19990226001809A

Accident · Substantial damage

FAA accident report · Amtr RV-6 · Vacaville, CA · February 26, 1999

Date
February 26, 1999 · 13:30 local
Place
Vacaville, CA
Phase of flight
Fcd/Prec Ldg From Cruise
Operating rules
General operating rules (Part 91)
Damage
Substantial damage
Aircraft
N36VR
NTSB investigation
NTSBLAX99LA111
Reported as
Amtr RV6
Reported engine
Lycoming O360*
People aboard
1
Fatal injuries
0
Pilot’s flight hours
3,479 total67 in this make and model68 in the last 90 days

From the FAA’s Accident/Incident Data System (AIDS), through its Aviation Safety Information Portal, as reported. The NTSB investigates accidents separately, and its record of an accident is the fuller one. The aircraft is matched to the registry by N-number and event date, checked against the reported make and model; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

What happened

The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.

Acft experienced engine failure and crash-landed along the shoeline of lake berryessa, other circumstances are unknown. (.19) on February 26, 1999, about 1330 hours pacific standard time, an experimental vans cooper RV-6, N36VR, sustained substantial damage when it collided with terrain during a forced landing approximately 15 miles north-northwest of Vacaville, California. The airline transport pilot and his passenger were not injured. The aircraft was owned, operated and constructed by the pilot. The local area personal flight was conducted under 14 CFR part 91 and originated at Vacaville about 1310. Visual meteorological conditions prevailed and no flight plan was filed. The pilot stated he was selling the aircraft. He departed his home base of hanford, California, about 1030 that morning and arrived in Vacaville approximately 1 hour 15 minutes later. He flew the 1/2-hour demonstration flight from Vacaville and encountered no problems. He wanted to take a friend, who had helped him build the aircraft, up for a local flight. He departed Vacaville at 1310 and had been flying for 20 to 25 minutes when he detected a faint metallic clicking sound coming from the engine. The sound grew louder and he detected a noticeable loss of thrust. This was followed by loud metallic sounds, and white smoke was observed in the cockpit. The smoke smelled like oil and was cleared by opening the fresh air vents. The propeller kept spinning a short while; then the engine seized. He tried to turn it with the starter, but it would not turn. He was over rough terrain so he glided to a spot on the shoreline of lake berryessa. Impact with the uneven terrain collapsed the nose wheel. The front of the aircraft sustained impact damage and the firewall was buckled. The left wing was wrinkled and the empennage was buckled under the left horizontal stabilizer. Several engine pieces were along the wreckage path. The aircraft and its Lycoming O-360 engine had accumulated a total time of approximately 70 hours. (-4) on February 26, 1999, about 1330 hours pacific standard time, an experimental vans cooper RV-6, N36VR, sustained substantial damage when it collided with terrain during a forced landing approximately 15 miles north-northwest of Vacaville, California. The airline transport pilot and his passenger were not injured. The aircraft was owned, operated, and constructed by the pilot. The local