.4

connecting rod crankweb

It is evident that fatigue cracking initiated in the crankweb between the No.4 main-
bearing journal and the No.4 connecting-rod journal as a result of damage created

– 84 –
by contact between the No.4 main-bearing inserts and the No.4 main-bearing
journal fillet radius, figure 6.47.

Figure 6.47: The nature of No.4 main bearing journal fillet radius damage

Contact between the rotating crankshaft and bearing inserts created two types of
journal damage: circumferential scoring; and a series of short cracks created by
localised thermal expansion of the journal surface. The circumferential scoring
changes the geometry of the fillet radius and increases the level of local stress
concentration. The series of ‘thermal’ cracks, oriented parallel to the journal axis,
create discontinuities in the surface hardened zone of the journal and also act to
increase local stress concentration levels.
Because of the orientation of the plane of fatigue fracture through the No.4
main/No.4 connecting-rod crankweb, rotational forces could be transferred between
the two halves of the crankshaft following final fracture. However, continued
engine operation following the fracture of the No.4 main/No.4 connecting-rod
crankweb, creates a condition of high alternating stress at the fillet between the
No.3 main journal and the No.3 main/No.3 connecting-rod crankweb. The effect of
increased alternating stress in this location, results in rapid fatigue crack initiation
and crack growth. The engine ceased to function following the fracture of the No.3
main/No.3 connecting-rod crankweb.

– 85 –
Figure 6.48: Crankshaft secondary fracture, No.3 main/No.3 connecting
rod crankweb

The crankshaft was marked with the following identifiers, part number LW 10346,
serial number 87928.

– 86 –
6.4.5 Occurrence 2001/4799 VH-BEM

Reported evidence
Shortly after commencing descent, the pilot reported that the left engine started to
shudder, before it stopped suddenly with the propeller in the unfeathered position.
A visual inspection of the engine from the cockpit revealed oil streaming from the
engine cowling. It was also reported that the leads between spark plugs in the No.3
and No.1 cylinders, had been transposed for a period of time before the engine
failure.
Time since overhaul: 298 hours

Physical evidence
Examination of the engine revealed that the crankcase had been holed near the No.5
cylinder and the crankshaft had fractured. The mechanism of fracture was fatigue
cracking. Fatigue cracking initiated below the surface of the fillet radius between
the No.3 main-bearing journal and the No.5 connecting-rod journal, and cracking
propagated through the No.3 main/No.5 connecting-rod crankweb.
Note: Teledyne Continental Motors number cylinders, journals and bearings from
the rear of the engine, in contrast to Lycoming engines, which are numbered from
the front of the engine.

Figure 6.49: The fracture through No.3 main/No.5 connecting-rod

crankweb

– 87 –
Figure 6.50: Detailed views of the site of fatigue crack initiation, scanning
electron micrographs

– 88 –
6.4.6 Occurrence 2001/5866 VH-JCH

Reported evidence
Approximately 10 minutes after entering the cruise phase of flight, the flight crew
became aware of a developing engine problem when the propellers ‘dropped out of
synchronisation’. The following observations were noted by the flight crew:
Gyro pressure gauge ‘spiked’ and dropped to approximately four inches
(lower limit), pneumatic ‘inop’ light was on, the right-engine oil temperature
was 245˚F (max), right-engine cylinder-head temperature was in the normal
range, right-engine oil pressure was approximately 65 psi and falling.

Finally, the speed of the right engine fluctuated up and down, approximately 100
rpm. At this point, the crew elected to shut the engine down in accordance with the
engine-securing checklist.
Time since overhaul: 1,055 hours

Physical evidence
During the initial examination of the engine, it was apparent that the No.6
connecting rod had separated from the crankshaft journal and had collided with the
camshaft, figure 6.51. The impulse transmitted through the camshaft to the
accessory drive train resulted in the fracture of the pneumatic pump coupling, figure
6.52.

Figure 6.51: The No.6 connecting rod, as recovered

– 89 –
Figure 6.52: Pneumatic pump coupling fracture, right engine JCH

Separation of the No.6 big-end housing allowed the piston to strike the domed
surface of the combustion chamber with sufficient force to deform the edge of the
piston crown, see figure 6.53.

Figure 6.53: The nature of piston edge deformation created by the impact
of the No.6 piston against the No.6 cylinder head

The separation of the No.6 big-end housing involved the loosening of nuts installed
on the big-end housing bolts and the eventual loss of one nut. Evidence of nut
loosening is provided by the fretting wear damage on the bolt threads and those
regions of the boltholes that contact the bolt thread or guide surface, see figure 6.54.

– 90 –
Figure 6.54: Examples of No.6 connecting rod big-end bolt thread and
bolthole damage

While it is clear that both parts of the connecting rod big-end housing (rod and cap)
had remained intact (figure 6.55), it is evident that the inner surface of the housing
had been damaged by rotational contact with the crankshaft journal in the absence
of the big-end bearing inserts. The damage was sufficient to initiate fatigue
cracking in the centre of the cap, figure 6.56.
The No.6 big-end bearing inserts had been reduced to fragments of steel backing.
The fragments had been reduced uniformly in thickness while lubricating oil was
supplied to the bearing, figure 6.57. There was no evidence of overheating of the
big-end bearing associated with a loss of lubrication.

– 91 –
Figure 6.55: The No.6 connecting rod big-end, as recovered

Figure 6.56: The location of fatigue cracking, extending from the inner
surface of the No.6 connecting rod big-end cap

– 92 –
Figure 6.57: Fragments of the No.6 big-end bearing inserts recovered
from the engine sump

Upon disassembly of the engine, it was clear that the crankshaft had fractured at the
No.6 connecting-rod journal, see figure 6.58. The two halves remained supported
by the main bearings. The orientation of the plane of fracture allowed rotational
forces to be transmitted between the two halves.

Figure 6.58: The fractured No.6 connecting-rod journal, in situ

– 93 –
It is evident that with continued engine operation and crankshaft rotation the
interlocking parts of the crankshaft halves were being progressively deformed, see
figure 6.59. Continued operation with progressive deformation of the fracture
surfaces will have an effect on engine timing and as such, engine performance. It is
a design feature of the horizontally-opposed engine that ignition and valve timing
for all cylinders is indexed to the position of the crankshaft through a gear train
driven from the rear of the crankshaft. Correct timing for all cylinders relies on the
fixed location of all connecting-rod journals with the timing-gear train.

Figure 6.59: Detailed views of the No.6 connecting-rod journal

Fracture was caused by fatigue crack initiation and growth. Fatigue cracking
initiated at the transition between the journal and the crankweb fillet. Distinctive
fatigue ‘progression’ marks were present on the fatigue fracture surface, figure
6.60. These marks are created by major changes in the alternating loading spectrum.
Typically, for engine crankshafts, they are associated with engine start/stop cycles.
It was estimated that fatigue crack growth had occurred over a period of at least 76
engine start/stop cycles.

– 94 –
Figure 6.60: Progression marks associated with fatigue crack growth,
No.6 connecting-rod journal

Fatigue cracking initiated at the transition between the No.6 journal surface and the
fillet of the crankarm between the No.6/No.5 connecting rod journals at a site below
the journal surface, figure 6.61. This region of the fatigue fracture surface had been
affected by heating and localised deformation. It is noticeable that a ‘steplike’
feature extended from the site of initiation to the surface, figure 6.62.
The failure of the left engine of VH-JCH is characterised by several processes of
wear, crack growth and progressive deformation affecting a number of components
over varying periods of operational time before the final engine stoppage.

– 95 –
Figure 6.61: Views of the fatigue fracture, No.6 connecting-rod journal

Figure 6.62: Detailed views of the site of fatigue crack initiation

Crankweb side of the fracture. Journal side of the fracture.

– 96 –
6.4.7 Occurrence 2004/2291 VH-VEC

Reported evidence
During the cruise phase of flight, the pilot noticed that the manifold pressure of the
right engine dropped from the cruise setting of 32 inches of mercury to 29 inches.
Engine power could not be recovered through throttle movement. Subsequently, the
oil pressure dropped, suddenly, to zero and the manifold pressure decreased to 20
inches.
A deviation to a nearby airport was initiated and the engine was shutdown
according to procedure. In response to the shutdown procedure, the engine stopped
suddenly, however, the propeller took between 30 and 60 seconds to feather.
Time since last maintenance action (bulk strip as a result of propeller damage
caused during an undercarriage collapse occurrence): 600 hours

Physical evidence
Examination of the engine revealed that no engine oil was lost, 11quarts were
recovered. Further examination revealed that the crankshaft had ‘machined’
material from the crankcase at both ends of the shaft (figure 6.63), the oil
filters/screens had been clogged by metallic particles, a piston-pin plug from the
No.3 piston assembly had fractured (figure 6.64), and the No.3 connecting rod big-
end bearing had overheated (figures 6.65-6.67).

Figure 6.63: The regions of crankcase ‘machining’ wear caused by

crankshaft expansion

Front of engine Rear of engine

– 97 –
The engine had been operated under conditions that induced piston-pin shuttle. For
cases of piston pin shuttle, the high contact pressures between the piston-pin plug
and cylinder wall results in excessive plug wear and possible plug fracture.

Figure 6.64: The extent and nature of damage to piston-pin plugs

No.3 piston-pin plug damage.

Detailed view of piston-pin plug wear (piston pin from another cylinder in the engine).

– 98 –
Figure 6.65: The nature and extent of damage to the No.3 connecting rod
big-end bearing

Figure 6.66: Evidence of copper diffusion through the steel backing of the
bearing insert and into the No.3 connecting rod housing

Figure 6.67: Composite view showing the crankshaft journals

– 99 –
6.4.8 Occurrence 2005/02231 VH-IGW

Reported Evidence
During a flight from Essendon to Armidale, the left engine of a Piper PA31P-350
(VH-IGW) failed during cruise at 17,000 ft. The pilot reported that, prior to the
failure, there was a slight variation in the left engine rpm and an increase in left
engine vibration. The variation in engine rpm was corrected by adjusting the left
propeller speed. The indications on the engine instruments were normal and there
were no visible signs of leaking oil. A time period of approximately ten minutes
elapsed between the initial observation of engine irregular performance and final
failure. The engine shutdown procedure was completed successfully. The aircraft
descended to 10,000 ft and diverted to land at Bankstown without further incident.
Time since overhaul: 291 hours

Physical evidence
Initial examination of the Lycoming TIO-540-V2AD engine revealed that the
crankshaft had fractured in two places allowing the section containing the No.3 and
No.4 connecting-rod journals (the section between the two intermediate main
bearings) to become displaced, see figure 6.68.

Figure 6.68: The fractured section of the crankshaft in the position found
during initial engine examination

Further examination of the engine revealed that the crankshaft had fractured in two
locations: through the crankweb between the No.4 main-bearing journal and the
No.4 connecting-rod journal; and through the crankweb between the No.3 main-
bearing journal and No.3 connecting-rod journal, see figure 6.69.

– 100 –
Figure 6.69: The location of both fractures and their orientation with
respect to the crankshaft webs

The fracture of the web between the No.4 main and No.4 connecting rod journals
occurred as a result of fatigue crack initiation and growth, figure 6.70. The fatigue
fracture progression marks present on the fracture surface indicated that crack
growth had occurred over a period of approximately 50 engine start/stop cycles.

– 101 –
Figure 6.70: Crankshaft web fracture, No.4 main/No.4 connecting rod

Maintenance history
Engine s/n L8484-61A, had completed 291.3 hours since overhaul. The crankshaft
had been installed in the engine prior to overhaul and had been examined for cracks
(magnetic particle inspection) prior to engine reassembly.
The crankshaft was identified by a series of hand etched, stamped, and as-forged
numbers. The part number of the crankshaft was LW 17740 (letter stamped into
propeller flange), the crankshaft serial number was V5311 (hand etched on the
propeller flange). Two, as-forged, numbers (17707 and V60) were present on the
edges of two crankshaft webs.
Engine logbook entries on the 20 August 2002 and 21 October 2002 indicated that
the crankshaft had been assessed for compliance with Lycoming Service Bulletins,
SB 552 and SB 553 and associated Airworthiness Directives. On both occasions,
the Service Bulletins where found to be not applicable. A review of Lycoming
Service Bulletins, SB 550, SB 552, SB 553, SB 566, SB 569, SB 569A, that address
a material issue with Lycoming crankshafts, found that the engine model, TIO-540-

– 102 –
V2AD, engine serial number, L8484-61A, and crankshaft serial number, V5311,
were not listed.

– 103 –
6.5 Crankshaft bearing, reported service difficulties and
defects
As a result of some concerns regarding the reliability of crankshaft bearings, a
survey of the Australian Major Defect Reporting database was conducted by DP
Sprigg (2003, pers. comm., 11 May). On the basis of this survey and the physical
examination of bearings, where they were available, it was concluded that there was
an increasing trend (over the period 1993 – 2003) for sections of aluminium-tin
bearing alloy to separate from the crankshaft bearing inserts of high-power
Lycoming engines. Similar examples of bearing alloy separation from crankshaft
bearing inserts, manufactured with a copper-lead bearing alloy, were not observed.

Figure 6.71: Example of aluminium-tin bearing alloy separation, 2000/2276

VH-ODE

Time since overhaul 835 hours, bearing part number 74309 – M03, date of manufacture
1-98

– 104 –
Figure 6.72: Example of aluminium-tin bearing alloy separation, 2002/3474
VH-ACZ

Time since overhaul 157 hours, bearing part number SL 13521-M03, date of manufacture
1-00.

Figure 6.73: Example of aluminium-tin bearing alloy separation, Major

Defect Report 02/0277, VH-OMM, PA 31-350, 12 March 2002
(photo, Sprigg, 2003)

Time since overhaul 719 hours, bearing part number 74309 – M03, date of manufacture
1-01.

– 105 –
Figure 6.74: Back surface of the big-end bearing inserts from VH-OMM
(photo, Sprigg, 2003)

Figure 6.75: Main bearing surface wear, VH-OMM (photo, Sprigg, 2003)

The main bearing inserts fitted to OMM were manufactured with a copper-lead bearing alloy
intermediate layer.

– 106 –
6.6 References
Lan CE and Roskam J 1988, Airplane Aerodynamics and Performance, Roskam
Aviation and Engineering Corporation, USA, p 274
Sprigg, DP 2003, Summary of Lycoming Engine Plain Bearing Failure Events in
Australia, 28 June 2003.

– 107 –
7 EVALUATION OF POWERTRAIN COMPONENT
FAILURES

7.1 Introduction
The development of an understanding of the factors that may affect reciprocating-
engine reliability requires the evaluation of evidence associated with powertrain
component failure events against component failure control plans.
Powertrain component failure was not limited to a particular component and
particular mechanism of failure. Of the 20 failures of engines investigated over the
period 2000 to 2005, a range of powertrain components was affected and a number
of mechanisms initiated failure:
• one engine failure involved cylinder head fatigue fracture;
• three engine failures involved cylinder attachment stud fatigue fracture;
• four engine failures involved piston edge melting;
• two engine failures involved connecting rod little-end fatigue fracture;
• two engine failures involved connecting rod big-end fatigue fracture;
• two engine failures involved crankshaft connecting rod journal fatigue fracture
(these two engine failures also involved the failure of the big-end bearing
housing and big-end bearing inserts);
• three engine failures involved crankshaft crankweb fatigue fracture, fatigue
cracking initiated in the fillet between the main journal and crankweb; and
• two engine failures involved connecting rod big-end bearing insert failure.
In this chapter, use is made of cause-and-effect flow charts are used in the
evaluation of failure control plans. The elements of these charts are illustrated in
figures 7.1 and 7.2. An event is described as a key event if it creates an outcome
that impacts directly on the operation of a system. An event is described as a
contributing event if it does not directly affect the operation of a system but, in
combination with other events, leads to a key event. Initiating events have their
origin in the fundamental processes or mechanisms upon which a system is created.

Figure 7.1: Linear cause and effect linkage schematic

– 109 –
Cause-and-effect sequences do not have to be linear. A number of events may
combine to create a new event, figure 7.2. The logical connection between events
may be described by binary logic relationships, for example:
‘AND’, each contributing event must combine to create the new event;
‘OR’, one or any combination of contributing events will result in the new
event; and
‘XOR’, exclusive OR, either one event or the other will result in the new
event.
However, not all connections between events can be described by binary logic
relationships. Some events are the result of the synergistic action of several other
events. A new event is the result of the sum of a variable percentage of each
contributing event, annotated in cause and effect diagrams as:
Σ % of each event.

Figure 7.2: Schematic representation of possible logical connections

between events

– 110 –
7.2 Cylinder head fatigue fracture

7.2.1 Cylinder assembly design

Each engine cylinder assembly and piston in a multi-cylinder reciprocating engine
is the reaction vessel where the discontinuous combustion of a gaseous fuel-air
mixture occurs. . As with all aircraft structures and components, there is a dominant
requirement to provide the function with minimal weight (power-to-weight) while
meeting other requirements of reliability (safe operation for a defined period of
time) and ease of manufacture and durability (cost of power per unit time).
The cylinder assemblies fitted to air-cooled reciprocating engines normally
comprise of an aluminium alloy head joined to a steel barrel by a threaded joint.
The cylinder head is a complex form that contains the inlet and exhaust ports and
valves. The need to create this form, and maximise strength at engine operating
temperatures, requires an alloy that can be cast and is microstructurally stable. The
aluminium-copper-nickel alloys used to manufacture cylinder heads, are resistant to
overaging and strength reduction at normal engine operating temperatures. The
design of the air-cooling system; the cylinder-head fins, the engine cowling, and the
baffles between cylinders, is required to maintain the cylinder-head temperature
within the design allowable range.

7.2.2 Cylinder stresses

The stresses created in a cylinder assembly during engine operation are derived
from two sources; the gas pressures created by combustion, and the thermal strains
(expansion and contraction) created by heating and cooling. As a result of the cyclic
nature of combustion in a reciprocating engine and the cyclic nature of heating and
cooling with each flight, the stresses in the cylinder assembly alternate in
magnitude. A region of high stress created by combustion gas pressure is located at
the head-to-barrel connection (Kolchin and Demidov, 1984).

Figure 7.3: Cross-section of an aircooled cylinder assembly

– 111 –
 Whenever the thermal expansion or contraction (thermal strain) of a body is
prevented, thermal stresses develop. It is common to distinguish between thermal
stresses caused by external constraint and those that develop without external
constraint because of temperature differences within the body. Stress can be created
in a uniformly heated or cooled body if it is constrained. For the case of bodies that
are not constrained, stresses in the body can be created between regions of varying
temperature. For example, cooling the surface of a hot body creates tensile stresses
in the surface as the contraction of the cooled material in the surface is restrained by
the expanded hot core.
Thermal stresses may be large enough to result in yielding, buckling or fracture.
Repeated development of thermal stresses below the elastic limit may result in the
initiation and propagation of fatigue cracks.

7.2.3 Fatigue fracture control plan

The cylinder head of an air-cooled cylinder assembly is designed to have an
operational life not limited by the separation of the head from the barrel due to
fatigue cracking at the head-to-barrel threaded connection. The consequences of
this type of failure, through the potential to rupture fuel lines, create a threat to
aircraft safe operation. The difficulty of detecting fatigue crack growth from the
inner surface of the cylinder head in the vicinity of the barrel connection, and the
lack of any prior warning through a loss of compression, means that fatigue
cracking in this area of the cylinder head must be prevented.
In practice, the prevention of cylinder head separation through fatigue cracking is
based on ensuring that the magnitude of the alternating stresses created at the head-
to-barrel threaded joint, do not exceed the fatigue endurance strength of the cylinder
head.
Fatigue cracking may initiate in the threaded joint between the head and barrel if
any one, or combination, of the following conditions occurs:
• the fatigue endurance strength of the cylinder head is lower than the design
allowable strength;
• the operating stress at the head to barrel joint exceeds the design allowable
stress;
• stress concentrating features are created at the head to barrel connection during
manufacture, operation, or maintenance;
• the residual stress state in the head to barrel connection differs from the
designed state.

– 112 –
 Figure 7.4: Cause-and-effect diagram for fatigue cracking in the head-to-
barrel connection

Differential thermal expansion/contraction cycles may result in fatigue cracking in

other areas of the cylinder head. However, this form of fatigue cracking may
provide an indicator of its presence through a loss of compression prior to final
fracture and may be controlled by an ‘on-condition’ 1 approach.

7.3 Piston crown edge melting

7.3.1 Piston design

The piston in a reciprocating engine provides a movable surface in the combustion
chamber and allows the forces developed by combustion in the chamber to be
transmitted to the crankshaft through the connecting rod. The piston must be able to
withstand the applied forces and provide a gas sealing mechanism that operates
under sliding motion.
The requirement to minimise inertia forces developed through the reciprocating
action of a piston, has resulted in the use of aluminium alloys to minimise the
reciprocating mass. Aluminium alloy pistons may be forged or cast.
The use of an aluminium alloy to form pistons brings with it the need to limit the
piston temperature during operation. A threat to the function of a piston is created if
localised melting breaches the gas sealing of the piston.
The temperature of the piston is a function of the amount of heat energy created
during each combustion cycle and the rate at which heat energy is transferred from
the piston. Heat energy from the combustion gases is transferred to the piston crown
and is subsequently transferred through the piston rings to the cylinder barrel,

1 ‘On-condition’ means an inspection/functional check that determines a component’s performance

and may result in the removal of a component before it fails in service.

– 113 –
 through the piston pin to the connecting rod, and through oil splash against the
underside of the piston crown, to the engine oil. In high-power engines, additional
piston cooling may be provided by directing an oil spray to the underside of the
piston crown.

7.3.2 Melting control plan

Piston temperature is a function of a balance between the rate heat energy transfer
to the piston crown and the rate of heat energy removal from the piston through the
various heat flow paths. The control of piston crown melting requires the control of
the rate of heat transfer to the piston crown and the rate of heat transfer from the
piston.
An increase in temperature to the incipient melting point of the aluminium alloy at
the edge of the piston crown will occur if any one, or combination, of the following
conditions occurs:
• the quantity of heat energy produced during combustion exceeds the design
allowable amount;
• the rate of heat transfer to parts of the piston crown is increased;
• the rate of heat energy transfer from the piston is reduced.

