ATL92LA063

NTSB accident investigation · Beech A36 · Mt. Pleasant, TN · March 15, 1992

Accident · Serious injuriesLimited investigationFinal report
Date
March 15, 1992, 11:45 local (17:45 UTC)
Place
Mt. Pleasant, TN
Injuries
1 serious, 3 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N174ODBeech A36
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 1993
Report
Approved by Office Director
Case key
8572

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The manufacturer's failure to provide adequate torque information which resulted in the loss of torque on the cylinder hold down nuts and the complete loss of engine power.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfCruise
Engine assembly,cylinder - separation
Engine assembly,cylinder - undertorquedCause
Maintenance,overhaul - inadequateManufacturerCause
Procedure inadequateManufacturerCause
Forced landingDescent - emergency
In flight collision with objectDescent - emergency
Object - tree(s)

Analysis

While cruising the engine developed a vibration and started running roughly. The pilot reduced power and established a track for an emergency landing to a nearby county airport; the airplane crashed about one mile short of the airport. Examination of the engine assembly disclosed that a piece of the crankcase was broken above number 2 cylinder and the cylinder was partially secured by one hold down nut on the bottom left side. Further examination revealed fretting between the cylinder flange and the engine case. All crankcase fractures showed signs of overload failure. The engine maintenance logs disclosed that the engine's crankcase had been replaced on 10/24/90; this engine malfunction occurred 258 hours later. Subsequent to this accident, Continental motors issued a service bulletin which increased the torque value for the cylinder hold down nuts, and instructed that the standard six point hold down nuts be replaced with twelve point nuts during overhaul.

Aircraft

Registration
N174OD
Reported as
Beech A36
Category
Airplane
Serial number
E1796
Airframe hours
3,273
Engine
Continental IO-520-BB, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Snyder, Michael C.
Registered owner
Snyder, Michael C.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 7, 1992 · 30 hours before
Departed
HSV · Huntsville, AL
Destination
SPI · Springfield, IL
Airport
MRC · Maury County, runway 5, 5,003 × 75 ft, asphalt

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
53
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
1,420 total · 87 in this make and model · 1,262 as pilot in command · 24 in the last 90 days · 9 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
10° at 15 knots
Visibility
15 statute miles
Lowest ceiling
4,500 ft overcast
Temperature
45 °F, dew point 21 °F
Altimeter
30.00 inHg
Observed at
BNA, 35 nm away