area personal flight was conducted under 14 CFR part 91 and originated at Vacaville about 1310. Visual meteorological conditions prevailed and no flight plan was filed. The pilot stated he was selling the aircraft. He departed his home base of hanford, California, about 1030 that morning and arrived in Vacaville approximately 1 hour 15 minutes later. He flew the 1/2-hour demonstration flight from Vacaville and encountered no problems. He wanted to take a friend, who had helped him build the aircraft, up for a local flight. He departed Vacaville at 1310 and had been flying for 20 to 25 minutes when he detected a faint metallic clicking sound coming from the engine. The sound grew l ouder and he detected a noticeable loss of thrust. This was followed by loud metallic sounds, and white smoke was observed in the cockpit. The smoke smelled like oil and was cleared by opening the fresh air vents. The propeller kept spinning a short while; then the engine seized. He tried to turn it with the starter, but it would not turn. He was over rough terrain so he glided to a spot on the shoreline of lake berryessa. Impact with the uneven terrain collapsed the nose wheel. The front of the airplane sustained empact damage and the firewall was buckled. The left wing was wrinkled and the empennage buckled under the left horizontal stabilizer. Several engine pieces were found along the wreckage path. The engine was a Textron Lycoming 0-360, s/n L-8649-36A. The engine was assembled by a specialty shop, which catered to the homebuilt airplane market. A review of logbook entries revealed that maintenance releases were obtained from FAA certified repair stations for the engine case, crankshaft, and camshaft. The shop installed new pistons, rings, exhaust valves, rod bolts and nuts, oil pump gears, piston pins, bearings, and other miscellaneous keepers and bolts. The assembler signed the engine off as ready to run in. The owner installed the engine in the airplane and accululated a total time of approx. 70 hours prior to the mishap. The safety board investigator inspected the engine on April 22, 1999, at a hangar in hanford, CA. The owner provided one cam followeder and one valve lifter that he recovered in the debris field about 50 feet behind the airplane. The investigator removed the cowling. He observed the no. 2 rod cap, a rod bolt piece with a nut on it, and two pieces of bearing material lying on the bottom right side of the lower cowling. The nut only engaged two threads of the bolt and the investigator could easily turn the nut with his fingers. The top of the case had two large sections missing and the bottom of the case had a section missing at cylinder no. 3. The connecting rods for cylinders 2 and 4 were leaning on the camshaft. The connecting rods and their bearings were not discolored. The camshaft was not discolored. The crankshaft did not exhibit any discoloration or mechanical damage. The investigator removed cylinders nos. 1, 2, and 4. Cylinder no. 1'S valves were seated, the rings rotated freely, and the piston was not mechanically damaged or discolored. This was the only cylinder that had its connecting rod attached to the crankshaft. However, the nuts on the connecting rod were finger tight. The investigator was unable to remove cylinder number three. The piston remained in the top portion of the cylinder