Figure 7.5: Cause-and-effect diagram for piston crown edge melting

Localised melting in an aluminium alloy cylinder head, sometimes associated with

piston crown edge melting, is affected by the same parameters. The only difference
is the manner in which heat is removed. Heat is transferred from cylinder heads by
the provision of cooling air over the external surface of the head. Investigations of
occurrences where localised melting of a piston and cylinder head have occurred,
need to consider the different mechanisms of heat transfer from each component to
the external environment.

– 114 –
7.4 Cylinder attachment fastener fatigue fracture

7.4.1 Threaded fastener design

Threaded fasteners, in the form of studs anchored in the crankcase and through
bolts that join both crankcase halves, form the connections between the cylinder
assemblies and the crankcase of horizontally-opposed engines. Threaded fasteners
are required to allow the engine to be assembled initially and, subsequently,
disassembled and reassembled during overhaul.
Each cylinder attachment fastener is subjected to alternating stresses created by the
cyclic gas pressures developed in each cylinder during the combustion cycle.
Because of the number of alternating stress cycles created by the combustion
cycles, cylinder attachment fasteners are designed to have an operational life not
limited by fatigue crack initiation and growth to final fracture.
The nature of load transfer in bolted joints between elastic members, allows the
magnitude of the alternating stresses experienced by a preloaded (tightened)
threaded fastener, in a joint subjected to alternating loads, to be limited to a
magnitude below the endurance strength of the fastener. During assembly, a preload
is created in the fastener when a torque is applied to the nut during the process of
tightening. The magnitude of fastener preload is critical in limiting the magnitude
of alternating stresses in the fastener.

7.4.2 Threaded fastener fracture control plan

Fracture control is based on ensuring that an adequate preload is established in the
fastener during assembly, and retained during operation, so that the magnitude of
alternating stress in the fastener does not exceed the endurance strength of the
fastener.
Cylinder attachment threaded fastener fatigue fracture may occur if any one, or
combination, of the following conditions occurs:
• the magnitude of alternating loads imposed on the bolted joint exceeds the
design allowable value;
• the preload established in the fastener during assembly is insufficient to achieve
the design endurance strength of the bolted joint (fastener preload may be
reduced after assembly if deformation occurs within the joint).

– 115 –
 Figure 7.6: Cause-and-effect diagram for cylinder attachment threaded
fastener fatigue fracture

7.5 Connecting rod bearing housing fatigue fracture

7.5.1 Connecting rod design

The connecting rod provides the link between each piston and the crankshaft. The
conversion of reciprocating piston motion to rotational power creates alternating
stresses in the connecting rod. The rod and bearings are placed under compression
by the combustion gas pressure loads and are placed under tension by the inertia
loads created by the change of piston direction at the top of its travel.
Because of the requirement to transmit force between two components in relative
motion, bearings are provided at both ends of the connecting rod - the ‘little-end’
bearing provides the connection to the piston pin and the ‘big-end’ bearing provides
the connection to the crankshaft journal. The differences in surface sliding speed
between the low-speed oscillating motion of the little-end bearing and the high
speed rotational motion of the big-end bearing, combined with the need to be able
to assemble this part of the powertrain mechanism, shapes the nature of the bearing
surface and the bearing housings.
The little-end bearing housings of connecting rods used in horizontally-opposed
engines are of one piece. The bearing surface is provided by a press-fit leaded
bronze bush. The big-end bearing housing is split, and provided with bolts, to allow
assembly onto the crankshaft journal. Two precision inserts comprising of various
bearing alloys coated onto a steel backing provide the bearing surface. These inserts
are retained in the housing by an interference fit created by a dimensional
difference between the housing and inserts, and the tightening of the big-end
housing bolts.
Because of the number of alternating stress cycles created during engine operation,
connecting rods are designed not to have an operational life limited by fatigue crack
initiation and growth to final fracture.

– 116 –
7.5.2 Connecting rod little-end fatigue fracture control
Fatigue fracture control is based on ensuring the magnitude of alternating stresses
created during engine operation does not exceed the endurance strength of the
connecting rod little-end.
Connecting rod little-end fatigue fracture may occur if any one, or combination, of
the following conditions occurs:
• the engine operating limitations are exceeded (the tension stress developed in
the connecting rod is at a maximum when the engine is operated at maximum
speed under conditions of low engine load);
• the material fatigue endurance strength is lower than the specified value;
• stress concentrating features are created in the housing during manufacture,
operation or maintenance.

Figure 7.7: Cause-and-effect diagram for connecting rod little-end fatigue

fracture

Each of the potential initiating events may be examined in more detail. For
example, it is known that galling (adhesive wear) on the inner surface of the little-
end housing is a potent initiator of fatigue cracking. However, galling cannot occur
if the little-end bearing remains intact. Observations of galling between the little-
end housing and piston pin, requires a sequence of events to occur that result in the
breakup of the little-end bearing. These events may relate to the lubrication of the
bearing, the magnitude of the bearing retention force, or an abnormal loading
condtion.

– 117 –
 Figure 7.8: Cause-and-effect diagram for the creation of a stress
concentrating feature in the little-end housing during
operation

7.5.3 Connecting rod big-end fatigue fracture control

Fatigue fracture control is based on ensuring that the magnitude of alternating
stresses created during engine operation does not exceed the endurance strength of
the connecting rod big-end. Because the big-end housing is a bolted assembly, and
because it is larger than the little-end housing, fracture control is more complex. In
addition to stresses developed through gas pressure loads and inertia, stresses
arising from housing flexure need to be considered. A fracture control plan also has
to be developed for the bolts used to assemble the housing. The control of bolt
fatigue fracture is based on the establishment of a preload in the bolt, of sufficient
magnitude, to prevent the alternating stresses in the bolt exceeding the endurance
strength of the bolt.
Connecting rod big-end fatigue fracture may occur if: any one, or combination, of
the following conditions occurs:
• the engine operating limitations are exceeded (the tension stress developed in
the connecting rod is at a maximum when the engine is operated at maximum
speed under conditions of low engine load, the compression stress developed in
the connecting rod is at a maximum when the engine is operated under
conditions that create maximum combustion gas pressures);
• the material fatigue endurance strength is lower than the specified value;
• the flexure of the housing is increased while operating within specified engine
limits;
• stress concentrating features are created in the housing during manufacture,
operation or maintenance.

– 118 –
Figure 7.9: Cause-and-effect diagram for connecting rod big-end fatigue
fracture

Each initiating event may be examined in more detail, for example, a fatigue
fracture initiating on the housing outer surface, at a point of change in stiffness,
may be associated with a chain of events that starts with the breakup of the big-end
bearing inserts.

Figure 7.10: Cause-and-effect diagram for fatigue fracture at a point of

change in big-end housing stiffness

– 119 –
7.6 Crankshaft fatigue fracture

7.6.1 Crankshaft design

The crankshaft in a multicylinder reciprocating engine combines the force created
by combustion of the fuel-air mixture in each cylinder to provide rotational power
at the end of the shaft.
The crank is the key element in the mechanism for translating reciprocating motion
to rotary motion. Cranks are formed by bending a shaft through several right angle
bends so that a small section of the shaft is displaced parallel to the main axis of the
shaft.
The form of a crankshaft is shaped by; the length of the crank arm, the arrangement
of multiple cylinders around the crankshaft, the need to provide bearing journals of
sufficient area to maintain bearing loads within the design limit of the bearing, and
to limit the magnitude of crankshaft alternating stresses developed during engine
operation.
During engine operation each crank is acted upon by the gas pressure developed in
the combustion chamber; the inertia forces of the reciprocating masses, and
centrifugal forces developed by rotation. These forces on the crankshaft are created
by the engine through the crankshaft main bearings to the crankcase and engine
mounts. During each combustion-exhaust-induction-compression cycle (two
crankshaft revolutions for a four stroke engine) the forces acting on the crank vary
continuously in magnitude and direction.
The varying forces acting on a crankshaft create alternating stresses in the shaft
through the alternating flexure of the shaft in both lateral and torsional directions.
The magnitude of the alternating stresses created by the alternating lateral and
torsional flexure of the shaft, depends on the manner in which multiple cylinders
are attached to the crankshaft and the detail of design of journals and crankwebs.
There are only two ways to arrange multiple cylinders around a crankshaft; in a row
or rows along the length of the crankshaft, or radially around a crankshaft like the
spokes of a wheel. The two layouts of interest to aircraft reciprocating engines are
the horizontally-opposed layout (two equal rows of cylinders all within the same
horizontal plane) and the radial layout (one or more banks of up to nine cylinders
arranged around the crankshaft).
Because the cylinder layouts of radial and horizontally-opposed engines are very
different, the form of the crankshafts are very different and the phenomena that
have impacted on crankshaft reliability are different.
The short length of a radial-engine crankshaft, and its inherent lateral stiffness,
limits the magnitude of stresses developed through lateral flexure. The effect of the
impulses from combustion pressures in multiple cylinders, acting on one crank for
each revolution of the shaft, creates the need to control the magnitude of stresses
developed through torsional flexure and the potential for resonant conditions.
The length of a horizontally-opposed engine crankshaft, the limited stiffness of the
engine crankcase, and the placement of main bearings between every two
connecting rod journals, creates the need to control the magnitude of stresses
developed through lateral flexure, as well as the stresses developed through
torsional flexure.

– 120 –
 Inherent points of stress concentration are created at the transitions between the
crankshaft bearing journal and the crankwebs. The magnitude of alternating stresses
at these sites, created by crankshaft flexure, is controlled by; the sizing of journals
and crankwebs, the overlap between adjacent journals, the rigidity of the supporting
structure (crankcase), the size of the fillet radius between the journals and
crankwebs, and the creation of residual compressive stresses in the material at the
fillets.
The dimensions of the bearing journals are also based on a consideration of the
maximum allowable bearing loading.
Because the journals are subjected to abrasive wear, through the action of fine
abrasive particles suspended in the lubricating oil, journal surfaces in aircraft
engines are hardened. Nitriding is the preferred method of hardening. In addition to
creating a wear resistant surface, nitriding also creates a compressive residual stress
in the surface zone of the journal and journal fillets. This residual compressive
stress acts to increase the resistance to fatigue crack initiation in the region of the
journal.

7.6.2 Crankshaft fatigue fracture control

Because of the very high number of alternating loading cycles created by engine
operation (thousands per minute – engine revolutions), crankshaft design,
regardless of the end application of the engine, is centred on restricting the
magnitude of alternating stresses created by the alternating external loads so that the
fatigue endurance strength of the crankshaft is not exceeded. Crankshafts are
designed to have a life not limited by the initiation and growth of fatigue cracks.
The endurance strength of a crankshaft is a function of; the geometry of the shaft
(dimensions of journals, webs, and journal fillets), the presence of surface
hardening, the presence of residual compressive surface stresses, and the crankshaft
material properties. Reductions in the endurance strength of a crankshaft to levels
below the design limit may erode safety margins and result in fatigue fracture
during engine operation. Similarly, increases in the magnitude of alternating
stresses developed during engine operation that exceed the design limit may erode
safety margins and result in fatigue fracture during operation.
Crankshaft fatigue fracture may occur if any one, or combination, of the following
conditions occurs:
• engine operating limitations, such as, engine maximum speed or combustion gas
pressures (bmep), are exceeded;
• stress concentrating features are created at critical locations during manufacture,
operation or maintenance;
• the journal surface hardening treatment does not meet the design specification;
• the fatigue strength of the steel alloy is lower than the design allowable value.

– 121 –
 Figure 7.11: Cause-and-effect diagram for crankshaft fatigue fracture

7.7 Powertrain plain bearing failure

7.7.1 Plain bearing design

Plain bearings are used to allow the transmission of force between the piston,
connecting rod, crankshaft, and crankcase. Plain bearings operate through the
creation of a hydrodynamic oil film when two components are moving relative to
each other. A slight eccentricity in the rotation between the two components results
in a converging wedge geometry being formed between the two bearing surfaces.
The action of rotation with convergent wedge geometry is to increase the oil
pressure, from the supply pressure, to a pressure that prevents bearing surface
contact under the loads imposed on the bearing during engine operation.
Because hydrodynamic lubrication is dependent on rotation between two
components, there will be short periods when the rotational speed is insufficient to
establish or maintain hydrodynamic lubrication. This lubrication regime is known
as boundary lubrication and, normally, is encountered during engine starting and
stopping when the operational loads are low. Bearing surfaces are designed to
accommodate these periods of bearing surface sliding contact, without seizure,
through the principle that low friction sliding contact occurs between dissimilar
metals. For example, lead-tin alloys, aluminium-tin alloys, and lead-copper alloys
are used as bearing couples with steel.
The bearing load is a function of the bearing area and the magnitude of the
operational load. For the case of powertrain bearings, two types of relative motion
shape the size and nature of the bearings. The motion between the piston pin and
connecting rod little-end bearing is characterised by low-speed oscillating
movement. Because oscillating bearings operate at low average surface speeds, the
problem of wear is less than that in rotating bearings as the heat generated by

– 122 –
friction is relatively small, so bearing material selection is made on the basis of high
endurance strength in preference to low friction surfaces, conformability and
embedability. As the name suggests, the connecting rod little-end bearing is smaller
than the big-end bearing, and a leaded bronze alloy is used as the bearing material.
The high-speed rotational movement between the connecting rod big-end and
crankshaft, and between the crankshaft and main bearings in the crankcase, require
a consideration of wear, heat, endurance strength, and bearing load.
A limit on the use of a simple coating of lead or tin alloy on a bearing housing, is
the low-bearing load capacity of the alloy under repeated loading conditions (low
fatigue strength). Bearings have developed from in-situ formed lead-tin or tin-lead
alloy coatings, to precision bearing inserts with various alloy layers, in response to
the need to; provide accurate geometric conditions necessary for hydrodynamic
lubrication, cope with boundary lubrication, and allow efficient replacement after
wear.
Connecting rod big-end bearings and crankshaft main bearings are manufactured as
a laminate of different metal alloys; depending on the number of layers used they
are termed bimetal or trimetal bearings. Each layer in the bearing insert has a
particular function.
A low-carbon steel layer provides support to the bearing alloy layers. The strength
of the steel allows the bearings to be seated in their housings with a high degree of
conformance and be retained by an interference-fit force sufficient to retain the
inserts under all normal operating conditions. Precision bearing inserts are retained
in their housings by an interference fit created during assembly. Simply, the
circumference of the outer surface of the precision bearing inserts exceeds the
circumference of the housing bore. The difference in dimension is commonly
referred to as ‘bearing crush’. The lugs formed on the end of each insert are
provided to locate the inserts accurately in the housing prior to final tightening of
the housing bolts. The surface finish of the housing and precision bearing insert
backs are required to be of high quality to ensure that the bearing is not distorted,
the interference fit is established, and heat transfer through metal-to-metal contact
can occur.
The factors that determine which bearing alloy is used, are related to the need to be
able to withstand the repeated bearing loads created by the alternating inertia and
combustion gas pressure loads and the surface properties of the bearing. For the
case of light-weight high-power engines, the fatigue-endurance strength of the
bearing alloy needs to be maximised.
Lead-tin or tin-lead alloys provide the best bearing surface under conditions of
boundary lubrication and the best ability to accommodate fine abrasive material
(embedability) entrained in the lubricating oil. However, they have the lowest
fatigue endurance strength.
The optimum bearing performance is achieved through a thin layer of lead-tin alloy
bonded to a thicker layer of a copper-lead, or aluminium-tin, bearing alloy layer,
which is in turn, bonded to a steel backing layer. Bearing inserts of this type are
known as trimetal bearings. The intermediate bearing material increases the fatigue
endurance strength of the bearing and provides protection from seizure if the
overlay is removed, by wear, within the specified overhaul interval of the engine.

– 123 –
7.7.2 Plain bearing failure control plan
Plain bearings can be considered to have failed when; seizure occurs between the
bearing surfaces, the bearing surface breaks up to an extent that destroys the
hydrodynamic lubrication operating regime, or when other associated components
are damaged by wear, increased flexure, or heat. Plain bearing failure control plans
are based on the maintenance of hydrodynamic lubrication under all operating
conditions, except the low load conditions at engine start and stop, and the retention
of bearing inserts in their housings.
The critical features for successful bearing operation are the dimensions and
geometry of the shaft and bearing, the surface roughness of the shaft and bearing,
the rotational speed of the shaft in the bearing, and oil viscosity.
Hydrodynamic oil films possess some capacity for self correction when changes
occur in oil viscosity, bearing load or shaft speed. The extent of oil film stability is
commonly shown by the relationship between the coefficient of friction of the
bearing and the bearing characteristic parameter, μN/P (μ –viscosity, N – rotational
speed, P – load per unit of projected bearing area), see figure 7.12.

Figure 7.12: Variation of the coefficient of friction with bearing

characteristic parameter (Shigley and Mischke, 1989, p.485)

If the bearing operating parameters are to the right of the line BA and there is a
change in viscosity, speed or loading pressure that decreases the bearing
characteristic parameter, then the reduction in friction results in a reduction in heat
in the lubricant and an increase in viscosity. If the bearing parameters lie to the left
of the line BA, then a decrease in viscosity would increase friction, a temperature
rise would occur and the viscosity would be reduced further, resulting in unstable
lubrication and the increasing possibility of metal to metal contact.
The magnitude of clearance between the bearing and shaft has an important effect
on plain bearing performance (Shigley and Mischke, 1989, p.508). If the radial
clearance is too tight, the temperature within the bearing will be too high and the oil
film thickness will be too low. Large clearances also result in low oil film thickness.
Bearing failure may occur through fatigue cracking in the bearing alloy under full
oil film conditions if the repeated bearing pressure loads are higher than the design
allowable value or the bearing endurance strength is lower than the design
allowable value.
Bearing failure, through excessive wear or excessive friction, may occur if
boundary lubrication conditions occur during periods of high bearing load.
Boundary lubrication is favoured by high bearing operating temperatures, sliding

– 124 –
speeds that exceed the design allowable value, and oil viscosities lower than the
design allowable value.

Figure 7.13: Cause-and-effect diagram for plain bearing breakup

Plain bearings can also be considered to have failed if the bearing inserts are
displaced from their housings and damage is created in other components, for
example, housing surfaces or journal fillets. The control of bearing insert movement
is based on creating a retention force of sufficient magnitude to resist the
operational forces that act to move inserts during engine operation.
Bearing insert movement may occur if the insert retention force is lower than the
design allowable force. The retention force is developed by an interference fit and,
as such, is affected by the geometric differences between the housing and insert, the
closure of the bolted assembly, and the coefficient of friction between the insert
back and housing surface.
Bearing insert movement may also occur if the operational forces on the bearing
insert exceed the design allowable force. Boundary lubrication under high engine
loading conditions, shaft flexure beyond design allowable limits, and high friction
coefficients between the bearing and journal surface, following wear of the bearing
surface, may result in insert movement.

– 125 –
 Figure 7.14: Cause-and-effect diagram for plain bearing insert movement

7.8 References
Kolchin A and Demidov V 1984, Design of automotive engines, translated from
Russian by Zabolotnyi P, MIR Publishers, Moscow, p.302
Shigley JE and Mischke CR 1989, Mechanical Engineering Design Fifth Edition,
McGraw-Hill Book Company, New York, 1989

– 126 –
8 ANALYSIS OF POWERTRAIN STRUCTURAL
FAILURES

8.1 Introduction
The initiating events leading to powertrain structural failures investigated in this
study, are dominated by combustion chamber component melting, the initiation and
growth of fatigue cracking in components that are designed to have a life not
limited by fatigue, and plain bearing breakup or movement. The factors that
contribute to these initiating events are those factors that affect heat transfer to and
from components, affect the fatigue endurance strength of a component and the
magnitude of alternating stresses during engine operation, and affect bearing
surface behaviour and bearing insert retention in their housing. Engine design seeks
to control these factors, so that the sequence of events leading to powertrain
component failure does not occur during engine operation.
For the engines studied, operational experience has established that powertrain
components can perform reliably within the specified operational limits, overhaul
periods, and maintenance actions. There is no one solution to the goal of producing
a specified output power/torque for a minimal weight. While some design features
displayed by different models and different manufacturers are similar, other
features are different. For example: a particular power output may be achieved by
various combinations of gas pressure (bmep) and engine speed; component fatigue
endurance strength may be achieved by a combination of the sizing of the
component and the dimensions of design details such as fillets.
Use is made of safety factors to achieve a reliable design in situations where
properties are not known with certainty and behaviours are not clearly defined. It is
important to be aware that safety factors are not constant for all components and all
conditions. Some engine designs will display sensitivity to variations in particular
initiating factors. Variations from predicted properties and behaviours may occur
during component manufacture, engine assembly, engine operation, and engine
maintenance.
In order to understand why powertrain components and high-power reciprocating
engines are not meeting the expectation of reliable operation, it is necessary to
examine, in detail, the factors that affect component melting, fatigue crack
initiation, and bearing behaviour. There are relationships between these factors that
range from simple to complex. For example, the factors involved with the
combustion of the fuel-air mixture may affect the rate of heat transfer to
combustion chamber components and affect the nature of stresses developed in a
number of powertrain components (connecting rods, crankshafts, bearings,
fasteners). It is also apparent that in any one engine, multiple event sequences may
occur

– 127 –
8.2 Factors associated with combustion

8.2.1 Normal combustion

The operation of a conventional spark-ignition engine is based on the combustion of
a gaseous mixture of hydrocarbon fuel and air. The process of combustion is
characterised by the propagation of a flame front (a narrow zone of intense
chemical reactions) radiating from the site of spark ignition. When flame
propagation continues throughout the entire fuel-air charge, without abrupt change
in speed or shape, combustion is termed normal.
As far as engine performance is concerned, the important aspect of flame
propagation is on the development of gas pressure in each combustion chamber. A
secondary issue is the control of the effects of heat generated by discontinuous
combustion.

Figure 8.1: Typical curve of gas pressure versus crank angle (θ) for a 4-
cycle engine, with resultant torque on crankshaft, (Taylor,
1999, vol.2 p.270)

Combustion process design is based on control of flame propagation within the

engine design allowable limits of maximum pressure and rate of pressure rise.
For an established aircraft engine design, the operator-controlled variables of
engine power setting, temperature control, and fuel-air mixture selection, have a
significant effect on the combustion process through their affect on flame velocity,
maximum gas pressure, and fuel-air charge temperature.

8.2.2 Abnormal combustion – detonation

Combustion may not always progress to completion by the propagation of a flame
front through the fuel-air mixture. There are occasions when the conditions in the
combustion chamber result in the combustion of the fuel-air mixture in front of the
flame front. This phenomenon is described as auto-ignition. The sudden increase in
the rate of combustion created by auto-ignition. The accompanying propagation of

– 128 –
shockwaves through the gas in the combustion chamber is known by the term
detonation (Taylor 1999, vol.2 pp.34-85).
Detonation may affect the reliability of powertrain components through increased
maximum pressure, increased pressure rise rate, and increased heat transfer to
pistons and cylinder heads. The effect of detonation on powertrain reliability is a
function of the intensity of detonation. The intensity of detonation, in turn, is related
to the volume of end-gas that is involved in the auto-ignition event – the larger the
volume of end-gas subjected to auto-ignition, the more intense the detonation.
Examples of combustion chamber pressure development for varying degrees of
detonation are shown in figure 8.2.

Figure 8.2: Examples of detonation on pressure development in a

reciprocating-engine combustion chamber (GAMI)

– 129 –
The aim of engine design is to establish the combination of mechanical design, fuel
resistance to auto-ignition (octane rating), and operational control that allows
engine power to be developed without detonation.
For an established engine design, and a fuel of known detonation resistance, the
likelihood of end-gas detonation is dependent on those factors that increase the
temperature of the end gas (Taylor 1999, vol.2 p.61) – factors such as; inlet air
temperature, extent of inlet air pressure boosting (turbo-charging), combustion
chamber surface temperature, high power setting, high rate of pressure rise (ignition
advance or surface ignition in addition to spark ignition), and fuel-air mixture.
Detonation control is based on establishing operational limits for each of these
factors.
Fuel-air mixture control is an important variable in the control of detonation in
aircraft reciprocating engines, rich mixtures allow higher engine power to be
developed without detonation, while at lower engine power, leaner mixtures allow
less fuel to be used. A typical relationship between engine power and fuel-air
mixture is shown in figure 8.3. The effect of fuel-air mixture variation is related to
the effect of the fuel-air ratio on the velocity of flame propagation and, particularly
at very rich mixtures, the cooling effect of fuel vapourisation. Flame velocity is a
maximum at a mixture that is slightly rich of the stoichiometric 1 mixture and
decreases as the fuel-air ratio is increased (enriched) or decreased (leaned) (Turns,
1996, pp.224-225).

Figure 8.3: Schematic representation of detonation boundaries, as a function

of fuel-air ratio and engine power setting, for variation in factors
that increase the tendency for detonation (AFM 51-9, 1954)

Any change that increases the tendency for end-gas detonation to occur will shift the
detonation boundary in the direction of the arrow, lowering the detonation limited power for
constant fuel-air ratios.

1 The stoichiometric mixture is the mixture of fuel and air that results in the complete combustion
of the mass of fuel with the mass of oxygen in the air

– 130 –
The relationship between engine power setting (manifold pressure), fuel-air mixture
(fuel flow) and detonation, has been determined experimentally for a high-power
horizontally-opposed air-cooled aircraft reciprocating engine (GAMI), figure 8.4.

Figure 8.4: Effect of mixture and power setting with effect of variation in
cylinder head temperature (GAMI)

Pre-ignition and multiple ignition events

The term pre-ignition refers to the ignition of the fuel-air mixture before normal
spark ignition. In this case, ignition of the charge is caused by contact with a hot
surface, for example, hot spark plug electrode or other heated, high melting point
materials, projecting into the combustion chamber. The effects of pre-ignition are
similar to an increase in spark advance – the rate of pressure rise is increased and,
with the consequent increase in end-gas compression heating, there is an increased
tendency for detonation to occur.
The term pre-ignition is also used to refer to a runaway detonation process where
detonation leads to a cycle of combustion chamber heating, the creation of non-
spark ignition sites, more intense detonation, and finally combustion chamber
component melting.
Ignition of the fuel-air mixture from hot surfaces may also occur after the spark
ignition event. In this case, additional flame fronts are created and the mixture is
combusted more rapidly, resulting in a rapid rate of pressure rise.

Combustion chamber deposits

In a clean engine, it is usual for detonation to be the limiting factor for maximum
manifold pressure or compression ratio. However, pre-ignition has been found to be
the limiting factor (Taylor 1999, vol.2, p.153) in high-compression engines that

– 131 –
 have accumulated deposits from the combustion of leaded fuels. The heated
deposits create non-spark ignition sites, either prior to spark ignition or after spark
ignition.
The presence of deposits on combustion surfaces may also increase the tendency for
detonation. This increase in susceptibility has been attributed to an increase in
effective compression ratio (lowering of combustion chamber volume) and an
increase in combustion chamber surface temperature (Taylor 1999, vol.2, p.84).

8.2.3 The effect of combustion on engine roughness

In addition to controlling the maximum combustion chamber pressure (measured as
the brake mean effective pressure), engine roughness is a phenomenon that affects
engine design. Roughness has been observed in spark-ignition engines when the
rate of pressure rise developed through normal combustion exceeds a particular
level. Investigation has shown that roughness is caused by severe vibration of
certain engine parts, usually including crankshaft bending vibration (Taylor, 1999,
vol.2, p.32). Roughness can be controlled by controlling the rate of pressure rise
during combustion or by stiffening the engine structure.
The mechanical control of roughness relies on creating a stiff engine structure. In
particular, in order to eliminate crankshaft bending vibration, the crankshaft needs
to be stiff and the supporting crankcase structure needs to be stiff (Taylor, 1999,
vol.2, p.297). Short compact engines, with generous crankshaft dimensions, are
inherently stiffer `than longer engines, for example, the V8 engine layout is stiffer
than the inline eight-cylinder layout.
When an engine structure cannot be stiffened, roughness can only be controlled by
reducing the rate of pressure rise. For cases where the combustion chamber design
is fixed, control of the flame speed may be used to control the rate of pressure rise.

8.2.4 Combustion chamber condition - engines studied

Examination of the combustion chambers from the engines examined in this study,
where available, revealed that deposits of a lead oxybromide compound, Pb3O2Br2
(Heath et al., 2005), were present on piston crowns and cylinder heads, figures 8.5 -
8.24. This compound is not volatile, melting point 709°C, 1308°F (Newby and
Dumont, 1953), and persists on the combustion chamber surfaces during continued
engine operation. The presence of glassy (melted and resolidified) deposit edges,
see for example figure 8.16, provides evidence that lead oxybromide deposits have
been heated, locally, to temperatures exceeding its melting point during engine
operation. It is likely that these deposit ‘hot spots’ would provide sites of fuel-air
mixture ignition.
It is also evident that there is a cycle of deposit buildup followed by deposit loss
through the mechanical effects of heating and cooling, and, possibly, detonation.

– 132 –
Figure 8.5: Cylinder head surface condition, 2000/90, VH-MZK (left
engine)

– 133 –
Figure 8.6: Piston surface condition, 2000/90, VH-MZK (left engine)

– 134 –
Figure 8.7: Piston surface condition, 2000/2157, VH-MZK (left engine)

This engine was recovered after immersion in seawater for several days.

– 135 –
Figure 8.8: Cylinder head surface condition, 2000/2157, VH-MZK (left
engine)

The condition of the combustion chamber surfaces at engine disassembly, showing the
effects of immersion in seawater.

– 136 –
Figure 8.9: Cylinder head surface condition, 2000/2157, VH-MZK (right
engine)

The condition of the combustion chamber surfaces at engine disassembly, showing the
effects of immersion in seawater.

– 137 –
Figure 8.10: Piston surface condition, 2000/2157, VH-MZK (right engine)

While the piston crown surfaces from this engine were affected by immersion in
seawater, it is evident from the residual deposits on the pistons that the engine was
operating under very different combustion conditions to the left engine (MZK) prior
to engine failure, see figures 8.6 and 8.7, and other Lycoming TIO-540 engines, see
for example figures 8.12 – 8.14.

– 138 –
Figure 8.11: Cylinder head surface condition, 2001/5866, VH-JCH (right
engine)

– 139 –
Figure 8.12: Piston surface condition, 2001/5866, VH-JCH (right engine)

– 140 –
Figure 8.13: Piston surface condition, 2000/2276, VH-ODE (left engine)

– 141 –
Figure 8.14: Piston surface condition, 2000/3675, VH-NPA (right engine)

– 142 –
Figure 8.15: Piston surface condition, 2002/3474, VH-ACZ (left engine)

– 143 –
Figure 8.16: Piston surface condition, 2001/2544, VH-TTX (left engine)

Detail of piston crown deposit showing the features created by deposit edge melting and
resolidification

– 144 –
Figure 8.17: Cylinder head surface condition, 2001/4799, VH-BEM (left
engine)

– 145 –
Figure 8.18: Piston surface condition, 2001/4799, VH-BEM (left engine)

– 146 –
Figure 8.19: Cylinder head surface condition, 2003/2701, VH-OCF (left
engine)

– 147 –
Figure 8.20: Piston surface condition, 2003/2701, VH-OCF (left engine)

– 148 –
Figure 8.21: Piston surface condition, 2001/1405, VH-LTW (left engine)

Figure 8.22: Cylinder head surface condition, 2001/2885, VH-MJA (left

engine)

– 149 –
Figure 8.23: Piston surface condition, 2000/1327, VH-BNN

Figure 8.24: Piston surface condition, 2004/2291, VH-VEC (right engine)

– 150 –
 Lead oxybromide deposits may also form in low power engines. However, it is
apparent in the example shown in figure 8.25 that localised heating to the deposit
melting point has not occurred under the engine operating conditions.

Figure 8.25: O-360 low power engine (180 HP) deposits

8.2.5 Engine control settings

Because of the operational need to maximise engine power and reduce fuel
consumption during takeoff, climb and cruise phases of flight, the margin between
operational settings and the detonation limited power boundary is minimised. In
practice, the control of detonation depends on knowledge of the detonation-limited
power boundary, for a particular engine and fuel, as a function of engine power and
fuel-air mixture, and the control of the operational factors that shift the boundary.
In this present study of high-power horizontally-opposed aircraft engine powertrain
failures, it became apparent that there was considerable variation in fuel-air mixture
control during the climb and cruise phases of flight.

Fuel-air mixture control

Takeoff
During takeoff, the engine systems are designed to create a ‘full’ rich mixture
appropriate for the rated power of the engine with no scope for operational
variation.
Climb
A survey of Lycoming TIO-540-J2B engine operation revealed that mixture setting
during climb ranged from ‘full’ rich to various degrees of leaning, for example, 36
inches MAP/2400 rpm, full rich; 40 inch MAP/2400 rpm, 33 US gal/h; 38 inches
MAP/2400 rpm, 30 US gal/h; 36 inches MAP/2400 rpm, 27 US gal/h; 35 inches
MAP/2400 rpm, 25 US gal/h.
Engine test data (GAMI) shows that cylinder gas pressures increase to the same
level as those at take-off power when the mixture is leaned at climb power settings
In addition, the rate of pressure rise is increased and the peak pressure is developed
with the crank closer to top centre, see figure 8.26.

– 151 –
Figure 8.26: Effect of engine control settings on peak pressure and the
timing of peak pressure development (GAMI)

Leaning at climb power reduces the margin between the power setting and the onset
of detonation, figure 8.27.

Figure 8.27: Detail from experimentally determined detonation limited

power as a function of power and mixture (GAMI)

At typical climb power settings (38 inches manifold pressure), leaning from a full
rich mixture will increase the likelihood of encountering end gas detonation.

– 152 –
The extent of detonation; light, medium or heavy, depends on the presence of other
factors that determine the position of the detonation-limited power boundary, for
example, cylinder head temperatures approaching or exceeding limits, ignition
advance, and increase in the rate of pressure rise.
Cruise
The survey of Lycoming TIO-540-J2B operators also showed that there was
considerable variation in mixture settings at cruise power. Typically, cruise mixture
settings are made with reference to the peak exhaust gas temperature (EGT). The
cruise settings ranged from: 32 inches MAP/2300 rpm, peak EGT; 30 inches
MAP/2200 rpm, between peak EGT and 50°F rich of peak; 32 inches MAP/2200
rpm, 125°F rich of peak. The engine test data presented in figure 8.4 shows that, at
cruise power settings, fuel-air mixture adjustment is not detonation limited.
The mixture setting used in climb and cruise does have an effect on combustion
chamber component temperature, see figure 8.28.

Figure 8.28: Comparison of piston operating temperature, as evidenced

by the extent of varnish formation, for two climb/cruise
mixture settings.

Occurrence 2000/90; Time since overhaul, 1673 hours, mixture setting - climb 27
US gal/h, cruise between peak EGT and 50°F rich of peak.

Time since overhaul, approximately 1000 hours, mixture setting – climb, full rich,
cruise 100°F rich of peak EGT.

– 153 –
8.2.6 The effect of detonation – shockwave propagation
The effect of detonation is a function of its intensity; light, medium or heavy. The
affect on powertrain component reliability can be related to high local combustion
gas pressures, high rates of pressure rise, the mechanical effects of shockwave
propagation across the piston crown, and the effects of shockwave propagation on
the heat transfer to combustion chamber components.

Mechanical effects
With normal combustion, the pressure rise in a combustion chamber acts uniformly
on the piston. However, when detonation occurs, localised regions of high pressure
are created. As these regions of high pressure move, shockwaves are created.
It is a feature of horizontally-opposed reciprocating engines that two spark plugs are
used to initiate flame fronts during each combustion cycle. Each flame front
radiates from its site of ignition leaving the regions of end gas, at a circumferential
location, approximately 90° from the spark plugs, see figure 8.29. The effect of
non-uniform piston pressure distribution on the piston and connecting-rod
assembly, is a function of engine layout. For the case of a horizontally-opposed
engine layout, end-gas detonation will occur in the regions over the piston pin ends,
with shockwave propagation in a direction parallel with the piston pin, see figure
8.29. The piston and connecting rod assembly will be affected by the rocking of the
piston pin in the little-end bearing and the out-of-plane rocking of the big-end
bearing. For the case of a radial engine layout, the regions of end-gas detonation at
sites 90° to the piston pin ends, with shockwave propagation in a direction
perpendicular to the piston-pin, see figure 8.29. End-gas detonation in a radial
engine will cause the piston to rotate in the plane of the little-end bearing, rocking
about the piston pin will not occur.

Figure 8.29: Schematic showing the locations of end-gas detonation

(coloured red) for different engine layouts

Horizontally-opposed layout. Radial layout.

– 154 –
 Combustion chamber component temperature
The rate of heat transfer from the combustion gas to the combustion chamber
(cylinder head and piston) is controlled, under normal combustion conditions, by
heat transfer across a gas boundary layer adjacent to the combustion chamber
surface. However, as the intensity of detonation and associated shockwave
propagation increases, the increasing turbulence in the combustion gases disrupts
the gas boundary layer. Once the gas boundary layer is disrupted, heat is transferred
rapidly to the combustion chamber components, leading to a rapid, large increase in
component temperature, and component failure when the incipient melting point is
reached.

8.2.7 Summary
A change in the combustion process – from flame propagation throughout the fuel-
air mixture to the auto-ignition of some part of the mixture – has the potential to
affect the reliability of powertrain components. The effect of detonation is related to
the intensity of detonation, which in turn, is dependent on the volume of end-gas
that undergoes auto-ignition. Light to medium detonation may result in some
mechanical damage. The actual nature of mechanical damage is dependent on the
robustness of powertrain components and assemblies to abnormal loading. Heavy
detonation results in the melting of aluminium alloy combustion chamber
components.
Detonation-free operation, for a fuel of known detonation resistance, is based on
limiting the operator-controlled engine parameters of manifold pressure (power),
speed, mixture, and engine load. Additionally, detonation-free operation is based on
designed limits for; combustion chamber surface temperatures (spark plugs, piston
crown and cylinder head inner surface, the presence of deposits), inlet air
temperature, and rate of pressure rise (spark ignition advance, ignition from sites
other than spark plugs). Variations in any of these factors, beyond designed limits,
will increase the likelihood of detonation during engine operation. In addition, the
cumulative effect of variations in a number of factors may also act to increase the
likelihood of detonation. The general form of relationships between factors which
may contribute to the onset of detonation is shown in figure 8.30.
For the engine failure occurrences investigated in this study, it is clear that leaning
at climb power settings increases the likelihood of detonation. It is also evident that
the fuel-air mixture settings – lean climb and lean cruise, resulted in the deposition
of a non-volatile lead compound on combustion chamber surfaces. The presence of
non-volatile deposits also increases the likelihood of detonation.

– 155 –
Figure 8. 30: Schematic showing the general form of relationships
between factors that contribute to the onset of detonation

– 156 –
8.3 Factors associated with bearing surface breakup
There are three processes that may lead to bearing surface breakup; fatigue cracking
of the bearing surface under hydrodynamic lubrication conditions, a change from
hydrodynamic to boundary lubrication during periods of high engine power, and
abrasive wear caused by particles entrained in the oil. The evidence examined in
this study indicates that the first two processes are important factors in the breakup
of connecting-rod bearings.

8.3.2 Connecting rod little-end bronze bush breakup

The sequence of events leading to the fracture of a connecting rod little-end
housing, on two occasions, involved the breakup of the little-end bearing, see, for
example, figure 8.31. It is evident from an examination of the remnants of the
bushes and the condition of other little-end bushes, that the process of bearing
breakup did not involve bearing seizure but occurred as a result of the development
of cracking at bush edges and axial displacement of the bush, figures 8.31, 8.32 and
8.33.

Figure 8.31: Remnants of the little end bush, No.6 connecting rod little
fracture, VH-OCF (left engine)

Figure 8.32: No.1 connecting rod little end bush, VH-OCF (left engine)

– 157 –
 Figure 8.33: No.1 connecting rod little-end bearing, VH-OCF (right engine)

The physical evidence of little-end bearing breakup, indicates that the alternating
loads imposed on each bearing, through the piston pin, was not uniform. It is
apparent that bearing breakup was associated with the rocking of the piston pin.
A significant factor in the development of piston-pin rocking, in horizontally-
opposed engines, is the propagation of shockwaves, in the combustion gases, across
the surface of a piston.

8.3.3 Connecting rod big-end bearing boundary lubrication

Bearing design is based on selecting values of oil viscosity, sliding speed between
the bearing surfaces, and load per unit of projected bearing area (a function of load
and bearing dimensions) to maintain hydrodynamic oil film lubrication during all
engine operating conditions other than starting and stopping.
For an established bearing design in an aircraft engine, control of the oil film
temperature in the bearing is the critical factor in maintaining hydrodynamic
lubrication. The temperature of the oil film is a function of the temperature of the
oil introduced into the bearing and the heat created through the continual shearing
of the oil film.
There is a particular value of the bearing characteristic that defines the boundary
between hydrodynamic oil film lubrication and boundary lubrication, figure 8.34. In
the hydrodynamic regime self-correction of the effects of oil-film heating occurs.

– 158 –
Any increase in oil-film temperature is accompanied by a lowering of oil-film
viscosity and a decrease in oil-film frictional heating, resulting in a return to the
normal oil-film temperature (Shigley and Mischke, 1989, p.485). However, if the
increase in oil-film temperature is too high the oil film will breakdown and allow
metal to metal contact to occur. Metal-to-metal sliding contact (boundary
lubrication) will result in the increased frictional heating of the bearing.

Figure 8.34: The relationship between the bearing characteristic

parameters and lubrication regime (Shigley and Mischke,
1989, p.485)

Loads associated with oil-film breakdown

There are two loading conditions that may lead to hydrodynamic oil-film
breakdown; loads from the gas pressures developed in combustion chambers, and
loads developed by the rotation and reciprocating action of powertrain components.
The type of loading, gas pressure or inertia, will affect different regions of the
bearing. For the case of connecting rod big-end bearings, boundary lubrication
caused by high gas pressure loading will affect the region of the big-end bearing
adjacent to the connecting rod, while boundary lubrication caused by high-inertia
loading will affect the region of the big-end bearing adjacent to the connecting-rod
cap.

Figure 8.35: An example of localised bearing surface wear associated with

oil-film breakdown under gas pressure loading

TCM GTSIO-520 engine, trimetal bearing inserts with a copper-lead intermediate layer.

– 159 –
 Figure 8.36: Typical region of bearing surface wear (gas loads)

VH-TTX (left engine) No.5

VH-MZK (left engine) No.4

Lycoming TIO-540-J2B, trimetal bearing inserts with an aluminium-tin intermediate layer.

8.3.4 Connecting rod big-end bearing breakup

Connecting rod big end bearing structure

The key feature of the alloys used in the intermediate layer of trimetal bearings is
the inclusion of a soft metal phase that will provide a low friction couple with the
journal under conditions of boundary lubrication if the normal lead-tin alloy surface
layer is removed by a process of wear, figure 8.37. Two alloy systems are used as
the intermediate bearing alloy in trimetal bearings; copper-lead, and aluminium-tin.
Normally, the lead or tin phase is distributed throughout a matrix of the stronger
copper or aluminium phase, figure 8.38. The nature of this distribution determines
the fatigue endurance strength of the alloy used as the intermediate bearing layer,
and, in turn, affects the endurance strength of the bearing.

– 160 –
Figure 8.37: Examples of trimetal bearing surface alloy wear (Aluminium
tin) trimetal (rod side)

Examples of bearing surface wear from bearings that had been in service for a short time
(top), and an engine that had been in service for approximately 1,300 hours (bottom).

Figure 8.38: Photomicrographs showing the layers present in two types of

trimetal bearings

Note: the roughness of the bearing surface evident in the micrographs was created during
the mounting of bearing sections in a mineral filled plastic mounting compound.