barrel. The piston pin boss fractured in an irregular pattern and the piston pin was missing. All of the spark plugs were oily. Their electrodes were circular, the gaps were similar, and none exhibited any mechanical damage. The oil sump had a hole in the front side. The investigator removed the sump and found that it contained a connecting rod, wrist pin, bearings, may pieces of metal debris, and several rod cap bolts and nuts. None of the rod cap bolts in the sump were intact. They all were bent, fractured, and separated approx. at their midpoint. The pieces were covered with oil. The number one intake tube inside the sump had a hole that was 4 inches long around half of its diameter. Cylinders nos. 1,2 and 4, were retained by the investigator. He also retained all conmnecting rods, rod caps, connecting rod nuts and bolts, and bearing that he found. He delivered these pieces to seal labatories in el segundo, CA., for metallurgical examination and analysis . The following is a summary of their findings. The lab arbitrarily assigned numbers to the pieces. They assigned H-1 to stand for the head of bolt 1, B01 to stand for the body of bolt 1, and N-1 to stand for nut 1. Among the various nuts retrieved, they could positively match only three bolt bodies to the corresponding head or nut. These included H-1, B-1; B-2, N-2; and H-3, B-3. They observed flattened and polished threads on B-1, B-2, B-3, B-4, and B-5. They stated that these markings are an indication that the bolt was loose within its fixture. The report stated the fracture surfaces of B-1 and B-3 indicated overload, and the fracture surfaces of B-4 and B05 resembled overload. The fracture surface of B-2 showed fatrigue followed by overload. They inspected the fracture surfaces for the bolts under a scanning electon miscroscope (sem). Bolts B-1, B-4, and B-5 indicatedd the presence of ductile overload fracture. One section of B-4 also exhibited evidence of some shearing during fracture. Bolt B-3 had three areas that exhibited ductile overload; one area also exhibited some shearing, and the other some sh earing or rubbing. They examined three areas on the fracture surface of bolt B-2. One area indicated ductile overload fracture. The second area exhibited some characteristics of fatigue including multiple crack origins, indicative of high stress low cycle fatigue and fatigue striations. The third area revealed evidence of fatigue striations. The fatigue area contained some secondary cracks, which indicated high stress. This fracture surface resembled low cycle-high stress reverse bending fatigue followed by ductile overload. They made no observations for the fracture surface on H-10 due to the severity of the damage. Head H-10 remained in the rod cap for cylinder number three. The fracture surface on H-12 indicated overload, while the fracture surface for H-11 indicated fatigue followed by overload. They inspected the fracture surfaces for the heads under the sem. They examined four areas on H-1. Three areas indicated ductile overload fracture. The fourth area exhibited a duectile overload fracture containing some shearing and mechanical damage by rubbing. Head H-3 indicatedd ductile overload fractures. Theyexamined three areas on H-11. Two areas contained features characteristic of fatigue including multiple crack origins. They could not distinguish