– 161 –
Aluminium-tin alloy endurance strength change during operation
The distribution of the soft-metal phase is critical in determining the structural
response of the bearing to repeated loading. It is expected that the distribution and
morphology of the soft-metal phase will not change during operation and that the
structural response of the bearing will not change during continued operation
(Romeyn, 2006).
The distribution and morphology of phases in alloy systems can change as a result
of diffusion of one or more elements. Diffusion occurs when one metallic element
is soluble in another. It is important to note that for the aluminium-tin alloy system,
tin is not soluble in aluminium below 228°C. However, it is slightly soluble in
aluminium above 228°C (ASM, 1992, vol.3, p.2.52). In contrast, lead only becomes
very sparingly soluble in copper at temperature of 326°C (ASM, 1992, vol.3,
p.2.175).

Bearing Temperature
The temperature of a plain bearing is a function of the rate of heating by friction (oil
film shearing and metal-to-metal sliding) and the rate of heat removal from the
bearing by oil flow and conduction to the bearing housing.
Conduction to the bearing housing is affected by resistance to heat transfer from the
bearing insert to the bearing housing. In the course of this study, it has become
evident that contact between the insert back and housing, has been affected by the
inclusion of a variety of lubricants between the insert back and housing. The
temperatures attained during operation have been sufficient to carbonise the
lubricant, see figure 8.39.

Figure 8.39: An example of a bearing insert back showing the carbonised

residue of oil included between the insert back and bearing
housing

VH-TTX No. 5

Aluminium-tin alloy microstructure

Metallographic examination of bearing inserts, from engines that have been the
subject of this study, has revealed that the distribution and morphology of the tin

– 162 –
phase, in bearings manufactured with an aluminium-tin intermediate layer, may
change during engine operation. A characteristic of the modified distribution of tin
is the formation of coarse particles of tin at the interface between the aluminium-tin
layer and the nickel plating on the steel backing, see figures 8.40 and 8.41.

Figure 8.40: Metallographic section through an aluminium-tin intermediate

layer, occurrence 2000/2276, VH-ODE

This section is taken through a region of surface layer wear, backscattered electron image. A
coarse particle of tin at the interface between the intermediate layer and insert backing is
arrowed.

Figure 8.41: Tin x-ray line scan, micrograph 8.41

The formation of coarse particles of tin, at the interface between the aluminium-tin
layer and the steel backing, will reduce the endurance strength of the bearing. The
endurance strength will no longer be determined by the endurance strength of the
aluminium phase but will be determined by the endurance strength of the tin phase.
It is apparent, through the observation that tin diffusion in the aluminium-tin
intermediate layer has occurred during engine operation, that bearing temperatures
may reach 228°C (the melting point for the tin phase) during some periods of
engine operation. Under these conditions, the endurance strength of the bearing will
be determined by the distribution of coarse particles of molten tin at the boundary
between the aluminium-tin alloy layer and the steel backing. It would be expected
that bearing breakup would involve the loss of sections of the aluminium-tin alloy
layer, with separation at the interface with the steel backing. Examples of this type
of bearing surface breakup are shown in figures 8.42 and 8.43.

– 163 –
Figure 8.42: Bearing surface breakup, trimetal bearing with aluminium-tin
intermediate layer, occurrence 2000/2276, VH-ODE

Figure 8.43: Bearing surface breakup, trimetal bearing with aluminium-tin

intermediate layer, major defect report 99/1447, Piper PA 31-
350, Lycoming LTIO-540-J2BD

Effect of the nickel plating between the lead-tin surface layer and the
aluminium-tin intermediate layer
It is common practice to incorporate a thin layer of nickel between the surface layer
and intermediate layer of trimetal bearings. In the course of this safety study, it has
become apparent that nickel plating applied to the aluminium-tin intermediate layer

– 164 –
remains attached to the aluminium alloy even after the removal of the surface lead-
tin alloy by wear, see figures 8.44, 8.45.

Figure 8.44: Metallographic section showing the exposed, adherent,

nickel plate in a region where the lead-tin alloy has been worn
away

X-ray maps, figure 8.45, clearly show that in regions where the lead-tin surface
layer has been worn through the nickel layer overlying, the aluminium-tin
intermediate layer is exposed and remains adherent.
The effect of an adherent film of nickel is to isolate the intermediate bearing alloy
layer. In cases where the surface bearing alloy layer has been removed by wear, the
intermediate bearing alloy cannot act to provide a suitable bearing surface during
periods of boundary lubrication. The sliding couple, in this case, is nickel against
steel with a consequential increase in frictional heating and a greater frictional force
acting to move the bearing insert in its housing.

– 165 –
Figure 8.45: Trimetal bearing, worn lead-tin surface layer, aluminium-tin
intermediate layer, X-ray distribution maps for tin, lead,
aluminium and nickel

Backscattered electron image showing surface topography and compositional contrast. The
light regions indicate the presence of high atomic number elements, e.g. lead. The dark
regions indicate the presence of low atomic number elements, e.g. aluminium.

The light regions in the X-ray maps indicate the presence of the element, while the black
regions indicate the absence of the element

– 166 –
Bearing clearance
Bearing clearance is an important variable that affects the nature of bearing
lubrication through its affect on oil-film thickness and oil-film temperature, figure
8.46. If the radial clearance is too small, the increase in oil film temperature and
decrease in oil film thickness will lead to boundary lubrication.

Figure 8.46: The effect of bearing clearance on oil-film thickness (Shigley

and Mischke, 1989, p.508)

Crankshaft journals may wear during engine operation. The effects of journal wear
may be corrected during engine overhaul by polishing the journals to an ‘undersize’
diameter, and installing ‘oversize’ bearing inserts. For Lycoming engines, journals
may be reduced in diameter by 0.003in during overhaul. The oversize bearing
inserts include a marking ‘M03’, (journal, minus 0.003in) with the bearing part
number marking.
Two powertrain failure events investigated in this study were associated with
crankshafts that had been polished to an undersize condition during overhaul;
occurrence 2000/2276, VH-ODE and occurrence 2002/3474, VH-ACZ. The
physical evidence available for occurrence 2002/3474, VH-ACZ, indicated that
bearing damage, through boundary lubrication, differed from other occurrences
investigated, figures 8.47 and 8.48. It is apparent that boundary lubrication affected
the surface of both the rod and cap inserts, and was localised to several
circumferential tracks. A detailed metrological inspection of the journals revealed
that polishing to an undersize state had left the journals in an out-of-round
condition, figure 8.49.

– 167 –
Figure 8.47: An overview of the nature of connecting-rod bearing surface
damage and journal markings, occurrence 2002/3474, VH-
ACZ

The inserts on the rod side of the big end bearings are shown at the top of the figure and the
cap side inserts are shown at the bottom of the figure

– 168 –
Figure 8.48: Detailed view of the nature of the No.5 connecting-rod
bearing inserts, VH-ACZ

Connecting-rod cap insert.

Connecting-rod insert.

– 169 –
Figure 8.49: Crankshaft journal roundness traces, VH-ACZ No.5
connecting-rod journal

Notes: the reference circle is a least squares circle, the plot magnification is 5,000 times,
trace 3 is over the oil hole, traces 2 and 4 are adjacent o the oil hole.

– 170 –
The available connecting-rod bearing inserts from the occurrence involving VH-
ODE, also show a wear pattern that indicates a lack of uniformity in the roundness
of crankshaft connecting-rod journals, figure 8.50.

Figure 8.50: An example of the connecting rod bearing surface wear from
occurrence 2000/2276, VH-ODE

Bearing insert marked M03

– 171 –
Steel backing breakup
It is a characteristic feature of the breakup of trimetal connecting rod big-end
bearings, manufactured with an aluminium-tin intermediate layer, that the steel
backing is reduced in thickness while being lubricated with oil. It appears that the
deformation of the steel backing involves progressive extrusion through the
clearance between the sides of the connecting rod big-end housing and the
crankshaft journal, figures 8.51 and 8.52.

Figure 8.51: Example of steel backing deformation and breakup,

occurrence 2000/2276, VH-ODE

– 172 –
 Figure 8.52: Detailed view showing the typical features created during the
process of steel-backing deformation, trimetal bearing with
aluminium-tin intermediate layer

8.3.5 The effects of boundary lubrication on trimetal bearing inserts

manufactured with a copper-lead intermediate layer
The response of trimetal bearings manufactured with a copper-lead intermediate
layer differs from trimetal bearings manufactured with an aluminium-tin
intermediate layer.
Under conditions of bearing surface wear, removal of the surface lead-tin layer
exposes the underlying copper-lead layer. Unlike the behaviour of the aluminium-
tin trimetal bearings, the nickel plating between the surface and intermediate layers
does not remain firmly attached to the intermediate layer. The exposure of the
intermediate layer allows it to fulfil its designed purpose as a backup bearing
surface during periods of boundary lubrication.
The distribution and morphology of the dispersed lead phase in the copper-lead
alloy, is thermally stable. However, it is evident that under conditions of high
bearing load and sustained boundary lubrication, the bearing temperature may
increase to a level where copper diffuses through the steel backing, and may diffuse
into the connecting rod big-end housing and the crankshaft journal, see figure 8.53.
For occurrence 2004/2291, VH-VEC, the heating of the No.3 journal resulted in the
expansion of the crankshaft, ‘machining’ of the crankcase by the ends of the
crankshaft, followed by a loss of engine oil pressure as the oil filter screen was
blocked by ‘machining’ debris.

– 173 –
Figure 8.53: The effect of high-load boundary lubrication, copper-lead
trimetal bearing, No.3 connecting-rod journal, occurrence
2004/2291 VH-VEC

The No.3 bearing inserts; the temperature created by continued boundary lubrication during
engine operation, was sufficient to allow copper from the intermediate layer to diffuse through
the steel backing.

The No.3 connecting-rod journal was also affected by copper diffusion from the intermediate
layer of the connecting-rod bearing inserts.

– 174 –
8.4 Factors associated with the retention of bearing
inserts in their housings
Connecting rod big-end and crankshaft main-bearing inserts, are retained in their
housings by an interference fit created during assembly. Simply, the circumference
of the outer surface of the precision bearing inserts exceeds the circumference of
the housing bore. The difference in dimension, commonly referred to as ‘bearing
crush’, creates a radial force between the insert and housing when the housing is
assembled and bolts tightened. The action of this force, in combination with the
coefficient of friction between the insert back and housing surface, provides a
resistance to forces that act to move the bearing, circumferentially or axially, in the
bearing housing.
The surface finish of the housing and the bearing-insert backs are required to be of
high quality to ensure that the bearing is not distorted, the interference fit is
established, and heat transfer through metal to metal contact can occur.

8.4.2 Connecting rod big-end bearing insert retention

In the course of this safety study, evidence of connecting rod big-end movement
was observed in the connecting rod assemblies in a number of engines. This
evidence comprised of wear damage created by, small scale, relative movement
between the insert back and housing surface, see for example, figures 8.54 to 8.56,
and deformation of the insert-locating tang, see figure 8.57.

Figure 8.54: Example of big-end insert back wear, occurrence 2001/2544,

VH-TTX

– 175 –
Figure 8.55: Example of big-end insert back wear, occurrence 2001/5866,
VH-JCH

Figure 8.56: No.4 big-end housing surface and insert wear, occurrence
2000/2157, VH-MZK (left)

The insert back is shown on the left and the corresponding housing surface is shown on the
right.

– 176 –
Figure 8.57 Example of insert-locating tang deformation

It was also evident during the course of this safety study, that connecting rod big-
end bearings had been assembled with lubricant placed between the back of the
bearing insert and the housing surface, figure 8.58. The lubricants varied from oil to
anti-galling compounds. In many cases, the oil had been carbonised as a result of
the temperatures attained at the insert back. The inclusion of lubricant between the
back of a bearing insert and the bearing housing surface will reduce the coefficient
of friction between the two surfaces and, as a result, reduce the bearing insert
retention force.

– 177 –
Figure 8.58: Examples of lubricant residue present on the backs of
connecting-rod bearing inserts

The presence of anti-galling compound can be discerned through the residue of fine copper
flakes, see VH-MZK left 2000/2157, VH-ODE left 2000/2276, and VH-JCH right 2001/5866.

– 178 –
8.4.3 Crankshaft main-bearing retention
During engine assembly, the bolts used to join the crankcase halves also compress
the main bearing inserts and create a radial force between the inserts and housing.
The friction force that acts to retain the inserts in the housing is created through the
action of the radial force and the coefficient of friction between the contacting
insert and housing surface.
Main bearings, in a horizontally-opposed six-cylinder engine, are subjected to
forces arising from the need to resist crankshaft bending moments created by the
inertia of rotating masses and combustion events in multiple cylinders.
Operational experience has shown that the rearmost intermediate main bearing in a
six cylinder horizontally-opposed engine (No.4, Lycoming numbering convention,
No.2 Continental numbering convention) is the most sensitive to increases in the
magnitude of crankshaft bending moment. This sensitivity is related to the
placement of intermediate main bearings between two connecting-rod journals, the
distance of the bearing from the propeller, and the successive firing of cylinders on
either side of the bearing.
The movement of main-bearing inserts in their housings is a function of the
magnitude of the insert retention force and the magnitude of the forces acting to
move the inserts. Movement may lead to the rotation of the inserts in the housing
and/or axial displacement of the inserts in the housing, culminating in contact with
the fillet radius of the crankshaft. Contact between the edge of a main bearing insert
and the fillet radius of a nitrided crankshaft changes the fillet radius through wear
and creates a series of cracks in the nitrided surface through localised thermal
expansion, figures 8.59 and 8.60.

Figure 8.59: An example of crankshaft fatigue fracture initiated by main

bearing insert contact, occurrence 2001/2544, TTX

– 179 –
Figure 8.60: An example of the type of damage created in the main
bearing journal radius through contact with the bearing
insert, occurrence 2001/2544, VH-TTX

Note: the scoring damage is circumferential and the thermal expansion cracks in the nitrided
surface are aligned in a radial direction.

The inclusion of any material between the parting faces of the main bearing
housings will have the effect of reducing the difference in the circumference of the
housing and the outer circumference of the bearing inserts, and will reduce the
magnitude of the insert retention force. Examination of the main bearing housings
from the engine involved in occurrence 2005/02231, VH-IGW, revealed that a
jointing compound had been placed on the parting faces of each main bearing
housing, see figures 8.61 and 8.62.

Figure 8.61: No.4 main bearing displacement, occurrence 2005/02231, VH-

VEC

The extent of bearing displacement is shown on the left, and the extent of damage to the
housing created by the bearing tang is shown on the right.

– 180 –
 Figure 8.62: Detailed view of the material placed between the parting
faces of each main bearing housing, occurrence 2005/02231,
VH-IGW

8.4.4 Summary
Plain bearings in high-powered aircraft reciprocating engines are an example of a
complex subsystem operating within a complex thrust system. Complexity brings
with it a variety of failure modes and a sensitivity of the failure process to initial
conditions.
The failure of bearings in aircraft horizontally-opposed engines can be related to
factors that affect hydrodynamic oil film stability, factors that lead to an increase in
the temperature of bearing materials, factors that control the magnitude of the
bearing insert retention force, and factors that control the magnitude of forces
which act to displace the bearing insert. These factors are shaped by the functioning
of other engine subsystems and the actions of operators and maintainers.
The key factor in the loss of oil film stability was found to be the development of
high combustion gas pressures during high power operation.
The key factors that were found to increase the temperature of bearings were high
engine power operation combined with boundary lubrication, the presence of an
adherent nickel layer between the lead-tin and aluminium-tin bearing layers
exposed after bearing surface wear, and the loss of metal-to-metal contact between
the bearing insert and housing through the inclusion of a lubricant.
The effect of increased bearing temperature on those bearing inserts manufactured
with an aluminium-tin intermediate layer was the change in the distribution of tin
through diffusion. The formation of coarse tin particles at the interface with the

– 181 –
insert backing results in a reduction of strength of the intermediate layer and the
breakaway of sections of the bearing.
The key factors in bearing insert movement were found to relate to the magnitude
of the friction force created by the interference fit and the magnitude of forces
acting to move the insert circumferentially and axially.
The magnitude of the forces acting to move an insert in its housing are affected by
increases in sliding surface friction (boundary lubrication and, in particular, the
sliding of a steel journal against an adherent nickel bearing surface) and the nature
of loading created by combustion. Combustion may have an effect through an
increased load on the bearing surface, increased bending moments on the main
bearings of crankshafts, and increased big-end bearing edge loads associated with
non-uniform gas loads on the piston and the propagation of shock waves in the
combustion gases during combustion with light to medium detonation.

– 182 –
8.5 Factors associated with fatigue cracking in
powertrain components
The powertrain components are designed to have a life not limited by fatigue crack
initiation and propagation to final fracture, within the bounds of specified
operational limits.
Powertrain components are subjected to alternating loading cycles through the
effect of discontinuous combustion in multiple cylinders and the reciprocating
motion of the crankshaft/connecting rod/piston assembly. The magnitude of the
alternating stress cycles created in powertrain components, as a result of the
alternating loading cycles, increases with increased combustion gas pressure and
speed of motion (piston speed and engine revolutions per minute). The frequency of
the alternating stress cycles may be related to each engine revolution or each
combustion cycle (once every second engine revolution for four stroke engines).
Powertrain components are subjected to an extremely high number of alternating
stress cycles over the duration of their expected service life, for example, 1.5x107
once per rev. cycles, will be created over a period of 100 hours for an engine speed
of 2,500 rpm. Because of the exposure to a very high number of alternating stress
cycles, powertrain component design is based on controlling the magnitude of
alternating stress cycles to a value that does not exceed the fatigue endurance
strength of the component, figure 8.63.

Figure 8.63: Schematic representation of the relationship between

alternating stress amplitude and number of cycles to failure
showing the fatigue endurance strength

The fatigue endurance strength of a component is a function of; the material,

component form, presence of stress concentrators, presence of residual stress,
component surface finish, and the presence of surface hardening. It is well

– 183 –
established that the fatigue endurance strength of a mass-produced component is
not known with certainty. The scatter in endurance strength requires design to be
based on knowledge of the probability distribution for the endurance strength for
the component, see figure 8.64. Factors of safety are used to accommodate the
uncertainties and scatter in component endurance strength.

Figure 8.64: The relationship between maximum alternating stress and the
distribution of component fatigue endurance strength –
infinite life

Fatigue failure will occur in some components from a batch of designed (part
number) components if the magnitude of the alternating stress overlaps the
distribution of endurance strength for the component, see figure 8.65.

Figure 8.65: The relationship between maximum alternating stress and the
distribution of component fatigue endurance strength – finite
life, component failure

For the case of component designs that have passed certification testing and have
demonstrated fatigue-free operational performance, component failure indicates
that:
• the component was subjected to alternating stresses that exceeded the maximum
design allowable value;
• a change in the distribution of component endurance strength from the design
state has occurred;

– 184 –
 • a change in the component has occurred during operation, so that it is no longer
bounded by the component fatigue endurance strength distribution parameters;
or
• there was a combined reduction in component endurance strength and increase
in maximum alternating stress.
The magnitude of alternating stress cycles in a powertrain component, of
established design, may be a function of engine speed (crankshaft revolutions per
minute and piston speed), differential thermal expansion and contraction, or the
pressure of combustion gases. For the case of aircraft engine-coupled to a constant-
speed propeller, the speed of the engine is tightly controlled. However, the pressure
of combustion gases (bmep) may vary in response to power, speed and mixture
selection.
Increases in the magnitude of alternating stress beyond the design maximum
allowable value, may arise from operational factors and/or maintenance factors that
act, singly or synergistically, to increase the combustion gas pressure, the
engine/component speed, and thermal stresses beyond design allowable values.
Component fatigue endurance strength is affected by a lowering of material
strength, the creation of additional stress concentrating features, or a lowering of
designed compressive residual stress states.

8.5.1 Cylinder head fatigue failure

Cylinder heads are part of the structural assembly that, in effect, is a pressure vessel
subjected to alternating pressures and heating and cooling cycles. These alternating
pressures and thermal cycles are the source of alternating stresses in cylinder heads.
The location of fatigue cracking in the cylinder head, occurrence 2001/2885, VH-
MJA, site of fatigue crack initiation, and plane of fatigue crack growth, see figure
8.66, indicate that fatigue cracking initiated and propagated as a result of periods of
engine operation with high gas pressures in the cylinder. The cylinder head section,
at the joint between the head to barrel, is subjected to longitudinal stresses each
time the combustion chamber is pressurised.

Figure 8.66: Fatigue cracking features, occurrence 2001/2885, VH-MJA

Fatigue cracking initiated at several sites at the head/barrel thread root (the general regions
of crack initiation are arrowed), cracking propagated on a plane normal to the cylinder wall.

– 185 –
 It is evident that, in the case of occurrence 2001/2885, VH-MJA, the stresses
created at the head-to-barrel connection, through gas pressure in the combustion
chamber, exceeded the endurance strength of the cylinder head. It is important to
consider the effect of localised pressure, as developed under conditions of end-gas
detonation, as a factor in fatigue crack initiation. The site of fatigue crack initiation
in the cylinder head from MJA is located adjacent to a site of potential end-gas
detonation.

8.5.2 Cylinder attachment fastener fatigue failure

The cyclic development of combustion-gas pressure creates a condition of
alternating stress in the cylinder attachment fasteners. The magnitude of alternating
stresses in each fastener is controlled through the creation of a preload in the
fastener during assembly. The avoidance of fatigue crack initiation is dependent on;
the magnitude of the preload in the fastener, the magnitude of the load applied to
the fastened joint, and the endurance strength of the fastener. For a fastener of
specified endurance strength, fastener failure may occur if the combustion gas
pressure exceeds the design allowable value or the fastener preload is below the
design value.
Fastener preload may be reduced during engine operation through the deformation
of material included in the fastened joint. The inclusion of paint under the face of
the nut can result in a significant lowering of the preload in cylinder attachment
studs, see for example Lycoming Service Bulletin 271A. It is evident in the case of
occurrence 2002/5129, VH-TZY, that, not only had a thick paint film been applied
to the cylinder base flange under the bearing face of the nuts, paint had been applied
to the stud threads in the region where the nut thread engages with the stud thread,
see figures 8.67 to 8.69.

Figure 8.67: An example of paint applied to the region of the stud thread
that engages with the nut thread, occurrence 2002/5129, VH-
TZY

– 186 –
 Figure 8.68: Detailed view of the paint applied to the stud thread,
occurrence 2002/5129, VH-TZY

Figure 8.69: An example of the paint film applied to the cylinder base
flange, occurrence 2002/5129, VH-TZY

Note the presence of grey paint on the surface of the bolthole.

8.5.3 Connecting rod bearing housing fatigue failure

The resistance of connecting-rod bearing housings may be affected by the creation
of surface damage through the process of adhesive wear – galling – that occurs
when there is relative movement between the piston pin and housing surface,
following the breakup of the little-end bearing, or relative movement between the
steel backing of the big-end bearing inserts and the big-end housing. The fracture of
connecting rod little-end housings in occurrences, 2000/90, MZK, and 2003/03701,
OCF, are examples of the effect of galling damage on the inner surface of bearing
housings.

– 187 –
The connecting rod big-end housing fatigue fractures associated with occurrences,
2000/90, VH-BNN, 2001/1405, VH-LTW, 2002/3474, VH-ACZ, are characterised
by fatigue initiation at the outer surface of the housing at the point of transition
from the bolt boss to the connecting rod ‘I’ beam, see figure 8.70. Fatigue initiation
in this location is associated with big-end housing flexure under conditions of
connecting rod inertia loading. In practice, the degree of flexure is limited by the
clearance between the crankshaft journal and the big-end bearing.
Fatigue failure, involving initiation at the outer surface of the big-end housing, is an
indicator of an increase in the degree of housing flexure. The breakup of the big-
end bearing inserts creates increased clearance between the journal and the
connecting rod big-end allowing increased housing flexure under connecting rod
inertia loading, figure 8.71.

Figure 8.70: The site of fatigue crack initiation, occurrences 2000/90,

2001/1405, 2002/3474

Figure 8.71: A comparison of clearance between the crankshaft journal

and connecting rod big-end bearing (left) and the big-end
housing without the bearing inserts (right)

The diameter of the crankshaft journal is represented by the coloured circle.

– 188 –
8.5.4 Crankshaft fatigue failure
Crankshafts, regardless of the end application of the engine, are designed to have an
operational life not limited by fatigue. The complex interrelationships between
loads, geometric stress concentrators, residual stress, surface finish, surface
hardening, and material, results in scatter in fatigue behaviour. Safety factors are
applied to ensure that, for a particular crankshaft design, the maximum alternating
stress from engine, operation does not intersect the distribution of crankshaft fatigue
endurance strength.

Figure 8.72: Schematic showing the scatter in the relationship between

alternating stress magnitude and number of alternating
stress cycles for a crankshaft (Lee and Morrissey, 2001)

Two dominant fatigue failure modes have been identified by the designers of
crankshafts (Piraner, Pflueger and Bouthier, 2002):
• fatigue through a crankweb, associated with bending of the crank throw in its
plane, with crack initiation occurring at a main or crank journal fillet; and
• fatigue through a connecting-rod journal, associated with alternating shear
stresses generated by throw torsion, with fatigue cracking initiating at an oil
hole.
The initiation and propagation of fatigue cracks in a crankshaft is not simply a
matter restricted to the material from which the crankshaft is manufactured. It is a
matter of all factors that affect the magnitude of crankshaft alternating stresses, and
the crankshaft endurance strength.

Crankshaft alternating stress

External loads
The major loads imposed on a crankshaft during operation are loads created by
combustion gas pressure and the loads created by the inertia of rotating and
reciprocating assemblies. These loads create bending and torsional stresses in the
crankshaft journals and crankwebs. The maximum stress in the crankshaft is

– 189 –
developed when the engine is operated in a manner that results in maximum
combustion chamber gas pressure and/or maximum piston speed.
A feature of the layout of horizontally-opposed engines – the placement of a main
bearing between two connecting-rod journals – makes crankshaft bending a critical
loading condition, see figure 8.72. The magnitude of bending stresses in crankwebs
is strongly influenced by the placement of journals (Taylor, 1999, vol.2, pp.494-
495). Bending stresses are increased as the length of the crankweb between
neighbouring journals is increased.
Torsional stresses arise from the action of the gas pressure loads on the cranks and
the transmission of torque to the engine-output flange and accessory drivetrain. A
special loading case that is considered during design, and thoroughly tested during
engine certification, is that of torsional resonance. Torsional resonance is a function
of the frequency of gas pressure impulses and the elastic properties of the
crankshaft.
Stress concentration
The distribution of stress developed within a crankshaft, through crankshaft
bending and torsional, is not uniform (Taylor, 1999, vol.2, pp.496-498). Stress
gradients are formed under bending and torsion loading. The stress decreases in
magnitude from the surface to centre of the component. The form of a crankshaft
results in non-uniform distributions of stress. Torsional stresses are concentrated in
the journals and bending stresses are concentrated in the transitions between the
journals and crankwebs. For the case of crankshaft bending, the distribution of
bending stress in the journal fillet region is not uniform around the circumference of
the fillet or around the fillet radius, figures 8.74 and 8.80. The distribution of
bending stress is influenced by detailed geometry and the timing of the maximum
load with respect to the angular position of the crankshaft.

Figure 8.73: Schematic showing the typical locations for fatigue crack
initiation in the forward fillet of the No.6 journal and the rear
fillet of the No.5 journal, for the case of no fillet damage

– 190 –
Figure 8.74: Schematic showing the distribution of crankweb bending
stress at the forward fillet of a No.6 connecting rod journal

The orientation of the plane of fatigue cracking is related to the angular position of the
crankweb at the time of maximum combustion pressure; for normal operation the peak
pressure is developed approximately 20° after top centre.

Crankshaft endurance strength

The resistance of a crankshaft to the initiation of fatigue cracking is affected by the
mechanical properties of the crankshaft material and the nature of residual stresses
at the sites of operational stress concentration.
Aircraft engine crankshafts are nitrided to create a hard, wear resistant, surface. An
additional effect of nitriding is to create gradients of strength and compressive
stress across the hardened zone. These gradients of strength and residual stress have
a strong influence on resistance to bending fatigue (ASM, 1997, vol.19, p.682). The
superposition of the compressive residual stress gradient, with a high compressive
stress at the surface, on the applied stress gradient, with a high tensile stress at the
surface, results in a reduction in the magnitude of alternating stress at the surface of
nitrided crankshaft journal fillets. The gradient of material strength creates a
gradient in resistance to fatigue initiation. The highest resistance to fatigue initiation
is at the surface. An example of the extent of the effect of nitriding is shown in
figure 8.75.
For cases where the operational alternating stresses exceed the design allowable
value, the combined effect of operating stress gradient, residual compressive stress
gradient, and material fatigue strength gradient, results in fatigue crack initiation
below the surface of the fillet (ASM, 1997, v.19, p.612; Hertzberg, 1996 p.548;

– 191 –
Shigley and Mischke, 1989, pp.286-287; Forrest, 1970, p193). Subsurface initiation
occurs when the magnitude of crankshaft alternating loads just exceed the
endurance strength of the crankshaft. When the magnitude of alternating loads
greatly exceeds the endurance strength, fatigue cracking initiates at the fillet
surface.

Figure 8.75: Metallographic section taken from an aircraft crankshaft fillet

showing the extent of the effect of nitriding

The plane of the section is perpendicular to the fillet radius. The extent of the effect of
nitriding can be discerned by the change in colour from left to right (the unaffected core
material is coloured straw on the right side of the micrograph). The square shaped features
are microhardness indentations.

The initiation of fatigue cracking is further influenced by the nature of the

distribution of microstructural features. The steel alloy from which crankshafts are
manufactured is not a homogeneous material. The material can be described, in a
general sense, as being a fine dispersion of carbides (iron and other alloying
elements) in a polycrystalline ferrite matrix. In addition, there is a dispersion of
non-metallic, oxide and sulphide, inclusions. Fatigue crack initiation is affected by
the nature of the microstructural features at the site of highest stress concentration.
Any feature that increases the magnitude of local shear stresses, for example, free
surfaces associated with inclusions, or lowers the critical shear stress for plastic
deformation, will lower the operational alternating stress magnitude for fatigue
initiation.
The effect of non-metallic inclusions is minimised by the use of melting practices,
such as vacuum-arc remelting, that reduce the number and size of non-metallic
inclusions.
The effect of material variation on fatigue endurance strength, in an alloy of
specified composition, state of heat treatment, and method of melting and forming,
is established by testing standard test pieces. Any variation arising from material
features is accommodated in the design of a component by the use of safety factors.
Crankshaft endurance strength may also be reduced by changes in component form
or the creation of discontinuities during engine operation or component
maintenance.

– 192 –
8.5.5 Crankshaft fatigue failure – examples
The features of fatigue fracture in nitrided crankshafts are affected by the non-
uniform distributions of applied stress, residual stress, material endurance strength,
material inclusions. They are also affected by stress concentrating features that may
be created during maintenance actions or engine operation

No fillet damage, subsurface fatigue crack initiation

Example 1: Teledyne Continental GTSIO-520M engine; crankshaft p/n 635104, s/n
C874; reported major defect 1992. The crankshaft connecting-rod journals had been
resized 0.010 inch undersize.

Figure 8.76: Fatigue fracture forward fillet of the No.1 connecting-rod

journal, fatigue crack propagation through the crankweb
between the No.1 and No.2 connecting rod journals

The site of fatigue crack initiation is arrowed.

Figure 8.77: Low magnification scanning electron micrograph of the

region surrounding the site of fatigue crack initiation

– 193 –
Figure 8.78: Scanning electron micrograph showing the site of fatigue
crack initiation in more detail

Figure 8.79: Scanning electron micrograph of the site of fatigue crack

initiation at higher magnification showing that crack initiation
occurred at an alumino-silicate inclusion

– 194 –
Figure 8.80: Metallographic section through the No.1 connecting-rod
journal fillet

The fillet surface is at the left of the micrograph. The depth of nitriding can be distinguished
by the colourisation; the core material is at the right (straw/gold). Several non-metallic
inclusions are evident (arrowed).

Figure 8.81: The nature of a typical inclusion present in the crankshaft

steel

– 195 –
It is evident that fatigue crack initiation occurred at a material inclusion located in
the region of applied stress concentration, created by crankshaft bending during
engine operation (the transition between the fillet and crankweb), and the location
of highest residual tensile stress (the transition from the hardened surface to the
crankshaft core material).
Examination of the No.1 connecting rod big-end bearing revealed that the forces
created during engine operation had been sufficient to damage the bearing surface,
locally, in the region that is sensitive to combustion loads, figure 8.82.

Figure 8.82: No.1 connecting rod bearing boundary lubrication damage

(rod side insert)

Resolution of the issues contributing to the fatigue fracture of this crankshaft

requires the consideration of, both, material factors and the magnitude of
combustion loads in the No.1 cylinder.

– 196 –
Example 2: Teledyne Continental TSIO-520; crankshaft, s/n S789nc, inspection
marking 092/u/u; occurrence 2001/4799 VH-BEM. The marking 092/u/u indicates
that the crankshaft had been inspected ultrasonically, for the presence of fatigue
cracking, on two occasions.
The initiation of fatigue cracking in this crankshaft is consistent with the location of
highest applied stress and highest residual tensile stress when the magnitude of the
combined stresses just exceeds the fatigue endurance strength of the material. There
is no evidence of the presence of any abnormally large non-metallic inclusions,
figures 8.84 to 8.86.
On the basis of the results of two previous ultrasonic inspections, it is apparent that
fatigue initiation occurred after a long period of operation. Successful operation,
over a long period of operational time, indicates that the crankshaft material is not
the prime factor in fatigue crack initiation.
Resolution of the issues contributing to the fatigue fracture of this crankshaft would
require the consideration of possible changes in engine operation that increase the
magnitude of crankshaft bending at the No.3 main bearing.

Figure 8.83: Scanning electron micrograph showing the region

surrounding the site of fatigue crack initiation, forward fillet
of the No.3 main bearing journal. Fatigue cracking
propagated through the No.3 main and No.5 connecting-rod
crankweb

– 197 –
Figure 8.84: Detailed view of the region surrounding the site of fatigue
crack initiation. The features of the initiation site had been
obliterated by mechanical damage after the fracture of the
crankweb

Figure 8.85: Scanning electron micrograph showing the plane of

metallographic sectioning through the site of fatigue crack
initiation

– 198 –
Figure 8.86: Metallographic sections through the site of fatigue crack
initiation etched (left) and unetched (right)

The site of fatigue crack initiation is arrowed. The unetched micrograph shows the nature
and distribution of non-metallic inclusions.

– 199 –
Example 3: Lycoming TIO-540-J2BD; reported major defect, 96/0797.

Figure 8.87: Fatigue crack initiation, forward fillet of the No.3 main journal,
crack propagation through the crankweb between the No.3
main journal and No.2 connecting-rod journal

Figure 8.88: Scanning electron micrograph showing the region

surrounding the site of fatigue crack initiation

The site of crack initiation had been damaged mechanically following the fracture of the
crankweb.

– 200 –
Example 4: The Federal Aviation Administration (FAA) reported a series of
fatigue fractures in the crankweb between the No.6 and No.5 connecting journals of
Lycoming TIO (LTIO)-540 engine crankshafts. Note, however, that no fractures of
this type were reported to the ATSB during the period covered by this study.

Figure 8.89: FAA diagrams showing the nature of fatigue cracking in the
crankweb between the No.6 and No.5 connecting rod journals
(GASIL, 2002, p.28)

The fatigue initiation sites were reported to be below the surface of the forward fillet of the
No.6 connecting-rod journal or the rear fillet of the No.5 connecting-rod journal.

– 201 –
No fillet damage, surface fatigue initiation,
A number of crankshaft failure events involve multiple fractures. An engine can
continue to operate following the fracture of a crankweb as the plane of fracture
allows torque to be transmitted by continued contact between regions of the fracture
surface. The initial fracture creates a condition of abnormal high bending stress at
other crankshaft fillets.
Example 5: Lycoming TIO-540-V2AD, occurrence 2005/02231, VH-IGW.

Figure 8.90: Crankweb fracture No.3 main/No.3 connecting-rod journals

following the fracture of the crankweb between the No.4 main
and No.4 connecting rod journals

Fatigue crack initiation occurred at the transition of the fillet to the crankweb. The lack of
fatigue crack progression marks indicates that crack growth occurred within the period of one
flight.

– 202 –
Example 6: Lycoming TIO-540-J2B, occurrence 2000/2157, VH-MZK (left).
Continued operation of the engine following the fracture of the No.6 connecting-rod
journal, created a condition of abnormal loading on the No.5 connecting-rod journal
and the No.4 main journal. The fatigue cracking that resulted from the abnormal
loading condition (see figure 6.39), initiated at the fillet surface.

Figure 8.91: Fatigue cracking rear fillet of the No.4 main bearing journal
(top) and the forward fillet of the No.5 connecting-rod journal
(bottom)

The depth of fatigue cracking is indicated by arrows. Crack initiation was not restricted to a
specific material feature.

– 203 –
Modification of journal fillet radius, surface initiation
Example 7: Lycoming IO-540-C4B5 engine, reported major defect 1995,
crankshaft s/n 68499, connecting rod journals reduced in diameter by 0.003 of an
inch by abrasive polishing.
The fillets of all connecting rod journals had been notched, at the transition from
the journal bearing-surface to the crankweb fillet, during the journal polishing
process. Fatigue cracking initiated at the surface of the No.6 journal where the fillet
had been notched.

Figure 8.92: The nature of the plane of fatigue crack growth

Figure 8.93: Detailed view of the fatigue crack initiation site, crankweb
side

– 204 –
Figure 8.94: Detailed view of the fatigue crack initiation site, journal side

Figure 8.95: An example of fillet notching

It is apparent, in this example, that while the site of fatigue initiation coincided with
the predicted circumferential position of highest crankweb bending stress, the
severe stress-concentrating feature created at the journal-to-fillet transition, during
journal polishing, influenced the radial location of the initiation site in the fillet.
The change in the site of crack initiation, with respect to the fillet, affected the
plane of fatigue crack growth.

– 205 –
Planar defects created by rubbing contact between the connecting rod
and crankweb
Example 8: Lycoming TIO-540-J2BD, major defect report 94/1135.
The lack of ductility in the nitrided surface of a crankshaft creates the possibility of
the development of surface cracks if the surface is subjected to localised thermal
expansion stresses.
In this example, frictional heating through rubbing contact between the No.6
connecting rod big-end housing and the face of the crankweb, following the
distortion of the connecting rod during engine operation, created a number of fine
cracks in the nitrided surface of the crankweb.

Figure 8.96: The fatigue fracture in the crankweb

Figure 8.97: The region of rubbing contact damage, the site of fatigue
crack initiation is arrowed

– 206 –
Examination of the connecting rod established that the sequence of events leading
to the rubbing contact between the big-end housing and crankweb commenced with
the fatigue fracture of a counterweight-pin retention plate in one of the
counterweight assembly fitted to the crankweb. Connecting rod distortion occurred
when the unrestrained counterweight pin was caught between the face of the
counterweight and the connecting rod ‘I’ beam, figures 8.98 to 8.100.
Counterweight-pin retention plate fatigue indicates that the engine had been
operating in a manner that induced pin shuttle. Resolution of this failure would
require an investigation of the factors that contribute to counterweight pin shuttle.

Figure 8.98: Remnants of the fractured counterweight pin retention plate

Figure 8.99: The face of the counterweight showing evidence of localised

deformation created as the pin was dragged between the
counterweight and connecting rod

– 207 –
Figure 8.100: The extent of connecting rod deformation

The region of damage created by the freed counterweight pin is arrowed.

– 208 –
Planar defects created by journal grinding
The resizing of crankshaft journals to an undersize condition has been conducted,
on occasions, by grinding. There is a risk that, during the grinding process,
localised heating can lead to cracking in the hardened surface.
Example 9: Teledyne Continental IO-520F, major defect report 91/1262.
The crankshaft journal had been resized by grinding during overhaul, 25 hours prior
to the fracture.

Figure 8.101: The fatigue fracture, cracking initiated at the forward fillet of
the No.1 connecting-rod journal

While the nature of the initiation site of fatigue fracture had been obliterated by
damage created during continued crankshaft rotation, magnetic particle inspection
of the shaft revealed the presence of other small cracks in the region of journal
fillets. One of these crack indications was opened to allow the examination of crack
surface features, figures 8.102 and 8.103.
It is evident, from the crack surface features, that the region of cracking that
extended perpendicular to the fillet was formed by the brittle fracture of the
hardened zone in response to localised thermal expansion stresses. It is also evident
from the crack surface features, that the region of cracking that extended parallel to
the fillet, was formed as a result of fatigue crack growth and initiated as a result of
the presence of the thermal expansion crack.

– 209 –
Figure 8.102: Magnetic particle inspection indication (arrowed) of cracking
in the rear fillet of the No.1 connecting-rod journal

Figure 8.103: The crack surfaces of the magnetic particle indication

arrowed in figure 8.107

Radial crack, brittle fracture

Circumferential crack,
fatigue cracking

– 210 –
Example 10: Lycoming TIO-540-J2BD, major defect report 93/0787, crankshaft
p/n 10346, s/n 73Y19.
The connecting-rod journals had been resized by grinding during overhaul, 14 hours
prior to crankshaft fracture.

Figure 8.104: The fatigue fracture in the crankweb between the No.5 and
No.6 connecting rod journals

Fatigue cracking initiated at a number of locations in the rear fillet of the No.5 journal.

Figure 8.105: An example of cracking perpendicular to the fillet and plane

of fatigue cracking (arrowed)

– 211 –
Figure 8.106: Crack surface features, region of cracking arrowed in figure
8.105

Note that the initial region of cracking, from the surface into the nitrided-zone displays the
features of brittle fracture. Subsequent crack growth from the region of brittle fracture
occurred as a result of fatigue crack growth.

– 212 –
Example 11: Lycoming TIO-540-J2BD, major defect report 93/0498, crankshaft
p/n LW10346, s/n 91260.
The connecting-rod journals had been resized by grinding during overhaul 56 hours
prior to crankshaft fracture.

Figure 8.107: The fatigue fracture in the crankweb between the No.5 and
No.6 connecting rod journals

Fatigue cracking initiated at a number of locations in the rear fillet of the No.5 connecting rod
journal.

Figure 8.108: An example of magnetic particle inspection indications in the

fillet of another journal (arrowed)

– 213 –
Example 12: Lycoming TIO-540-J2BD, major defect report 93/0158, crankshaft
p/n LW 10346, s/n 69184.
The connecting rod journals had been resized by grinding during overhaul, 181
hours prior to crankshaft fracture.

Figure 8.109: The fatigue fracture in the crankweb between the No.5 and
No.6 connecting rod journals

Fatigue cracking initiated at a number of locations in the rear fillet of the No.5 connecting rod
journal.

Figure 8.110: Magnetic particle inspection indications of thermal expansion

cracks (arrowed) associated with fatigue crack initiation

– 214 –
Example 13: Lycoming IO-360-A1B6, major defect report 92/0575, crankshaft, s/n
130583.
The connecting-rod journals had been resized by grinding.

Figure 8.111: The fatigue fracture in No.3 connecting rod journal

Figure 8.112: Examples of magnetic particle inspection indications of

thermal expansion cracks in the fillets of the No.4 connecting
rod journal

The crack indications (left) show that circumferential cracking has developed from the series
of short thermal expansion cracks in the region of the No.4 journal between the crankwebs –
the region of highest stress under crankshaft bending. The crack indications on the opposite
side of the journal are shown on the right of the figure.