the mode of fracture for the third surface. The remaining surface was contaminated; howver, it revealed a ductile overload fracture. This fracture surface resembled reverse bending fatigue followed by ductile overload fracture. They thought this head was the mating fracture surface to B-2. Head H-12 displayed an area with features of a ductile overload fracture; severe rubbing prevented determination of the fracture mode on another area. Nut N-2 sustained slight damage; its threads appeared to be mostly undamaged. Nut N-6 sheared and sustained severe damage. The threads sustained damage, but appeared flattened. Severe damage prevented inspection fo the fracture surface. Nut N-7 sustained damage and was out of round. It had flattened threads on one end of the nut indicated a loose fit on the bolt. Nut N-8 sustained slight outside surface damage, and the threads appeared to be mostly undamaged. The outside surface of N-9 contained slight secondary damage. They observed severe flattening on one end of the threads; the remaining thread exhibited some secondary damage. They observed nut N-6 under the sem. They examined three areas. They determined all three areas fractured due to ductile overload, and that one area had some secondary damage. They performed a rockwell "c" hardness test for all of the bolts. The values were consistent. The values ranged from 36 to 40. The lab summarized its findings and conclusions and opined that the evidence strongly suggested that the nuts were not tightened on the connecting rod bolts. A thread section from a bolt that corresponded to the head of the bolt from cylinder number two exhibited failure characteristics of low cycle-high stress reverse bending fatigue. Reverse bending fatigue is indicative of an under-torqued bolt. The inspection revealed additional evidence that some of the runwa were not tightened to specifications. Some bolts had flattened and polished bolt threads, as well as wear marks on the bolt's outer diameters. Some nut threads were flattened on only one end. No fractured bolt had a nut on it except the fatigued bolt.

As the FAA filed it

ACFT EXPERIENCED ENGINE FAILURE AND CRASH-LANDED ALONG THE SHOELINE OF LAKE BERRYESSA, OTHER CIRCUMSTANCES ARE UNKNOWN. (.19) ON FEBRUARY 26, 1999, ABOUT 1330 HOURS PACIFIC STANDARD TIME, AN EXPERIMENTAL VANS COOPER RV-6, N36VR, SUSTAINED SUBSTANTIAL DAMAGE WHEN IT COLLIDED WITH TERRAIN DURING A FORCED LANDING APPROXIMATELY 15 MILES NORTH-NORTHWEST OF VACAVILLE, CALIFORNIA. THE AIRLINE TRANSPORT PILOT AND HIS PASSENGER WERE NOT INJURED. THE AIRCRAFT WAS OWNED, OPERATED AND CONSTRUCTED BY THE PILOT. THE LOCAL AREA PERSONAL FLIGHT WAS CONDUCTED UNDER 14 CFR PART 91 AND ORIGINATED AT VACAVILLE ABOUT 1310. VISUAL METEOROLOGICAL CONDITIONS PREVAILED AND NO FLIGHT PLAN WAS FILED. THE PILOT STATED HE WAS SELLING THE AIRCRAFT. HE DEPARTED HIS HOME BASE OF HANFORD, CALIFORNIA, ABOUT 1030 THAT MORNING AND ARRIVED IN VACAVILLE APPROXIMATELY 1 HOUR 15 MINUTES LATER. HE FLEW THE 1/2-HOUR DEMONSTRATION FLIGHT FROM VACAVILLE AND ENCOUNTERED NO PROBLEMS. HE WANTED TO TAKE A FRIEND, WHO HAD HELPED HIM BUILD THE AIRCRAFT, UP FOR A LOCAL FLIGHT. HE DEPARTED VACAVILLE AT 1310 AND HAD BEEN FLYING FOR 20 TO 25 MINUTES WHEN HE DETECTED A FAINT METALLIC CLICKING SOUND COMING FROM THE ENGINE. THE SOUND GREW LOUDER AND HE DETECTED A NOTICEABLE LOSS OF THRUST. THIS WAS FOLLOWED BY LOUD METALLIC SOUNDS, AND WHITE SMOKE WAS OBSERVED IN THE COCKPIT. THE SMOKE SMELLED LIKE OIL AND WAS CLEARED BY OPENING THE FRESH AIR VENTS. THE PROPELLER KEPT SPINNING A SHORT WHILE; THEN THE ENGINE SEIZED. HE TRIED TO TURN IT WITH THE STARTER, BUT IT WOULD NOT TURN. HE WAS OVER ROUGH TERRAIN SO HE GLIDED TO A SPOT ON THE SHORELINE OF LAKE BERRYESSA. IMPACT WITH THE UNEVEN TERRAIN COLLAPSED THE NOSE WHEEL. THE FRONT OF THE AIRCRAFT SUSTAINED IMPACT DAMAGE AND THE FIREWALL WAS BUCKLED. THE LEFT WING WAS WRINKLED AND THE EMPENNAGE WAS BUCKLED UNDER THE LEFT HORIZONTAL STABILIZER. SEVERAL ENGINE PIECES WERE ALONG THE WRECKAGE PATH. THE AIRCRAFT AND ITS LYCOMING O-360 ENGINE HAD ACCUMULATED A TOTAL TIME OF APPROXIMATELY 70 HOURS. (-4) ON FEBRUARY 26, 1999, ABOUT 1330 HOURS PACIFIC STANDARD TIME, AN EXPERIMENTAL VANS COOPER RV-6, N36VR, SUSTAINED SUBSTANTIAL DAMAGE WHEN IT COLLIDED WITH TERRAIN DURING A FORCED LANDING APPROXIMATELY 15 MILES NORTH-NORTHWEST OF VACAVILLE, CALIFORNIA. THE AIRLINE TRANSPORT PILOT AND HIS PASSENGER WERE NOT INJURED. THE AIRCRAFT WAS OWNED, OPERATED, AND CONSTRUCTED BY THE PILOT. THE LOCAL AREA PERSONAL FLIGHT WAS CONDUCTED UNDER 14 CFR PART 91 AND ORIGINATED AT VACAVILLE ABOUT 1310. VISUAL METEOROLOGICAL CONDITIONS PREVAILED AND NO FLIGHT PLAN WAS FILED. THE PILOT STATED HE WAS SELLING THE AIRCRAFT. HE DEPARTED HIS HOME BASE OF HANFORD, CALIFORNIA, ABOUT 1030 THAT MORNING AND ARRIVED IN VACAVILLE APPROXIMATELY 1 HOUR 15 MINUTES LATER. HE FLEW THE 1/2-HOUR DEMONSTRATION FLIGHT FROM VACAVILLE AND ENCOUNTERED NO PROBLEMS. HE WANTED TO TAKE A FRIEND, WHO HAD HELPED HIM BUILD THE AIRCRAFT, UP FOR A LOCAL FLIGHT. HE DEPARTED VACAVILLE AT 1310 AND HAD BEEN FLYING FOR 20 TO 25 MINUTES WHEN HE DETECTED A FAINT METALLIC CLICKING SOUND COMING FROM THE ENGINE. THE SOUND GREW L OUDER AND HE DETECTED A NOTICEABLE LOSS OF THRUST. THIS WAS FOLLOWED BY LOUD METALLIC SOUNDS, AND WHITE SMOKE WAS OBSERVED IN THE COCKPIT. THE SMOKE SMELLED LIKE OIL AND WAS CLEARED BY OPENING THE FRESH AIR VENTS. THE PROPELLER KEPT SPINNING A SHORT WHILE; THEN THE ENGINE SEIZED. HE TRIED TO TURN IT WITH THE STARTER, BUT IT WOULD NOT TURN. HE WAS OVER ROUGH TERRAIN SO HE GLIDED TO A SPOT ON THE SHORELINE OF LAKE BERRYESSA. IMPACT WITH THE UNEVEN TERRAIN COLLAPSED THE NOSE WHEEL. THE FRONT OF THE AIRPLANE SUSTAINED EMPACT DAMAGE AND THE FIREWALL WAS BUCKLED. THE LEFT WING WAS WRINKLED AND THE EMPENNAGE BUCKLED UNDER THE LEFT HORIZONTAL STABILIZER. SEVERAL ENGINE PIECES WERE FOUND ALONG THE WRECKAGE PATH. THE ENGINE WAS A TEXTRON LYCOMING 0-360, S/N L-8649-36A. THE ENGINE WAS ASSEMBLED BY A SPECIALTY SHOP, WHICH CATERED TO THE HOMEBUILT AIRPLANE MARKET. A REVIEW OF LOGBOOK ENTRIES REVEALED THAT MAINTENANCE RELEASES WERE OBTAINED FROM FAA CERTIFIED REPAIR STATIONS FOR THE ENGINE CASE, CRANKSHAFT, AND CAMSHAFT. THE SHOP INSTALLED NEW PISTONS, RINGS, EXHAUST VALVES, ROD BOLTS AND NUTS, OIL PUMP GEARS, PISTON PINS, BEARINGS, AND OTHER MISCELLANEOUS KEEPERS AND BOLTS. THE ASSEMBLER SIGNED THE ENGINE OFF AS READY TO RUN IN. THE OWNER INSTALLED THE ENGINE IN THE AIRPLANE AND ACCULULATED A TOTAL TIME OF APPROX. 