– 215 –
Main-bearing insert contact with journal fillet
In situations where crankshaft-bearing inserts are able to move in their housing,
damage through contact between the edges of the bearing inserts and the journal
fillet can occur. The nature of the localised rubbing contact has two effects. Firstly,
localised heating associated with the rubbing contact can cause thermal expansion
cracks to form in the hardened surface of the fillet and, secondly, wear associated
with rubbing contact can create notches in the fillet. Thermal expansion cracking
and wear notches in crankshaft fillets are features that can cause the initiation of
fatigue cracking in surface hardened crankshafts while an engine is operated within
its operational limits.
Example 14: Lycoming TIO-540-J2B, occurrence 2001/2544, VH-TTX, crankshaft
p/n LW 10346, s/n 87928.

Figure 8.113: Fatigue fracture, crankweb No.4 main/No.4 connecting rod

Fatigue cracking initiated in the forward fillet of the No.4 main bearing journal.

– 216 –
Figure 8.114: Detailed views of the site of fatigue crack initiation

The damage created by the contact between the main-bearing inserts and the main-bearing
fillet comprises of a series of thermal expansion cracks (oriented perpendicular to the fillet)
and notching/scoring of the fillet.

– 217 –
Example 15: Lycoming TIO-540-V2AD, occurrence 2005/2231 VH-IGW,
crankshaft p/n LW 17740, s/n V5311.
The crankshaft fractured through the crankweb between the No.4 main bearing
journal and No.4 connecting-rod bearing journal.

Figure 8.115: The site of fatigue crack initiation, No.4 main bearing journal
fillet

The location of the fatigue crack initiation is indicated with an arrow. Rubbing contact
between the edge of the bearing insert and journal fillet created circumferential scoring and a
series of short cracks (oriented perpendicular to the fillet).

– 218 –
Fatigue crack initiation, occurrences 2000/2157 VH-MZK (left) and
2001/5866 VH-JCH
Fatigue cracking, leading to the fracture of crankshafts in occurrences 2000/2157
VH-MZK (left engine) and 2001/5866 VH-JCH, initiated at the transition of the
journal No.6 connecting-rod bearing surface to the No.5/No.6 crankweb fillet (the
forward fillet of the journal). The location of the fatigue crack initiation site, with
respect to the crankweb, fillet radius, and circumferential position on the journal,
was similar to example 7, page 204, and example 13, page 215, examples where
fatigue crack initiation was influenced by a stress concentrating feature created
during maintenance. The location of crack initiation, with respect to the fillet
radius, differed from other examples of crankshaft fatigue fracture where there had
been no modification of the fillet radius or stress-concentrating features had been
created at different radial locations in the fillet.

Figure 8.116: The general form of fatigue cracking in the No.6 connecting
journals of occurrences 2000/2157 and 2001/5866, and
example 7.

The location of the site of fatigue crack initiation is arrowed

The location of the site of fatigue crack initiation at the transition of the journal to
crankweb fillet radius influenced the plane of fatigue crack growth. Crack growth
has occurred in response to stress state created by the combination of crankweb
bending and journal torsion.
While it is clear that modification of the fillet during journal resizing created a
stress concentration sufficient to initiate fatigue cracking in the crankshaft from
example 7, the stress-concentrating feature associated with fatigue initiation in
occurrences 2000/2157 and 2001/5866 is not so clear.

– 219 –
The site of fatigue crack initiation, occurrence 2000/2157, had been damaged
during the period of continued operation of the engine after the fracture of the No.6
connecting-rod journal. However, it is evident that fatigue cracking initiated below
the surface of the journal and that a planar feature, extending from the journal
surface to the point of crack initiation, oriented perpendicular to the fillet, was
present, figure 8.117.

Figure 8.117: Detailed views of the site of fatigue crack initiation,

occurrence 2000/2157

Light micrograph, the site of fatigue crack initiation is arrowed.

Scanning electron micrograph.

Serial metallographic sectioning was conducted to examine the nature of the planar
feature that extended to the site of fatigue initiation, see figures 8.118-8.123. It is

– 220 –
evident, from these sections, that the original feature associated with fatigue
initiation had been deformed following the fracture of the journal. It is also evident
that the original planar feature was crack-like, oriented perpendicular to the fillet,
and extended, approximately, 0.34 mm from the damaged journal surface into the
nitrided zone.

Figure 8.118: Serial metallographic sections, plane of sectioning parallel

with the journal surface

– 221 –
Figure 8.119: The microstructural features present in the section 0.13 mm
below the journal surface

Figure 8.120: The microstructural features present in the section 0.28 mm

below the journal surface

– 222 –
Figure 8.121: Detailed view, section 0.17 mm below the surface, scanning
electron micrograph

Figure 8.122: Detailed view, section 0.28 mm below the surface, scanning
electron micrograph

– 223 –
Figure 8.123: Metallographic section taken through the planar feature on
the crankweb side of the fracture, perpendicular to the
journal surface

The section shows a crack-like defect (oriented perpendicular to the fillet) at the site of
fatigue initiation.

The site of fatigue crack initiation, occurrence 2001/5866, had also been damaged
during the period of continued operation of the engine after the fracture of the No.6
connecting-rod journal. However, while the region had been damaged, it is evident
that fatigue cracking initiated below the surface of the journal and that a planar
feature, extending from the journal surface to the point of crack initiation, was
present, figure 8.124.

– 224 –
Figure 8.124: Fatigue crack initiation site, occurrence 2001/5866

The crankweb side of the fracture is shown at the top of the figure, the journal side of the
fracture is shown at the bottom of the figure. The site of fatigue crack initiation is arrowed.

The fatigue fracture of the crankshaft, No.6 connecting-rod journal, in the left
engine, occurrence 2000/2157, and the crankshaft, No.6 connecting rod journal, in
the right engine, occurrence 2001/5866, were not the only the only components in
the engines affected by a progressive failure mechanism. In both cases, progressive
failure mechanisms affected the No.6 connecting rod big-end assemblies.
The connecting rod, big end, bearing inserts had been reduced to fragments of steel
backing that had been extruded through the gap between the housing and journal.
Fatigue cracking in the big-end housings initiated as a result of increased housing
flexure (2000/2157) or housing surface damage (2001/5866), following bearing
insert breakup. Nuts on the big-end housing bolts had loosened, as a result of the
frictional heating of the bolts, when the central guide sections of the bolts contacted
the crankshaft journal following bearing insert breakup. Separation of the housings
from the crankshaft journals occurred prior to final engine failure – the evidence of
connecting rod collision with the camshaft, fracture of the pneumatic pump drive,
and pilot report of pneumatic ‘inop’ warning light illumination – as a result of
fatigue fracture (2000/2157) and loss of the nut from one big-end housing bolt
(2001/5866).
In addition, examination of big-end bearing inserts from other, intact, big-end
assemblies from both engines, revealed; that a lubricant had been placed between
the bearing inserts and their housings, evidence of relative movement between the
inserts and their housings, and bearing surface wear associated with high
combustion loads.
Resolution of the issues contributing to the No.6 connecting rod journal fatigue
fracture of the crankshafts in occurrence 2000/2157 and 2001/5866 requires the

– 225 –
 consideration of the effects of failure processes in the No.6 connecting rod big- end
bearing and the possible creation of stress concentrating features at the transition
between the journal and fillet.
If a Lycoming (L)TIO-540 engine big-end bearing insert did move, axially, as a
result of connecting rod out-of-plane rocking and reduced insert retention force, the
particular geometry of the big-end housing and fillet would result in bearing contact
damage at the transition between the journal surface and the fillet, figure 8.125.

Figure 8.125: Schematic showing the point of contact between a bearing

insert that has moved in its housing and the crankshaft
journal fillet

The location of fatigue crack initiation for occurrences 2000/2157 and 2001/5866, with
respect to the fillet, is arrowed.

8.5.6 Summary
The factors that were found to initiate fatigue cracking and fracture of cylinder
heads, cylinder attachment fasteners, connecting-rod bearing housings, and
crankshaft journals may be divided into two groups: those factors that increase the
magnitude of alternating stress in a component, and those factors that decrease the
endurance strength of a component.
In this study, sources of increased component alternating stress were found to have
been associated with the gas pressures produced by combustion, increased
component flexure, and reductions in component preload. Sources of decreased
fatigue endurance strength were found to have been associated with surface damage
created by adhesive wear (galling), surface scoring created by rubbing contact with
a closely associated component, and cracking in nitrided surfaces created by
localised frictional heating.
The initiation and propagation of fatigue cracks in a powertrain component is not,
simply, a matter restricted to the material from which the component is
manufactured. It is a matter of all factors that affect the magnitude of component
alternating stresses, and the component endurance strength.
In addition to the complex interrelationships between loads, preloads, geometric
stress concentrators, residual stress, surface finish, surface hardening, and material
of an individual component, there are clear interdependencies between the
combustion process in individual and multiple cylinders of a horizontally-opposed
engine, the physics of plain bearing lubrication, the mechanics of bearing insert
retention, and the process of fatigue crack initiation.

– 226 –
8.6 Multiple event sequences
It is apparent that some engine failure occurrences, analysed during the course of
this study, involved the failure of more than one subsystem or component. In some
occurrences, the sequences of events leading to subsystem or component failure are
independent, although they may have common initiating factors, figure 8.126. In
other occurrences, the event sequences have clear dependencies, figure 8.127.
When considering potential dependencies, it is important to realise that
reciprocating engines are engineered systems and, as such, human actions,
interactions and reactions can affect event sequence dependencies in addition to the
dependencies associated with pure mechanical interactions.

Figure 8.126: Occurrence 2000/3675, VH-NPA

Figure 8.127: Major defect report 94/1135, example 8

Refer to figures 8.96 to 8.100.

– 227 –
 Figure 8.128: Occurrence 2001/5866, VH-JCH

Figure 8.129: Occurrence 2000/2157, VH-MZK

8.7 References
AFM 51-9 1954, Department of the Airforce, Aircraft Performance Reciprocating
and Turbine Engine Aircraft, AFM 51-9
ASM 1992, ASM Handbook, Alloy phase diagrams, vol 3, ASM International,
Ohio 1992, p 2.52
ASM 1997, ASM Handbook, Fatigue and fracture, vol.19, ASM International,
Ohio, p.612
Forrest PG, 1970, Fatigue of metals, Pergamon Press, Oxford, p.193

– 228 –
GAMI, General Aviation Modification Inc., www.gami.com
GASIL, 2002, General Aviation safety Information Leaflet, 2 of 2002, issued June,
United Kingdom Civil Aviation Authority
Heath GA, Edwards AJ, Otieno-Alego V, Romeyn A, Sterns M 2005, The definitive
raman spectra of various Lead Oxyhalide compounds and particular application to
Lead-bearing combustion engine deposits, Sixth Australian Conference on
Vibrational Spectroscopy (ACOVS6), 26-30 September 2005, Sydney
Hertzberg RW, 1996, Deformation and fracture mechanics of engineering
materials fourth edition, John Wiley and Sons, New York, p.548
Lee Y-L and Morrissey W, 2001, Uncertainties of experimental crankshaft fatigue
strength assessment, International Journal of Materials and Product technology,
Vol.16, Nos 4/5, pp.379-392
Piraner I, Pflueger C, Bouthier O, Cummins crankshaft and bearing analysis
process, 2002 North American MDI User Conference,
support.mscsoftware.com/cgi-
bin/kb_files/Cummins_Pfleuger_paper.pdf?name=ri%2F1-13%2F1-13B2-
2668%2FCummins_Pflueger.pdf

Romeyn A, 2006, In-flight engine failure: an analysis of reciprocating engine plain

bearings, International conference on structural integrity and failure, 27-29
September 2006 Sydney, The Institute of Materials Engineering Australasia Ltd
Shigley, JE and Mischke, CR, 1989, Mechanical engineering design fifth edition,
McGraw-Hill Book Company, New York, 1989
Taylor FC 1998, The internal combustion engine in theory and practice Volume 1:
thermodynamics, fluid flow, performance, The M.I.T Press, Cambridge
Massachusetts
Taylor FC, 1999, The internal combustion engine in theory and practice Volume 2:
combustion, fuels, materials, design, The M.I.T Press, Cambridge Massachusetts
Turns SR 1996, An Introduction to combustion, concepts and applications,
McGraw-Hill, Inc, New York

– 229 –
– 230 –
9 ANALYSIS OF AIRWORTHINESS ASSURANCE
SYSTEM - AIRCRAFT PROPULSION

9.1 Introduction
Airworthiness is the term used to describe the continuing capability of an aircraft to
operate safely within its designed limits. It is based on the expectation that flight
operations will be performed with acceptable reliability in respect of flight crew
workload, flight handling characteristics, flight performance/envelope availability,
safety margins, welfare of occupants, punctuality, and economics (Leaflet 13-4,
CAAP 418). Airworthiness is an essential ingredient of safe air transport.
The issues associated with airworthiness management have evolved in parallel to
the issues associated with the broader field of quality management. Airworthiness
management has evolved from control, through checking for conformance with
specified processes and procedures, to assurance that the systems created to prevent
threats to safe aircraft operation continue to function. In keeping with the principles
upon which quality management standards are based, the airworthiness assurance
system should provide confidence that safety-critical aircraft systems are:
• well understood and effective; and
• action is taken to correct problems within a system, prior to system failure,
rather than reacting to system failure.
The focus of this chapter is the performance of the safety assurance system that is
concerned with the safe operation of propulsion systems.

9.2 Condition monitoring of propulsion systems

In the context of airworthiness assurance, condition monitoring is the term
commonly applied to the process of assessment of the effectiveness of systems,
sub-systems and elements. Condition monitoring plays an important role in the
airworthiness assurance system for aircraft propulsion. Engine in-flight shutdowns,
engine unscheduled removals, and engine component failures, reported in safety
investigations or service difficulty reporting schemes, may provide the basis for
changes to be made to propulsion system design, manufacturing processes,
operational limitations, or maintenance actions.
The principle behind data collection is that the data has to be to be of sufficient
quality and quantity to ensure that any adverse defect rate, trend, or reduction in
failure resistance, is identified quickly to control failure rates or prevent recurrence.
The analysis of failure events should, initially, consider each event individually to
determine if any immediate corrective action is appropriate. Further analysis of a
series of events may result in other corrective actions. The effectiveness of
corrective actions is measured by the data trends gained through the continued
process of condition monitoring.
The frequency of aircraft reciprocating-engine structural failure during the period
2000 to 2005 (in particular between 2000 and 2003), figure 9.1, suggests that there
was a breakdown in the systems created to ensure engine reliability, in particular,

– 231 –
 the systems created to ensure that structural failure of engine components does not
occur during flight.

Figure 9.1: Powertrain structural failure frequency distribution, 2000 -

2005

9.3 Corrective actions

A number of safety actions, addressing reciprocating engine component structural
failure, have been implemented by the ATSB, CASA, FAA, and Lycoming during
the period 2000 - 2005.

9.3.1 ATSB safety recommendations

As a result of the investigation of the fatal accident involving VH-MZK on the 31
May 2000, occurrence 2000/2157, the ATSB issued a number of recommendations
to FAA, CASA and Lycoming.

Fuel-air mixture leaning practices (issued 30 October 2000)

Safety recommendation R20000250
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority alert operators of aircraft equipped with turbo-charged engines to the
potential risks of engine damage associated with detonation, and encourage the
adoption of conservative fuel mixture leaning practices.
CASA response
The following response was received from the Civil Aviation Safety Authority on
22 March 2001:
CASA also accepts Recommendations [sic] R20000250 and has published an
article in the January/February aviation safety magazine Flight Safety
Australia. Furthermore, CASA is considering further action on this matter and
is consulting the aeroplane and engine manufacturers with a view to them
improving their engine leaning procedure.

Response status: CLOSED - ACCEPTED

– 232 –
Engine reliability (issued December 2001)
High power variants of horizontally opposed, six-cylinder, air-cooled reciprocating
engines power many aircraft employed in low capacity public transport operations
in Australia. At the time of publication of this report, there were 107 Piper
Chieftains on the Australian aircraft register and a much greater number in
operation worldwide. Many other single and multi-engine aircraft are equipped with
high-powered reciprocating engines. The engine failure analysis presented in this
report highlighted a number of issues that affect the reliability of these engines.
Accordingly, the following recommendations are issued:
Safety recommendation R20010254, Combustion deposits
The Australian Transport Safety Bureau recommends that the Federal Aviation
Administration (Piston Engine Certification Directorate) review the certification
requirements of piston engines with respect to the operating conditions under which
combustion chamber deposits that may cause preignition are formed.
FAA response
The following response was received from the FAA on 20 August 2002:
Preignition, like detonation, is a form of uncontrolled combustion that occurs
in piston engine cylinders. The symptoms and consequences of both these
events are very similar, differing only in the sequence of occurrence.
Preignition occurs before scheduled ignition, and detonation occurs after
ignition.
Current FAA certification requirements and guidance provide for margin
against detonation. The current FAA certification regulation that addresses
piston engine detonation is (Regulations)33.47. FAA guidance describing
acceptable methods of compliance with this regulation is contained in
Advisory Circular (AC) 33.47-1.
To meet these acceptable methods, the applicant must test the engine at worst-
case conditions for detonation, which are also the most critical conditions for
preignition. Instrumentation used to monitor for detonation, such as pressure
sensors or pieziolectric vibration sensors, will identify all types of
uncontrolled combustion, including both detonation and preignition.
To pass the test, the applicant must substantiate that a 12% margin exists
between the leanest fuel mixture and the onset of uncontrolled combustion.
This margin is intended to accommodate the deteriorating resistance of the
engine to detonation and preignition as it ages and accumulates combustion
chamber deposits during the overhaul interval.
The FAA is currently conducting an extensive evaluation of the detonation
characteristics of high performance reciprocating engines at the FAA
Technical Centre. The relationship between deposit formation and octane
rating increase of the engine will be investigated. Data from this evaluation
will be used to assess the adequacy of the current regulation and advisory
material.
Service experience with certificated reciprocating engines will also be
monitored for detonation incidents and appropriate corrective action will be
taken if a service problem is revealed.

ATSB response

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 The ATSB appreciates the consideration that the FAA has given the
recommendations and investigation report. A great deal of work and thought
went into the engine failure analysis, but it was beyond the resources of the
ATSB to delve too much further into the issues that we have raised. In this
regard, we were pleased to learn that the FAA considered that further
evaluation of the issues we had identified was justified. We are in the process
of preparing a case study that will include detailed information on 10 other
failures of high-powered reciprocating engines that we have investigated. We
will forward a copy of that document to you upon its release, as it may assist
your ongoing testing and other activities in this area.
The ATSB is greatly interested in the outcome of the work you will be
undertaking with respect to the two recommendations. We would appreciate
any advice you are able to provide, such as progress reports or other
information as it becomes available.

Subsequent ATSB response on 9 October 2003

I refer to two safety recommendations that the ATSB issued to the FAA in
December 2001 that arose from the ATSB's investigation into the Whyalla
Airlines PA3l-350 accident that occurred on 31 May 2000.
In your letter of 5 August 2002, you advised that an FAA Safety
Recommendations Review Board had classified responses to
recommendations 02.141 and 02.142 as "Closed -Acceptable Action". The
memorandum attached to your letter outlined the action that the Aircraft
Certification Service, Engine and Propeller Directorate intended to take
concerning the recommendations. As it is now over 12 months since receiving
your correspondence, I wanted to check with you regarding the progress the
FAA has made in examining those issues.
Further, our investigation into the engine malfunctions in the accident aircraft,
as well as engines that had malfunctioned in other aircraft, revealed clear
evidence of corrosion damage to the aluminium alloy layer in the bearings
where the alloy was exposed at the bearing insert ends. The ATSB's report on
the accident stated that the formation of lead oxy bromides instead of lead
bromide would affect the quantity of free bromine remaining after the
scavenge process. Excess bromine can find its way into the lubricating oil and
form hydrobromic acid. The ATSB would also be interested in any
observations or data the FAA might have gained regarding excess bromine
from the evaluation of piston engine performance characteristics it was
conducting.

Response status: CLOSED –PARTIALLY ACCEPTED

Safety recommendation R20010255, Use of anti-galling compounds
The Australian Transport Safety Bureau recommends that the Federal Aviation
Administration FAA (Piston Engine Certification Directorate) review the practice
during assembly of applying anti-galling compounds to the backs of connecting rod
bearing inserts with respect to its affect on the safety margin for engine operation of
the bearing insert retention forces achieved.
Subsequent ATSB response on 9 October 2003
I refer to two safety recommendations that the ATSB issued to the FAA in
December 2001 that arose from the ATSB's investigation into the Whyalla
Airlines PA3l-350 accident that occurred on 31 May 2000.

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 In your letter of 5 August 2002, you advised that an FAA Safety
Recommendations Review Board had classified responses to
recommendations 02.141 and 02.142 as "Closed -Acceptable Action". The
memorandum attached to your letter outlined the action that the Aircraft
Certification Service, Engine and Propeller Directorate intended to take
concerning the recommendations. As it is now over 12 months since receiving
your correspondence, I wanted to check with you regarding the progress the
FAA has made in examining those issues.
Further, our investigation into the engine malfunctions in the accident aircraft,
as well as engines that had malfunctioned in other aircraft, revealed clear
evidence of corrosion damage to the aluminium alloy layer in the bearings
where the alloy was exposed at the bearing insert ends. The ATSB's report on
the accident stated that the formation of lead oxy bromides instead of lead
bromide would affect the quantity of free bromine remaining after the
scavenge process. Excess bromine can find its way into the lubricating oil and
form hydrobromic acid. The ATSB would also be interested in any
observations or data the FAA might have gained regarding excess bromine
from the evaluation of piston engine performance characteristics it was
conducting.

Nil response
Response status: CLOSED-NO RESPONSE
Safety recommendation R20010256
The Australian Transport Safety Bureau recommends that Textron Lycoming
review the practice during assembly of applying anti-galling compounds to the
backs of connecting rod bearing inserts with respect to its affect on the safety
margin for engine operation of the bearing insert retention forces achieved during
assembly.
Textron Lycoming response
The following response was received from Textron Lycoming on 12 February
2002:
Textron Lycoming did not specifically respond to recommendation
R20010256, but on 12 February 2002, in comment with respect to the content
of the ATSB's final report stated; "Lycoming does not concur with the
specific findings in ATSB report 200002157 that attribute the failure of the
left engine to the presence of anti-seize compound between the bearing and
the connecting rod journal."

Repose status: CLOSED-NOT ACCEPTED

Safety recommendation R20010257, Reliability of aircraft propulsion systems
within Australia
The Australian Transport Safety Bureau recommends that the Civil Aviation Safety
Authority review the operating and maintenance procedures for high-powered
piston engines fitted to Australian registered aircraft, to ensure adequate
management and control of combustion chamber deposits, preignition and
detonation.
CASA response
The following response was received from Civil Aviation Safety Authority on 06
March 2002:

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CASA acknowledges the intention of the safety recommendation and advises
that the Authority has taken significant steps to address this issue with the
Federal Aviation Administration in relation to the, certification of the Piper
aircraft and engine.
In discussions with the Federal Aviation Administration (FAA) New York
Aircraft Certification Office and the FAA Atlanta Aircraft Certification
Office, CASA advised that one of the primary issues identified in the Whyalla
accident was aggressive fuel leaning.
CASA advised the New York and Atlanta FAA Offices of the discrepancies
identified between the Engine Operating Manual approved by the New York
Office and the Aircraft Flight Manual approved by the Atlanta Office.
Following these discussions, the Atlanta Office has responded with advice
that the FAA is of the opinion that fuel mixture leaning procedures were not a
contributing factor in the events of May 2000.
This response is not consistent with the findings of the ATSB in regards to the
resulting combustion chamber deposits, preignition and detonation.
CASA's actions in regards to this recommendation are ongoing, and
discussions are being held with the engine manufacturer. CASA undertakes to
advise the ATSB of the outcomes of these discussions as they progress.
In relation to the maintenance procedures for all high-powered piston engines
fitted to Australian registered aircraft, CASA advises that action in relation to
this matter is ongoing.
CASA intends to review current maintenance procedures applied to all high-
powered piston engines fitted to Australian Registered aircraft to ensure
compliance with manufacturer's published procedures, and in the opinion of
the Authority, this action will provide timely notice of engine distress
resulting from combustion chamber deposits.
In relation to the operating procedures for all high-powered piston engines
fitted to Australian Registered aircraft, CASA advises that the Authority has
notified all operators of Textron Lycoming and Teledyne Continental Motors
piston engines aircraft of reports of crankshaft bearing failures.
To minimise the risk of combustion chamber deposits resulting in abnormal
loading of the bearings, CASA has recommended the operators adopt
conservative fuel mixture leaning procedures.
A copy of this letter is provided for the information of the ATSB.
The following is a copy of the letter
To all operators of Textron Lycoming and Teledyne Continental Motors
piston engines with a take off power rating greater than 250 horsepower
And aircraft maintenance organisations
Subject: Lycoming and TCM Crankshaft Bearing and Connecting Rod
Bearing Failures

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Since August 2001, CASA has received 9 major defect reports relating to
crankshaft and connecting rod bearing failures. Six of the failures occurred in
Lycoming engines and three in TCM engines. All of the failures have
occurred at a low bearing time in service. All but one of the reports involved
large, high horsepower engines. A preliminary examination of a number of
the failed bearings indicates evidence of delamination of the bearing shell
layers. That examination result is consistent with undocumented reports of
warranty claims against engines exhibiting bearing material in the oil filters of
low time in service engines.
Textron Lycoming, Teledyne Continental Motors, Superior Air Parts and the
FAA have been advised. of the bearing defects being reported in Australia
CASA is conducting on-going discussions with Lycoming, TCM and Superior
Air Parts on the reported failures. `However, CASA, has been advised;
crankshaft bearings can also be supplied by non original equipment
manufacturers each with a unique prefix to the original part number. Air
Support and Engine Components Incorporated are two such suppliers. An Air
Support supplied bearing will have the prefix "AS", eg; AS 13884-M03
Textron Lycoming has advised; bearing delamination detects should not
present a safety of flight concern if the engine oil pressure filter and oil
pressure screen are inspected for metal contamination at each oil and filter
change. Cutting open the filter and examining the filter element as detailed in
Lycoming Service Bulletin Number 480D will provide ample opportunity to
detect an impending bearing failure. The FAA supports the Lycoming
response.
Aggressive fuel mixture leaning may be relevant to the reported bearing
defects.' The Australian Transport Safety Bureau, in investigating the dual
engine failures associated with the fatal Whyalla Airlines Piper PA31-350
accident, noted a relationship between bearing failures and aggressive fuel
leaning procedures. The ATSB lists engine operating practices as a
contributing factor in that accident. A copy of the ATSB report can be found
on the internet at www.atsb.gov.au. The CASA Flight Safety Australia
Jan/Feb 2001 "Lean and Mean" article advising of the real costs of aggressive
fuel mixture leaning also provides useful information on this subject.
Until a full understanding of the causes of the crankshaft bearing failures is
obtained, CASA recommends all Lycoming and TCM piston engine powered
aircraft operators and applicable maintenance organisations carry out the
following precautionary procedures.
1. Fuel mixture leaning procedures detailed in the aircraft
manufacturer's flight manual or pilot operating handbook may be
different to the procedures recommended by the engine
manufacturer. The engine manufacturer may recommend the use of
richer fuel mixtures than those approved by the aircraft
manufacturer. To limit crankshaft bearing exposure to abnormal
combustion loads occurring during aggressive leaning procedures,
observe the fuel mixture leaning procedure limits detailed in the
engine manufacturer's operators manual.
2. At each engine oil change and filter change, if applicable to the
engine model, inspect the oil pressure screen, oil suction screen and
cut open the oil filter and inspect the filter element for evidence of
metal contamination, Lycoming SB 480D and TCM SB M87-12
Rev.l refer; and

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 3. Carry out an engine oil change and, if applicable, an oil filter change,
at intervals as published by the engine manufacturer, Lycoming SB
480D and TCM SB M87-12 Rev. l refer; and
4. At each engine oil change, drain the oil whilst the engine is still hot
and strain the oil through a fine mesh screen filter. If a bearing defect
is present, hot oil will flush out bearing material 'flakes.
Defects found in carrying out the above recommendation should be reported
to CASA on the Major Defect Form available from the CASA website,
www.casa.gov.au. CASA is continuing to seek an understanding on the
primary cause of the bearing defects, in submitting such defect reports, please
include all available information on the supplier and part number of the
bearings fitted.

The following response was received from Civil Aviation Safety Authority
on 21 November 2003:
The Australian Transport Safety Bureau (ATSB) has requested that the Civil
Aviation Safety Authority (CASA) seek further clarification from the Federal
Aviation Administration (FAA) on detonation limiting conditions and
examine what steps CASA can take to ensure that operating procedures used
by operators of fleets of more than one aircraft type take account of the
requirements contained in varying operating manuals and handbooks.
In response to the first issue, the FAA has been advised of CASA's specific
concern with the fuel mixture leaning procedures being different in the three
Pilot Operating Handbooks (POHs) for the PA31-350 Chieftain. Despite all
serial numbers of PA31-350 aircraft having identical fuel systems, engines
and performance, a fleet operator may operate a mix of aircraft serial number
ranges, and yet, in ignorance, operate all aircraft to the one manual. CASA is
writing a follow up letter to the FAA reiterating our concerns on this issue and
CASA undertakes to advise the ATSB of the FAA's response.
In response to the second issue, CASA's auditing of fleet operators now
requires the approved Operating Procedures Manual be reviewed with
consideration given to the operating procedure document detailed in the
aircraft Type Certificate Data sheet (TCDS).
This review is carried out on each individual aircraft in the fleet by type,
model and the aircraft's manufacturer's serial number, and CASA believes that
this step will assist in ensuring that operators of fleets including more than
one model of a particular aircraft type take account of different versions of
operating manuals and handbooks.
Thank you for bringing these matters to the attention of the Authority.

Response status: CLOSED-ACCEPTED

9.3.2 Lycoming mandatory service bulletins - crankshafts

MSB 550
DATE: February 1, 2002 Service Bulletin No. 550

SUBJECT: Crankshaft Replacement in Lycoming TIO and LTIO-540

Engines Rated at 300 Horsepower and Higher

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 Lycoming has received several field reports of broken crankshafts in six-
cylinder turbocharged engines. Lycoming believes the problem is related to
the material used in these crankshafts.
Due to the nature of the problem, there is no field process currently available
to identify crankshafts potentially affected. Therefore, Lycoming requires that
all the engines listed below be returned to the factory for crankshaft
replacement within 10 hours of operation.

MSB 552, and supplement 1 (SB552S-1)

DATE: August 16, 2002 Service Bulletin No. 552 (Supersedes
and Replaces Service Bulletin No. 550)
SUBJECT: Crankshaft Replacement in Lycoming TIO and LTIO-540
Engines Rated at 300 Horsepower and Higher
Service Bulletin No. 552 applies only to TIO and LTIO-540 engines rated at
300 horsepower or higher.
Engines that previously complied with Service Bulletin No. 550 are also
affected by Service Bulletin No. 552.
Lycoming has received several field reports of broken crankshafts in six-
cylinder turbocharged engines rated at 300 horsepower or higher. The
problem is related to the material used in these crankshafts. Due to the nature
of the problem, there is no field process currently available to identify
crankshafts potentially affected.

MSB 553 and supplement 1 (SB553S-1)

DATE: September 16, 2002 Service Bulletin No. 553
Engineering Aspects of this Service Bulletin are FAA
Approved
SUBJECT: Crankshaft Inspection for Lycoming Six Cylinder
Turbocharged Engines
Lycoming has received a field report of a broken crankshaft in a six-cylinder
turbocharged engine. The report affected a product outside of the range
recalled by Service Bulletin No. 552. Metallurgical testing indicates that the
cause is material related. Lycoming requires that affected crankshafts be
inspected. During the inspection, three core samples will be removed from the
crankshaft propeller flange by a Lycoming authorized representative.

MSB 566 and supplement 1 (SB566S-1)

DATE: July 11, 2005 Service Bulletin No. 566
SUBJECT: Crankshaft Replacement in Lycoming Engines.
MODELS AFFECTED: Any Lycorning engine model specified below
manufactured, rebuilt, overhauled or repaired after March 1, 1999:
Engines that have complied with Service Bulletin No. 552 or Service Bulletin
No. 553 are not affected by this Service Bulletin.

– 239 –
 Lycoming has continued to analyze crankshafts in service. This analysis
indicates that replacement of certain crankshalts is warranted. Therefore,
Lycoming is recalling certain crankshafts in the specified four and six
cylinder engines.
All affected Lycoming crankshafts have a serial number format of "V5379"
followed by a 3 to 5 digit number.
Please note that not all "V5379" crankshafts are affected. The crankshaft
serial number is marked on the O.D. of the propeller mounting flange.

MSB 566, Supplement 1

DATE: November 30, 2005 Supplement No. 1, To Service
Bulletin No. 566
SUBJECT: Crankshaft Replacement in Lycoming Engines
MODELS AFFECTED: Any Lycoming engine model specified below
manufactured, rebuilt, overhauled or repaired after March 1, 1999:
Lycoming has continued to analyze crankshafts in service. This analysis
indicates that replacement of certain crankshafts is warranted. Therefore,
Lycoming is recalling certain crankshafts in the specified four cylinder
engines.

MSB 569
DATE: February 21, 2006 Service Bulletin No. 569
SUBJECT: Crankshaft Retirement for Certain Lycoming Engines

MODELS AFFECTED: Any Lycoming engine model specified below

manufactured, rebuilt, overhauled, or repaired after March 1, 1997:
Lycoming has continued to analyze crankshafts in service. While there have
been no failures in the crankshafts which are the subject of this Service
Bulletin, as part of our commitment to quality, Lycoming is initiating a
crankshaft retirement program. This crankshaft retirement program requires
the removal of the subject crankshafts when the crankcase is separated or at
overhaul, whichever occurs first, not to exceed three calendar years from the
date of this Service Bulletin, no later than February 21, 2009.

MSB 569A
DATE: April 11, 2006 Service Bulletin No. 569A (Supersedes
Service Bulletin No. 569)
SUBJECT: Crankshaft Retirement for Certain Lycoming Engines

MODELS AFFECTED: Any Lycoming engine model specified below

manufactured, rebuilt, overhauled, or repaired after March 1, 1997:
Engine models, engine serial numbers, and crankshaft serial numbers have
been added. Therefore, all owners of the engine models listed above need to
check this revised Service Bulletin even if it was previously determined that
you were not affected by Service Bulletin No. 569.
NOTE

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 1. Engines that have complied with Service Bulletin No. 552, Service Bulletin
No. 553, Service Bulletin No. 566, or Supplement No. 1 to Service Bulletin
No. 566 and have not had another crankshaft replacement in the field after
such compliance with one of the above Service Bulletins are not affected by
this Service Bulletin.
2. Any new, rebuilt, overhauled, or repaired (example: prop strike) engines
received from Lycoming after July 11, 2005 (logbook date of manufacture)
that have not had a crankshaft replaced in the field are not affected by this
Service Bulletin.

9.3.3 Airworthiness directives, Federal Aviation Administration -

crankshafts

AD 2002-04-51
Subject: EMERGENCY AIRWORTHINESS DIRECTIVE U.S.
Department of Transportation, Aircraft Certification Service,
Federal Aviation Administration, Washington, DC
DATE: February 11, 2002
Send to all U.S. owners and operators of Textron Lycoming LTIO-540 and
TIO-540 engines. These engines are installed on, but not limited to Piper
Navajo (PA 31, PA 31-350, and EMB-820), Piper Saratoga (PA 32-301T, PA
32R-301T, and PA 31-325), Piper Aerostar (PA 60-700P), Piper Malibu
Mirage (PA 46-350P), Piper Mojave (PA 31P-350) El Gavilian (EL-1), and
Cessna T-206.
This Emergency Airworthiness Directive (AD) is prompted by reports of 14
crankshaft failures in LTIO540 and TIO-540 engines, rated at 300 HP or
higher, that were assembled with crankshafts manufactured from March 1,
1999, through December 31, 1999. This condition, if not corrected, could
result in crankshaft failure, which could result in total engine power loss, in-
flight engine failure and possible forced landing.
Since an unsafe condition has been identified that is likely to exist or develop
on other Textron Lycoming LTIO-540 and TIO-540 engines, rated at 300 HP
or higher, that are listed by serial number (SN) in this AD, this AD requires
removal of the crankshaft within 10 hours time-in-service (TIS) after receipt
of this AD.

AD 2002-17-53
Subject: EMERGENCY AIRWORTHINESS DIRECTIVE Aircraft
Certification Service U.S. Department of Transportation Federal
Aviation Administration, Washington, DC
DATE: August 16, 2002
Emergency distribution is required.

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 This Emergency Airworthiness Directive (AD) supersedes Emergency AD
2002-04-51. Send to all U.S. owners and operators of Textron Lycoming
LTIO-540 and TIO-540 engines. These engines are installed on, but not
limited to Piper Navajo (PA 31, PA 31-350, and EMB-820), Piper Saratoga
(PA 32-301T, PA 32R-301T, and PA 31-325), Piper Aerostar (PA 60-700P),
Piper Malibu Mirage (PA 46-350P), Piper Mojave (PA 31P-350) El Gavilian
(EL-1), and Cessna T-206. This Emergency AD is prompted by reports of 17
crankshaft failures in LTIO-540 and TIO-540 engines, rated at 300 HP or
higher, that were assembled with certain crankshafts that were manufactured
using a hammer-forged process. The FAA is continuing the investigation into
the cause of the crankshaft failures, and further regulatory action will follow.
This condition, if not corrected, could result in crankshaft failure, which could
result in total engine power loss, in-flight engine failure and possible forced
landing.
FAA's Determination of an Unsafe Condition and Proposed Actions
Since an unsafe condition has been identified that is likely to exist or develop
on other Textron Lycoming LTIO-540 and TIO-540 engines, rated at 300 HP
or higher, with a crankshaft installed that is listed by serial number (SN) in
this AD, this AD requires removal of the crankshaft before further flight after
receipt of this AD.

AD 2002-19-03
Subject: [Docket No. 2002-NE-03-AD; Amendment 39-12883; AD 2002-
19-03] RIN 2120-AA64
Airworthiness Directives; Textron Lycoming I0-540, LTIO-540
and ‘I’ I0-540 Series Reciprocating Engines
Date: September 20, 2002
SUMMARY: This amendment supersedes emergency airworthiness directive
(AD) 2002-17-53 that was sent previously to all known U.S. owners and
operators of Textron Lycoming LTIO-540 and TIO-540 series engines, rated
at 300 horsepower (HP) or higher. That action requires, before further flight,
replacing certain serial-numbered crankshafts that were hammer forged with
crankshafts that were press forged. That AD was prompted by reports of
crankshaft failures in LTIO-540 and TIO-540 engines, rated at 300 HP or
higher. This amendment expands the suspect population of engines to include
engines with crankshafts that were manufactured between March 1997 and
the present and all 10-540 engines with crankshafts that were manufactured
between March 1997 and the present that have been modified by
supplemental type certificate (STC) by installing a turbocharger system. The
actions specified by this AD are intended to prevent failure of the crankshaft,
which could result in total engine power loss, in-flight engine failure and
possible forced landing.
DATES: Effective September 20, 2002.

AD 2005-19-11
Subject: [Docket No. FAA-2005-21864; Directorate Identifier 2005-NE-29-
AD; Amendment 39-14276; AD 2005-19-11] RIN 2120-AA64
Airworthiness Directives; Lycoming Engines (Formerly Textron
Lycoming) AEIO-360, IO-360, 0-360, LIO-360, LO-360, AEIO-
540, IO-540, 0-540, and TIO-540 Series Reciprocating Engines

– 242 –
 ACTION: Final rule.
Date: October 21, 2005
SUMMARY: The FAA is adopting a new airworthiness directive (AD) for
certain Lycoming Engines (formerly Textron Lycoming) AEIO-360, IO-360,
O-360, LIO-360, LO-360, AEIO-540, IO-540, O-540, and TIO-540 series
reciprocating engines rated at 300 horsepower (HP) or lower. This AD
requires replacing certain crankshafts. This AD results from reports of 12
crankshaft failures in Lycoming 360 and 540 series engines rated at 300 HP or
lower. We are issuing this AD to prevent failure of the crankshaft, which
could result in total engine power loss, in-flight engine failure, and possible
loss of the aircraft.
DATES: This AD becomes effective October 21, 2005. The Director of the
Federal Register approved the incorporation by reference of certain
publications listed in the regulations as of October 21, 2005.

AD 2006-06-16
Subject: [Docket No. FAA-2005-23269; Directorate Identifier 2005-NE-50-
AD; Amendment 39-14525; AD 2006-06-16] RIN 2120-AA64
Airworthiness Directives; Lycoming Engines (Formerly Textron
Lycoming) AEIO-360, IO-360, 0360, LIO-360, and LO-360 Series
Reciprocating Engines
Date: April 27, 2006
SUMMARY: The FAA is adopting a new airworthiness directive (AD) for
certain Lycoming Engines (formerly Textron Lycoming) AEIO-360, IO-360,
0-360, LIO-360, and LO-360 series reciprocating engines. This AD requires
replacing certain crankshafts. This AD results from a crankshaft failure in a
Lycoming LO-360-A1H6 reciprocating engine. We are issuing this AD to
prevent failure of the crankshaft, which could result in total engine power
loss, in-flight engine failure, and possible loss of the aircraft.

AD 2006-20-09
Subject: [Docket No. FAA-2006-24785; Directorate Identifier 2006-NE-20-
AD; Amendment 39-14778;] RIN 2120-AA64
Airworthiness Directives; Lycoming Engines (L)O-360, (L)IO-360, AEIO-
360, 0-540,10-540, AEIO-540, (L)TIO-540, IO-580, and IO-720 Series
Reciprocating Engines.
Date: November 3, 2006
SUMMARY: The FAA is adopting a new airworthiness directive (AD) for
certain Lycoming Engines (L)O-360, (L) IO-360, AEIO-360, O-540, IO-540,
AEIO-540, (L)TIO-540, IO-580, and IO-720 series reciprocating engines.
This AD requires replacing certain crankshafts. This AD results from reports
of 23 confirmed failures of similar crankshafts in Lycoming Engines 360 and
540 series reciprocating engines. We are issuing this AD to prevent failure of
the crankshaft, which will result in total engine power loss, in-flight engine
failure, and possible loss of the aircraft.
DATES: This AD becomes effective November 3, 2006. The Director of the
Federal Register approved the incorporation by reference of certain
publications listed in the regulations as of November 3, 2006.

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9.3.4 Civil Aviation Safety Authority Australia airworthiness directives
- crankshafts
The following series of Airworthiness Directives where issued by the Civil
Aviation Authority Australia in response to the mandatory service bulletins issued
by Lycoming.
AD/LYC/107 Amdt 1, 21 August 2002: Crankshaft Material
AD/LYC/107 Amdt 2, 2 October 2002: Crankshaft Replacement
AD/LYC/108, 2 October 2002: Crankshaft Material Inspection
AD/LYC/112, 28 October 2005: Lycoming Crankshaft Replacement
AD/LYC/115, 11 May 2006: Lycoming Crankshaft Replacement
AD/LYC/117, 23 November 2006: Lycoming Crankshaft Replacement

9.3.5 Safety advisory publications – mixture control

An article titled, ‘Chieftain investigation leads to safety recommendations’,
published in the ATSB supplement of Flight Safety Australia (Flight Safety
Australia, Nov.-Dec. 2000), introduced safety recommendation R 20000250 and
another recommendation relating to the carriage of life jackets for over-water flight.
The article drew attention to the apparent correlation between the leaning of the
fuel-air mixture during cruise to within 50°F of peak EGT (rich or lean side) and
engine component failure. It also drew attention to the extensive reliable
performance of Lycoming TIO-540 engines achieved by a number of public
transport operators when fuel-air mixture leaning during cruise was restricted to
100°F rich of peak EGT.
An article titled, ‘Lean and mean, best economy or false economy, what are the
costs of long-term aggressive leaning?’, written by CASA staff and published in
Flight Safety Australia (Flight Safety Australia, Jan.-Feb.) discusses detonation,
aggressive leaning, high power engines, and leaning procedures.
This article has created some confusion through its attribution of ‘aggressive
leaning’ as the dominant factor in the process of detonation.
Detonation: By definition, detonation is the uncontrolled explosion of the
fuel/air mixture, as distinct from an even and progressive burning. Detonation
occurs when the anti knock rating of the fuel is lower than required by the
pressure and temperature generated during engine operation. There are a
number of factors which combine to create detonation. Using fuel with an
octane number (anti-knock rating) less than that required for the engine is the
most obvious. However, more common is overleaning of the fuel/air mixture.
Leaning the mixture lowers the anti-knock rating of the fuel. Most high
performance engines require full rich during high power settings such as take-
off and climb. The reason? To ensure the fuel anti-knock rating is appropriate
for the combustion pressure and temperatures being developed at the high
power setting.
Conversely, an engine may be leaned when operating at low power settings
when the temperature and pressure is less severe. It is the level of leaning that
requires caution.