70 HOURS PRIOR TO THE MISHAP. THE SAFETY BOARD INVESTIGATOR INSPECTED THE ENGINE ON APRIL 22, 1999, AT A HANGAR IN HANFORD, CA. THE OWNER PROVIDED ONE CAM FOLLOWEDER AND ONE VALVE LIFTER THAT HE RECOVERED IN THE DEBRIS FIELD ABOUT 50 FEET BEHIND THE AIRPLANE. THE INVESTIGATOR REMOVED THE COWLING. HE OBSERVED THE NO. 2 ROD CAP, A ROD BOLT PIECE WITH A NUT ON IT, AND TWO PIECES OF BEARING MATERIAL LYING ON THE BOTTOM RIGHT SIDE OF THE LOWER COWLING. THE NUT ONLY ENGAGED TWO THREADS OF THE BOLT AND THE INVESTIGATOR COULD EASILY TURN THE NUT WITH HIS FINGERS. THE TOP OF THE CASE HAD TWO LARGE SECTIONS MISSING AND THE BOTTOM OF THE CASE HAD A SECTION MISSING AT CYLINDER NO. 3. THE CONNECTING RODS FOR CYLINDERS 2 AND 4 WERE LEANING ON THE CAMSHAFT. THE CONNECTING RODS AND THEIR BEARINGS WERE NOT DISCOLORED. THE CAMSHAFT WAS NOT DISCOLORED. THE CRANKSHAFT DID NOT EXHIBIT ANY DISCOLORATION OR MECHANICAL DAMAGE. THE INVESTIGATOR REMOVED CYLINDERS NOS. 1, 2, AND 4. CYLINDER NO. 1'S VALVES WERE SEATED, THE RINGS ROTATED FREELY, AND THE PISTON WAS NOT MECHANICALLY DAMAGED OR DISCOLORED. THIS WAS THE ONLY CYLINDER THAT HAD ITS CONNECTING ROD ATTACHED TO THE CRANKSHAFT. HOWEVER, THE NUTS ON THE CONNECTING ROD WERE FINGER TIGHT. THE INVESTIGATOR WAS UNABLE TO REMOVE CYLINDER NUMBER THREE. THE PISTON REMAINED IN THE TOP PORTION OF THE CYLINDER BARREL. THE PISTON PIN BOSS FRACTURED IN AN IRREGULAR PATTERN AND THE PISTON PIN WAS MISSING. ALL OF THE SPARK PLUGS WERE OILY. THEIR ELECTRODES WERE CIRCULAR, THE GAPS WERE SIMILAR, AND NONE EXHIBITED ANY MECHANICAL DAMAGE. THE OIL SUMP HAD A HOLE IN THE FRONT SIDE. THE INVESTIGATOR REMOVED THE SUMP AND FOUND THAT IT CONTAINED A CONNECTING ROD, WRIST PIN, BEARINGS, MAY PIECES OF METAL DEBRIS, AND SEVERAL ROD CAP BOLTS AND NUTS. NONE OF THE ROD CAP BOLTS IN THE SUMP WERE INTACT. THEY ALL WERE BENT, FRACTURED, AND SEPARATED APPROX. AT THEIR MIDPOINT. THE PIECES WERE COVERED WITH OIL. THE NUMBER ONE INTAKE TUBE INSIDE THE SUMP HAD A HOLE THAT WAS 4 INCHES LONG AROUND HALF OF ITS DIAMETER. CYLINDERS NOS. 1,2 AND 4, WERE RETAINED BY THE INVESTIGATOR. HE ALSO RETAINED ALL CONMNECTING RODS, ROD CAPS, CONNECTING ROD NUTS AND BOLTS, AND BEARING THAT HE FOUND. HE DELIVERED THESE PIECES TO SEAL LABATORIES IN EL SEGUNDO, CA., FOR METALLURGICAL EXAMINATION AND ANALYSIS . THE FOLLOWING IS A SUMMARY OF THEIR FINDINGS. THE LAB ARBITRARILY ASSIGNED NUMBERS TO THE PIECES. THEY ASSIGNED H-1 TO STAND FOR THE HEAD OF BOLT 1, B01 TO STAND FOR THE BODY OF BOLT 1, AND N-1 TO STAND FOR NUT 1. AMONG THE VARIOUS NUTS RETRIEVED, THEY COULD POSITIVELY MATCH ONLY THREE BOLT BODIES TO THE CORRESPONDING HEAD OR NUT. THESE INCLUDED H-1, B-1; B-2, N-2; AND H-3, B-3. THEY OBSERVED FLATTENED AND POLISHED THREADS ON B-1, B-2, B-3, B-4, AND B-5. THEY STATED THAT THESE MARKINGS ARE AN INDICATION THAT THE BOLT WAS LOOSE WITHIN ITS FIXTURE. THE REPORT STATED THE FRACTURE SURFACES OF B-1 AND B-3 INDICATED OVERLOAD, AND THE FRACTURE SURFACES OF B-4 AND B05 RESEMBLED OVERLOAD. THE FRACTURE SURFACE OF B-2 SHOWED FATRIGUE FOLLOWED BY OVERLOAD. THEY INSPECTED THE FRACTURE SURFACES FOR THE BOLTS UNDER A SCANNING ELECTON MISCROSCOPE (SEM). BOLTS B-1, B-4, AND B-5 INDICATEDD THE PRESENCE OF DUCTILE OVERLOAD FRACTURE. ONE SECTION OF B-4 ALSO EXHIBITED EVIDENCE OF SOME SHEARING DURING FRACTURE. BOLT B-3 HAD THREE AREAS THAT EXHIBITED DUCTILE OVERLOAD; ONE AREA ALSO EXHIBITED SOME SHEARING, AND THE OTHER SOME SH EARING OR RUBBING. THEY EXAMINED THREE AREAS ON THE FRACTURE SURFACE OF BOLT B-2. ONE AREA