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 Aggressive leaning: Aggressive leaning is adjusting the fuel/air mixture to the
lean side of peak EGT. Aggressive leaning reduces the fuel anti-knock rating
to a level where the engine is susceptible to detonation. That is, the margin
between normal combustion and detonation is minimal.
When running lean of peak, a defect such as a defective spark plug, fuel
nozzle etc, is not the real issue of concern, it is the deliberate reduction of the
available detonation margin by aggressive leaning
Pre-ignition: the presence of a static hot spot in a cylinder, such as a lump of
carbon or cracked spark plug ceramic, can lead to pre-ignition. A static hot
spot and aggressive leaning can lead to pre-ignition detonation, which almost
always results in destructive detonation. Detonation may destroy a piston or
con-rod bearing before the pilot could detect the damage occurring. Again, the
destruction is avoidable. The static hot spot is a minor defect, but aggressive
leaning turns it into induced destructive detonation.

Confusion arises from the failure to explain that the detonation-limited fuel-air
mixture is a function of engine power setting. Normally, the fuel-air mixture
adjustment of a high-power aircraft engine is detonation limited at take-off and
climb power settings but not at cruise power settings, see for example, figures 8.4
and 8.27. Mixture leaning close to peak exhaust gas temperature (EGT), or to the
lean side of peak EGT, is only performed at cruise power settings. Mixture
adjustment does not affect the anti-knock rating of the fuel.
For the situation where operating conditions are favourable for end-gas detonation,
the intensity of detonation depends on the mass of end gas that auto-ignites (Taylor,
1999, vol.2, p.56). Throttling an engine to cruise power reduces the total mass of
fuel-air mixture and, as a consequence, reduces the mass of end gas and the
potential intensity of end-gas detonation.

9.3.6 Safety advisory publications - bearings

The Federal Aviation Administration published a special airworthiness information
bulletin alerting operators of bearing surface delamination that had affected several
front main bearings of high-power (greater than 300 HP) Lycoming engines.
SPECIAL AIRWORTHINESS INFORMATION BULLETIN
U.S. Department of Transportation, Federal Aviation Aircraft Certification
Service Administration, Washington, DC
No. NE-01-37 August 16, 2001
Applicability
This Special Airworthiness Information Bulletin (SAIB) alerts you, an owner
or operator of Textron Lycoming IO-540 and TIO-540 series engines with
300hp or greater, that had Textron Lycoming Front Main Bearings P/N LW-
13885 installed after August 24, 2000. These bearings were shipped to
Textron Lycoming between August 24, 2000 and January 31, 2001 as
standard size bearings with a date code of "6-00" (without an "M" suffix after
the part number). Most were installed in new engines, and some were sold as
spare replacements or shipped from Textron Lycoming installed in rebuilt or
overhauled engines after August 24, 2000.
Introduction

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 Textron Lycoming has reported 6 events of front main bearings delaminating
and liberating metal particles into the oil system that ultimately accumulate in
the oil filter. Textron Lycoming found one delaminated bearing after the
routine disassembly of a new production engine and five other delaminated
bearings from routine oil filter checks at times varying between 25 hours and
350 hours. If this condition goes undetected, you could experience engine
seizure and an in-flight shutdown.
Textron Lycoming advised the FAA that delamination of front main bearings
is a relatively slow process that you can detect through routine oil filter
inspections. Field inspections have verified this method of detection (oil filter
inspections). The current Textron Lycoming oil filter replacement
recommendation for a new, overhauled or rebuilt engine is contained in
Textron Lycoming Mandatory SB 480D and specifies the oil filter inspection
intervals and oil filter inspection procedures.

The Civil Aviation Authority (CASA) Australia published an article titled ‘Check
your bearings’ that discusses issues relating to bearing material and reliability
(Flight Safety Australia, Jul.-Aug., 2003). CASA also issued an airworthiness
bulletin (AWB 85-1 issue 3, 1 November 2004), titled ‘Textron Lycoming Engine
Bearings’ which discusses issues relating to bearing construction, engine
operations, maintenance, assembly/overhaul practices, and a service difficulty
reporting program.

9.4 Performance of the feedback process

The formal actions of the regulatory authorities and the engine manufacturer, during
the period 2000 to 2005, have been concentrated on crankshaft material and
manufacturing issues, and have touched lightly upon the behaviour of plain
bearings manufactured with an aluminium-tin layer.
It is evident, however, in this study of powertrain structural failure, over the period
2000 – 2005, that threats to fight safety have been created by cylinder head fatigue,
piston melting, connecting rod little-end fracture, connecting rod big-end fracture,
the movement of main bearing inserts, and cylinder attachment fastener fracture.
The actions taken to address crankshaft material issues will have no effect on these
other types of powertrain structural failure.
A timeline of safety actions, promulgated during the period 2000 – 2005, combined
with timelines for the various types of powertrain structural failure is shown in
figure 9.2.
An important function of the airworthiness assurance system is the adjustment or
correction of the propulsion system following system malfunction events. System
correction relies on the process of feedback. Unlike simple feedback processes,
such as temperature control, in which cause-and-effect linkages are clearly defined
and ‘hard wired’, feedback processes that form the basis of airworthiness assurance
systems, do not have clearly delineated cause-and-effect linkages and rely on the
human processes of investigation, analysis and communication (Romeyn, 2006).
The resolution of differences between the operational reliability and design
reliability, is achieved by appropriate adjustment or correction of the sub-systems
and components that form the propulsion system. Recurrent propulsion system
failures are an indication that system adjustment or correction, through an effective
feedback process, is not occurring.

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Feedback is an important component in the airworthiness assurance system. Its
purpose is to ensure that defect information is received, analysed, and acted on in a
timely manner. For the system to succeed, complete and accurate defect analysis
must be provided to all those involved in the implementation of the system;
regulators, manufacturers, operators, maintainers. The importance of feedback in
the airworthiness assurance system was previously highlighted in the ATSB’s 2002
report Investigation into Ansett Australia maintenance safety deficiencies and the
control of continuing airworthiness of Class A aircraft. The investigation found
that:
The CASA Canberra central office database for major defect reports was
incomplete, partly due to deficiencies in reporting, and the information
received was not fully analysed. In addition, feedback to the initiators of
major defect reports, and to other operators, was limited. As a result, the
potential safety benefit of the major defect reporting system was not fully
achieved (ATSB, 2002, p.118).

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 Figure 9.2: Safety actions in the context of powertrain structural failure
type

9.4.1 Feedback barriers

Barriers to feedback may arise at a various levels in a system hierarchy; individual
interactions, organisational goals and interactions, and societal influences. For

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feedback, in response to system malfunction to be effective, information must be
sensed, perceived, put into context, evaluated, analysed, and communicated.
Feedback in a complex engineered-system is a function that relies on human
performance. Potential barriers to feedback may occur as a result of poor
communication, complacency, lack of knowledge, distraction, lack of teamwork,
fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness,
and accepted norms.
The complexity of systems has an important effect on the feedback process through
the inability to predict, with complete certainty, the consequences of interactions
between physical, chemical, mechanical and human processes.
The resolution of differences between operational and design reliability, in
situations where the feedback process is ineffective, results in a change in
expectation of propulsion system performance and an acceptance of a lower level of
reliability. The management of threats to the wellbeing of passengers and crew
becomes more dependent on system redundancy and the ability of pilots to manage
periods of abnormal operation. However, for some aircraft types, for example those
certified to FAR part 23, the defence of propulsion system redundancy is not
present for all phases of flight. It is also evident that the structural failure of
propulsion systems may create damage and an associated period of abnormal
operation beyond the capability of the pilot to complete the flight safely. In these
cases, the acceptance of a lower level of reliability increases the threat to wellbeing.
The issue of over reliance on system failure defences is noted in the UK CAA’s
handbook on condition-monitored maintenance.
In the case of a system designed to a multiple redundancy philosophy it has
been a common misunderstanding that, as redundancy exists, an increase in
failure rate can always be tolerated without corrective action being taken.
(leaflet 13-4 CAAP 418, p.7)

The tendency to accept deviations from initial performance standards is not

restricted to the operation of aircraft reciprocating engines. The subtle, insidious,
unpredictable effect of accepting deviations from agreed performance standards has
been highlighted in the reports of investigations into the Challenger and Columbia
space shuttle accidents.
The initial Shuttle design predicted neither foam debris problems nor poor
sealing action of the Solid Rocket Booster joints. To experience either on a
mission was a violation of design specifications. These anomalies were
signals of potential danger, not something to be tolerated, but in both cases
after the first incident the engineering analysis concluded that the design
could tolerate damage. These engineers decided to implement a temporary fix
and/or accept the risk, and fly. For both O-rings and foam, that first decision
was a turning point. It established a precedent for accepting, rather than
eliminating, these technical deviations. As a result of this new classification,
subsequent incidents of O-ring erosion or foam debris strikes were not defined
as signals of danger, but as evidence that the design was now acting as
predicted. (Columbia accident investigation, 2003, p.196)

The means of overcoming the barriers to effective feedback lies in developing an

awareness of the factors that: prevent the seeing of evidence clearly and in context,
result in incorrect classification, result in incorrect cause and effect linkages, and
interfere with communication at all levels. Feedback is highly dependent on
viewing the system in its entirety, and viewing its elements in detail. Feedback to

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 ensure continued safe operation should be based on the potential consequences of a
sequence of events.

9.5 References
Australian Transport Safety Bureau (ATSB), November 2002, Investigation into
Ansett Australia maintenance safety deficiencies and the control of continuing
airworthiness of Class A aircraft. P.118.
Columbia Accident Investigation Board, Report Volume 1, August 2003, p.196,
http://www.nasa.gov/columbia/home/index.html
Leaflet 13-4, Condition Monitored Maintenance: An Explanatory Handbook, Civil
Aviation Publication (CAP 418), Civil Aircraft Airworthiness Information and
Procedures, United Kingdom Civil Aviation Authority, 1 July 1990, pp.1-33.
Flight Safety Australia, Nov.-Dec. 2000, published by the Civil Aviation Safety
Authority (CASA) Australia, November-December 2000.
Flight Safety Australia, Jan.-Feb. 2001, published by the Civil Aviation Safety
Authority (CASA) Australia, January-February 2001.
Flight Safety Australia, Nov.-Dec. 2000, published by the Civil Aviation Safety
Authority (CASA) Australia, July-August 2003.
Romeyn A, 2006, When Something Breaks – The Anatomy of Failure Analysis,
Evolving System Safety 2006, 7th International Symposium of the Australian
Aviation Psychology Association, Manly, Australia, 9 – 12 November 2006
Taylor FC, 1999, The internal combustion engine in theory and practice Volume 2:
combustion, fuels, materials, design, The M.I.T Press, Cambridge Massachusetts,
p.56.

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10 CONCLUSIONS
The reliability of reciprocating engines is an issue for a significant portion of the
Australian civil aviation fleet. Over the six-year period of this study, 2000 – 2005,
1,270 reciprocating-engine powered aircraft on the Australian register operated for
about 220,000 hours. Of these aircraft, around 200 were employed in the low-
capacity regular public transport class of operation, providing public transport
connections throughout regional Australia.
A threat to the safe operation of these aircraft can be created by the structural
failure of powertrain components – combustion chamber assemblies, pistons,
connecting rods, and crankshafts.
Although propulsion system redundancy may be provided in this class of aircraft
through designs that employ two independent, wing-mounted, propulsion systems,
it is acknowledged that, following the failure of one propulsion system; the
remaining propulsion system is not capable of providing the thrust required for all
phases of flight. In addition to the safety threat created by the loss of thrust at
critical phases of flight, powertrain structural failure has the potential to create a
condition of high drag through the disruption of engine cowls, the potential to
fracture engine mounts, and the potential to affect wing structures through the
effects of fire.
In view of the potential consequences of powertrain structural failure, the reliability
of powertrain components is of critical importance and should not be diminished
through an over reliance on propulsion system redundancy and pilot response. The
number and frequency air safety occurrences involving powertrain structural failure
events during the six year period 2000 to 2005 suggests that there was a breakdown
in the system created to ensure the reliable operation of reciprocating engines.
The twenty events of powertrain component failure studied could be grouped into
several categories:
• piston edge and cylinder head melting
• connecting rod little-end bearing housing and big-end bearing housing fatigue
fracture
• plain bearing surface breakup
• movement of plain bearings within their housings
• cylinder head fatigue
• cylinder attachment fastener fatigue fracture
• crankshaft fatigue fracture.
These failure events were not restricted to one engine model or one engine
manufacturer.
The event sequences stemming from powertrain component failure were found to
vary in nature and consequence. The inherent complexity of the chemical, physical
and mechanical processes, and behaviours and interactions between the component
parts of assemblies affect the nature of failure sequences and, ultimately, the
consequence of the failure sequence – service difficulty, serious incident, or fatal
accident.

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Analysis of each failure mode revealed that factors that contribute to the failure
ranged from:
• a change in combustion from normal flame propagation to end gas auto-ignition
(detonation);
• a change in plain bearing lubrication regime;
• a change in the force acting to retain bearing inserts in their housings;
• a change in the force acting to move bearing inserts in their housing; and
• the initiation of fatigue cracking in components designed to have a life not
limited by fatigue cracking.
While a major variation in an initiating factor from the designed state, may cause
the failure of a powertrain component, for example, the development of heavy
detonation through the use of incorrect fuel or gross exceedence of operating
limitations will lead to the rapid melting of combustion chamber components, it is
evident that synergistic interactions between factors, with smaller variations from
the norm, can also cause component failure.
A change in the combustion process – from flame propagation throughout the fuel-
air mixture to the auto-ignition of some part of the mixture – has the potential to
affect the reliability of powertrain components. The effect of detonation is related to
the intensity of detonation, which in turn, is dependent on the volume of end-gas
that undergoes auto-ignition. Light to medium detonation may result in some
mechanical damage. The actual nature of mechanical damage is dependent on the
robustness of powertrain components and assemblies to abnormal loading. Heavy
detonation results in the melting of aluminium alloy combustion chamber
components.
Detonation-free operation, for a fuel of known detonation resistance, is based on
limiting the operator-controlled engine parameters of manifold pressure (power),
speed, mixture, and engine load. Additionally, detonation-free operation is based on
designed limits for; combustion chamber surface temperatures (spark plugs, piston
crown and cylinder head inner surface, the presence of deposits), inlet air
temperature, and rate of pressure rise (spark ignition advance, ignition from sites
other than spark plugs). Variations in any of these factors, beyond designed limits,
will increase the likelihood of detonation during engine operation. In addition, the
cumulative effect of variations in a number of factors may also act to increase the
likelihood of detonation.
For the engine failure occurrences investigated in this study, it is clear that leaning
at climb power settings increases the likelihood of detonation. It is also evident that
the fuel-air mixture settings – lean climb and lean cruise, resulted in the deposition
of a non-volatile lead compound on combustion chamber surfaces. The presence of
non-volatile deposits also increases the likelihood of detonation.
The effects of end-gas detonation, non-uniform pressure development on piston
crowns, and the propagation of shockwaves across piston crowns, have an effect
that is dependent on the layout of the engine (horizontally opposed or radial). The
location of the regions of end-gas detonation in a horizontally-opposed engine
combustion chamber (dual spark plugs) results in rocking of the piston pin in the
connecting rod little-end bearing and rocking of the connecting rod big-end bearing
about the crankshaft journal. The location of the regions of end-gas detonation in a

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radial-engine combustion chamber (dual spark plugs) results in the rotation of the
piston about the piston pin.
Plain bearings in high-powered aircraft reciprocating engines are an example of a
complex subsystem operating within a complex engineered-system. Complexity
brings with it a variety of failure modes and a sensitivity of the failure process to
initial conditions.
The failure of bearings in aircraft horizontally-opposed engines can be related to
factors that affect hydrodynamic oil film stability, factors that lead to an increase in
the temperature of bearing materials, factors that control the magnitude of the
bearing insert retention force, and factors that control the magnitude of forces
which act to displace the bearing insert. The functioning of other engine subsystems
and the actions of operators and maintainers influence these factors.
A change in plain bearing lubrication from hydrodynamic to boundary conditions is
affected by factors that increase the bearing load, or decrease the bearing clearance.
This analysis found that bearing surface damage created by boundary lubrication
was associated with loads arising from combustion. It was also established that
there were instances where bearing clearances had been reduced by maintenance
actions undertaken to resize crankshaft journals.
Factors that were found to increase the temperature of bearings were high engine
power operation combined with boundary lubrication, the presence of an adherent
nickel layer between the lead-tin and aluminium-tin bearing layers exposed after
bearing surface wear, and the loss of metal-to-metal contact between the bearing
insert and housing through the inclusion of a lubricant.
The response of plain bearings to increases in bearing temperature is dependent on
the nature of the various metallic layers that are used in their construction. It was
established that the differing behaviour of plain bearings constructed with an
intermediate bearing layer of an aluminium-tin alloy or a copper-lead alloy, was a
result of the microstructural changes that occur in the aluminium-tin alloy when the
bearing is heated, and the consequent lowering of the endurance strength of the
aluminium-tin layer.
Factors that result in bearing insert movement were found to be those factors that
affect the magnitude of the friction force created by the interference fit and the
magnitude of forces acting to move the insert circumferentially and axially.
Factors that affect the magnitude of the coefficient of friction between the backs of
bearing inserts and bearing housings have an important effect on insert retention. It
was evident in this analysis that lubricants had been placed between the backs of
connecting rod big-end bearing inserts and their housings during assembly.
The magnitude of the forces acting to move an insert in its housing are affected by
increases in sliding surface friction (boundary lubrication and, in particular, the
sliding of a steel journal against an adherent nickel bearing surface) and the nature
of loading created by combustion. Combustion may have an effect through an
increased load on the bearing surface, increased bending moments on the main
bearings of crankshafts, and increased big-end bearing edge loads associated with
non-uniform gas loads on the piston and the propagation of shock waves in the
combustion gases during combustion with light to medium detonation.
The factors that were found to initiate fatigue cracking and fracture of cylinder
heads, cylinder attachment fasteners, connecting-rod bearing housings, and

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crankshaft journals may be divided into two groups: those factors that increase the
magnitude of alternating stress in a component, and those factors that decrease the
endurance strength of a component.
In this study, sources of increased component alternating stress were found to have
been associated with the gas pressures produced by combustion, increased
component flexure, and reductions in component preload. Sources of decreased
fatigue endurance strength were found to have been associated with surface damage
created by adhesive wear (galling), surface scoring created by rubbing contact with
a closely associated component, and cracking in nitrided surfaces created by
localised frictional heating.
The initiation and propagation of fatigue cracks in a powertrain component is not,
simply, a matter restricted to the material from which the component is
manufactured. It is a matter of all factors that affect the magnitude of component
alternating stresses, and the component endurance strength.
In addition to the complex interrelationships between loads, preloads, geometric
stress concentrators, residual stress, surface finish, surface hardening, and material
of an individual component, there are clear interdependencies between the
combustion process in individual and multiple cylinders of a horizontally-opposed
engine, the physics of plain bearing lubrication, the mechanics of bearing insert
retention, and the process of fatigue crack initiation.
The formal actions of the regulatory authorities and the engine manufacturer, during
the period 2000 to 2005, have been concentrated on crankshaft material and
manufacturing issues, and have touched lightly upon the behaviour of plain
bearings manufactured with an aluminium-tin layer.
It is evident, however, in this study of powertrain structural failure, over the six-
year period 2000 – 2005, that threats to fight safety have been created by cylinder
head fatigue, piston melting, connecting rod little-end fracture, connecting rod big-
end fracture, the movement of main bearing inserts, and cylinder attachment
fastener fracture. The actions taken to address crankshaft material issues will have
no effect on these other types of powertrain structural failure.
The resolution of differences between the operational reliability and design
reliability of reciprocating-engine powered propulsion systems is achieved by
appropriate adjustment or correction of the sub-systems and components that form
the propulsion system. Recurrent propulsion system failures are an indication that
system adjustment or correction, through an effective feedback process, may not be
occurring.
Barriers to feedback may arise at a various levels in a system hierarchy: individual
interactions, organisational goals and interactions, and societal influences. For
feedback in response to system malfunction, to be effective, information must be
sensed, perceived, put into context, evaluated, analysed, and communicated.
Feedback in a complex engineered-system is a function that relies on human
performance. Potential barriers to feedback may occur as a result of poor
communication, complacency, lack of knowledge, distraction, lack of teamwork,
fatigue, lack of resources, pressure, lack of assertiveness, stress, lack of awareness,
and accepted norms.
The complexity of propulsion systems powered by reciprocating engines has an
important effect on the feedback process through the inability to predict, with

– 254 –
complete certainty, the consequences of interactions between physical, chemical,
mechanical and human processes.
The means of overcoming the barriers to effective feedback lies in developing an
awareness of the factors that: prevent the seeing of evidence clearly and in context,
result in incorrect classification, result in incorrect cause and effect linkages, and
interfere with communication at all levels. Feedback is highly dependent on
viewing the system in its entirety, and viewing its elements in detail. Feedback to
ensure continued safe operation should be based on the potential consequences of a
sequence of events.
Analysis of failure events in complex engineered-systems should be undertaken
with regard to component failure control plans and the safety assurance system as it
is applied to the aspects of design, manufacture, operation, and maintenance.

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