INDICATED DUCTILE OVERLOAD FRACTURE. THE SECOND AREA EXHIBITED SOME CHARACTERISTICS OF FATIGUE INCLUDING MULTIPLE CRACK ORIGINS, INDICATIVE OF HIGH STRESS LOW CYCLE FATIGUE AND FATIGUE STRIATIONS. THE THIRD AREA REVEALED EVIDENCE OF FATIGUE STRIATIONS. THE FATIGUE AREA CONTAINED SOME SECONDARY CRACKS, WHICH INDICATED HIGH STRESS. THIS FRACTURE SURFACE RESEMBLED LOW CYCLE-HIGH STRESS REVERSE BENDING FATIGUE FOLLOWED BY DUCTILE OVERLOAD. THEY MADE NO OBSERVATIONS FOR THE FRACTURE SURFACE ON H-10 DUE TO THE SEVERITY OF THE DAMAGE. HEAD H-10 REMAINED IN THE ROD CAP FOR CYLINDER NUMBER THREE. THE FRACTURE SURFACE ON H-12 INDICATED OVERLOAD, WHILE THE FRACTURE SURFACE FOR H-11 INDICATED FATIGUE FOLLOWED BY OVERLOAD. THEY INSPECTED THE FRACTURE SURFACES FOR THE HEADS UNDER THE SEM. THEY EXAMINED FOUR AREAS ON H-1. THREE AREAS INDICATED DUCTILE OVERLOAD FRACTURE. THE FOURTH AREA EXHIBITED A DUECTILE OVERLOAD FRACTURE CONTAINING SOME SHEARING AND MECHANICAL DAMAGE BY RUBBING. HEAD H-3 INDICATEDD DUCTILE OVERLOAD FRACTURES. THEYEXAMINED THREE AREAS ON H-11. TWO AREAS CONTAINED FEATURES CHARACTERISTIC OF FATIGUE INCLUDING MULTIPLE CRACK ORIGINS. THEY COULD NOT DISTINGUISH THE MODE OF FRACTURE FOR THE THIRD SURFACE. THE REMAINING SURFACE WAS CONTAMINATED; HOWVER, IT REVEALED A DUCTILE OVERLOAD FRACTURE. THIS FRACTURE SURFACE RESEMBLED REVERSE BENDING FATIGUE FOLLOWED BY DUCTILE OVERLOAD FRACTURE. THEY THOUGHT THIS HEAD WAS THE MATING FRACTURE SURFACE TO B-2. HEAD H-12 DISPLAYED AN AREA WITH FEATURES OF A DUCTILE OVERLOAD FRACTURE; SEVERE RUBBING PREVENTED DETERMINATION OF THE FRACTURE MODE ON ANOTHER AREA. NUT N-2 SUSTAINED SLIGHT DAMAGE; ITS THREADS APPEARED TO BE MOSTLY UNDAMAGED. NUT N-6 SHEARED AND SUSTAINED SEVERE DAMAGE. THE THREADS SUSTAINED DAMAGE, BUT APPEARED FLATTENED. SEVERE DAMAGE PREVENTED INSPECTION FO THE FRACTURE SURFACE. NUT N-7 SUSTAINED DAMAGE AND WAS OUT OF ROUND. IT HAD FLATTENED THREADS ON ONE END OF THE NUT INDICATED A LOOSE FIT ON THE BOLT. NUT N-8 SUSTAINED SLIGHT OUTSIDE SURFACE DAMAGE, AND THE THREADS APPEARED TO BE MOSTLY UNDAMAGED. THE OUTSIDE SURFACE OF N-9 CONTAINED SLIGHT SECONDARY DAMAGE. THEY OBSERVED SEVERE FLATTENING ON ONE END OF THE THREADS; THE REMAINING THREAD EXHIBITED SOME SECONDARY DAMAGE. THEY OBSERVED NUT N-6 UNDER THE SEM. THEY EXAMINED THREE AREAS. THEY DETERMINED ALL THREE AREAS FRACTURED DUE TO DUCTILE OVERLOAD, AND THAT ONE AREA HAD SOME SECONDARY DAMAGE. THEY PERFORMED A ROCKWELL "C" HARDNESS TEST FOR ALL OF THE BOLTS. THE VALUES WERE CONSISTENT. THE VALUES RANGED FROM 36 TO 40. THE LAB SUMMARIZED ITS FINDINGS AND CONCLUSIONS AND OPINED THAT THE EVIDENCE STRONGLY SUGGESTED THAT THE NUTS WERE NOT TIGHTENED ON THE CONNECTING ROD BOLTS. A THREAD SECTION FROM A BOLT THAT CORRESPONDED TO THE HEAD OF THE BOLT FROM CYLINDER NUMBER TWO EXHIBITED FAILURE CHARACTERISTICS OF LOW CYCLE-HIGH STRESS REVERSE BENDING FATIGUE. REVERSE BENDING FATIGUE IS INDICATIVE OF AN UNDER-TORQUED BOLT. THE INSPECTION REVEALED ADDITIONAL EVIDENCE THAT SOME OF THE RUNWA WERE NOT TIGHTENED TO SPECIFICATIONS. SOME BOLTS HAD FLATTENED AND POLISHED BOLT THREADS, AS WELL AS WEAR MARKS ON THE BOLT'S OUTER DIAMETERS. SOME NUT THREADS WERE FLATTENED ON ONLY ONE END. NO FRACTURED BOLT HAD A NUT ON IT EXCEPT THE FATIGUED BOLT.

NTSB investigation

The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.