# NTSB BFO93FA131: Beech C33A, N3722Q, Paintsville, KY, July 20, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 20, 1993, 15:30 local (19:30 UTC) - Place: Paintsville, KY - Coordinates: 37.809772, -82.799308 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.8098&lon=-82.7993&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 30, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 8754 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO93FA131 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8754/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8754 - Page: https://openairdocs.org/ntsb/BFO93FA131 ## Probable cause 1) FATIGUE FAILURE OF THE ENGINE CRANKSHAFT AT THE NUMBER 2 MAIN JOURNAL DUE TO UNDETERMINED REASON (S) WHICH RESULTED IN THE TOTAL LOSS OF ENGINE POWER, AND 2) THE PILOT NOT MAINTAINING AN ADEQUATE AIRSPEED WHICH RESULTED IN AN INADVERTENT STALL/SPIN. A FACTOR IN THIS ACCIDENT WAS INADEQUATE ALTITUDE FOR THE PILOT TO RECOVER FROM THE STALL/SPIN. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, cruise - normal - engine assembly,crankshaft - fatigue (cause) - reason for occurrence undetermined (cause) - Forced landing, descent - emergency - In flight collision with terrain/water, landing - airspeed - inadequate, pilot in command (cause) - stall/spin - inadvertent, pilot in command (cause) - altitude - inadequate (contributing factor) - remedial action - not possible, pilot in command (contributing factor) - terrain condition - runway ## Analysis ACCORDING TO FAA PROVIDED TRANSCRIPTS OF COMMUNICATIONS THE AIRPLANE WAS AT CRUISE FLIGHT OF 10,000 FEET ABOVE MEAN SEA LEVEL AND 10 MILES SOUTHWEST OF THE AIRPORT WHEN THE PILOT REPORTED HE HAD LOST ENGINE POWER, AND REQUESTED THE NEAREST AIRPORT. INDIANAPOLIS AIR ROUTE TRAFFIC CONTROL CENTER CONTROLLER GAVE THE PILOT VECTORS TO THE AIRPORT. THE PILOT REPORTED HE HAD THE AIRPORT IN SIGHT AND THAT HE WOULD ATTEMPT TO LAND ON RUNWAY 31. A WITNESS REPORTED THAT HE SAW THE AIRPLANE MAKE A STEEP TURN AND THEN IT FELL TO THE GROUND. THE AIRPORT IS SITUATED IN A MOUNTAIN VALLEY WITH 500 FOOT HILLS ON BOTH SIDES. THE AIRPLANE IMPACTED ON RUNWAY 13 AND WAS DESTROYED BY POST IMPACT FORCES AND POST IMPACT FIRE. AN EXAMINATION OF THE ENGINE REVEALED A BROKEN CRANKSHAFT. THE CRANKSHAFT WAS REMOVED AND SENT TO THE NTSB LAB IN WASHINGTON, DC. A METALLURGICAL EXAMINATION REVEALED THE CRANKSHAFT HAD FAILED WHERE A FATIGUE CRACK HAD INITIATED ON THE SURFACE OF THE AFT RADIUS OF THE #2 MAIN JOURNAL. ## Factual narrative HISTORY OF FLIGHT On Tuesday, July 20, 1993, at 1530 eastern daylight time, N3722Q, a Beech C33A, operated by C & D Enterprises of Nashville, Tennessee, and piloted by Milton Cashion of Nashville, collided with runway 13 while on final approach during a power-off forced landing at Combs Field, Paintsville, Kentucky. Visual meteorological conditions prevailed and an Instrument Flight Rules (IFR) flight plan had been filed. The certificated commercial pilot was fatally injured. The aircraft was destroyed . The flight was conducted under 14 CFR 91 and originated at 1422 hours in Westfield, Massachusetts and was destined for Nashville. According to FAA provided transcripts of communications, when the airplane was at cruise flight of 10,000 feet above mean sea level, and 10 miles southwest of Paintsville, the pilot reported, " I just lost an engine and need an airport." Indianapolis Air Route Traffic Control Center controller gave the pilot vectors to Combs Field Airport, Paintsville. The pilot reported the airport in sight and that he would attempt a landing on runway 31. The airplane impacted on runway 13 about 500 feet from the approach end, and was destroyed by impact forces and a post impact fire. A witness who was in his backyard across the street from the runway reported that, "he saw an airplane coming down the runway as to make a normal landing, but we noticed the propeller was not turning." He stated that the airplane make a steep right turn, then it fell to the ground. The airport is situated in a mountain valley with 500 foot hills on both sides. The accident occurred during the hours of daylight, at 37 degrees 44.76 minutes North and 82 degrees 46.74 minutes West. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with single engine and multiengine land ratings. According to FAA records, the pilot's total flight time listed by him on his last FAA medical certificate was " over 4000 hours." AIRCRAFT INFORMATION The 1967 year model Beech C33A airplane, serial no. CE129 was equipped with a Continental IO 520BA engine, serial no. 121210 6 BA. According to the engine log book, the airplane had accumulated over 2497 hours of total flight time. This time was recorded on the last 100 hour inspection that was completed on August 18, 1992. The engine had accumulated over 1600 since major overhaul. METEOROLOGICAL INFORMATION The 1454 hours surface weather observation for Julian Carroll Airport, about 25 miles west of the accident site was as follows: Sky condition, 2500 feet scattered; visibility, 10 miles; temperature, 89 degrees (F); dew point, 67 degrees (F); wind condition, 290 degrees at 6 knots; and altimeter, 30.10 inches. WRECKAGE AND IMPACT INFORMATION The airplane impacted the runway separating the right tip tank. Examination of the accident site revealed the scatterpath was oriented on a magnetic bearing of 105 degrees. The initial ground scar was 500 feet from the threshold of runway 13. The scar was two feet in length and about 18 inches wide. Small fragments of green glass were found in the scar along with fiberglass fragments of white and red paint. About 22 feet from the initial impact point (IIP) was a one foot deep crater about two feet in diameter. The main wreckage was found about 56 feet from the IIP. Most of the airplane had been consumed in the post-crash fire. The airframe remained intact with all the major components in place, with the exception of the right tip tank which was located near the left tip tank, and the propeller forward of the engine. Both wings were damaged by fire. The left tip tank remained attached to the wing. The right tip tank had separated and was outside the area of the fire. About 1 gallon of fuel was found in the right tip tank. The empennage was intact. Flight control cable continuity was established to the left aileron in the left wing and to the right aileron bellcrank in the right wing. Continuity was also established to the rudder, both elevators, and both elevator trim tabs in the aft fuselage. The left elevator trim tab actuator measured 36 mm which according to Beech Aircraft engineering data corresponded to a trim setting of 4.6 degrees tab down. The right actuator measured 35 mm which corresponded to a trim setting of 3.3 degrees tab down. The landing gear actuator was consumed by fire. The position of the landing gear retract rods relative to the position of the actuator shaft indicated that the landing gear was extended at impact. The position of the roller in both the left and right inboard flap tract indicated the flaps were fully extended. Both flap actuators were consumed by fire. The melted aluminum on both actuators indicted that the flaps were extended. The forward fuselage and instrument panel were destroyed by fire. Examination of the engine revealed it had separated from its mounts. The engine was removed to a hangar at the airport where a teardown was completed under the supervision of the NTSB. The top spark plugs were removed and appeared grayish with the drive coupling intact. Both magnetos produced spark when rotated by hand. When the crankshaft flange was rotated by hand, the accessory drives, camshaft, #1 and #2 pistons revealed evidence of restriction. The crankcase was disassembled. The #2 main bearing was missing, and some of its fragments were found inside the crankcase. Marks on the crankshaft indicated that the #2 main bearing shifted aft. The crankshaft had separated aft of the #2 main journal at the offset for the #2 piston. The two parts of the crankshaft and all the bearings and bearing fragments were removed and sent to the NTSB Lab in Washington, DC for further examination. The examination revealed that the crankshaft failed as the result of fatigue cracking initiating on the surface of the aft radius of the #2 main journal. Details of the crankshaft examination is attached to this report. MEDICAL AND PATHOLOGICAL INFORMATION A Medical Examination was done by the State of Kentucky Office of the Medical Examiner on July 21, 1993. According to the Medical Examiner's report, the pilot died as a result of the injuries received in the accident. Toxicological tests did not detect alcohol, drugs, or carbon monoxide. ADDITIONAL INFORMATION The wreckage was released to Ms. Edna Cashion, the Executrix of the pilot's estate on September 22, 1993. ## Aircraft - Registration: [N3722Q](https://openairdocs.org/deregistered/N3722Q-1999-03-11), registration cancelled 1999-03-11, S/N CE-129 (OpenAirDocs) - Reported make and model: BEECH C33A - Registry model: [Beech 35-C33A](https://openairdocs.org/model/beech-35-c33a) (registry code 1151410) (OpenAirDocs) - Category: Airplane - Serial number: CE129 - Engines: CONTINENTAL IO-520BA 285 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: C & D Enterprises Inc. - Registered owner: C & D Enterprises Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, August 18, 1992 - Departed: BAF, WESTFIELD, MA - Destination: M88, NASHVILLE, TN - Flight plan: IFR - Airport: 3I6, Combs Field, runway 13, 3,200 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 4,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 66 °F - Altimeter: 30.00 inHg - Observed at: JKL, 25 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19930720024809A](https://openairdocs.org/incident/19930720024809A), Jul 20, 1993: Beech 35C33A, Paintsville, KY, Destroyed, 1 fatal. Lost power en route. Appears overshot runway. Tried reserse. Stalled. Hit runway. Crankshaft failed. ## Other investigations on N3722Q (1) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB MIA68D0282](https://openairdocs.org/ntsb/MIA68D0282), Apr 6, 1967: Beech C33A (N3722Q), S.Jose, Serbia, substantial damage ## Docket (18 files) The files NTSB released with the investigation on June 3, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8754. 2.0 MB in all. - Metallurgist Factual Report (item 1, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440153&FileExtension=.PDF&FileName=Metallurgist%20Factual%20Report-Redacted.PDF - Supplement A (item 2, .PDF, 202 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002062&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 3, .PDF, 275 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002063&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Witness Statement (item 4, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440154&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Map of Accident Area (item 5, .PDF, 408 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002065&FileExtension=.PDF&FileName=Map%20of%20Accident%20Area-Master.PDF - Map of Combs Field Airport (item 6, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002066&FileExtension=.PDF&FileName=Map%20of%20%20Combs%20Field%20Airport-Master.PDF - Wreckage Diagram (item 7, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002067&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Air Traffic Control Information (Chronological Summary of Flight, Transcription of Radio Communication) (item 8, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440155&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Information%20%20(Chronological%20Summary%20of%20Flight,%20%20Transcription%20of%20Radio%20Communication)-Redacted.PDF - Weather Report (item 9, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002069&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440156&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440157&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 12, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440158&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. Runway 13. Note crater left of centerline. (item 13, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002073&FileExtension=.PDF&FileName=Photo%201.%20%20Runway%2013.%20%20%20Note%20crater%20left%20of%20centerline.-Master.PDF - Photo 2. Main wreckage left of centerline runway 13. (item 14, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002074&FileExtension=.PDF&FileName=%20Photo%202.%20%20Main%20wreckage%20left%20of%20centerline%20runway%2013.-Master.PDF - Photo 3. View through left handcase at #2 cylinder position showing broken crankshaft. (item 15, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002075&FileExtension=.PDF&FileName=Photo%203.%20%20View%20through%20left%20handcase%20at%20%232%20cylinder%20position%20showing%20broken%20crankshaft.-Master.PDF - Photo 4. Top view of propeller. (item 16, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002076&FileExtension=.PDF&FileName=Photo%204.%20%20Top%20view%20of%20propeller.-Master.PDF - Photo 5. Left side of wreckage. (item 17, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002077&FileExtension=.PDF&FileName=Photo%205.%20%20Left%20side%20of%20wreckage.-Master.PDF - Photo 6. Right side of main wreckage. (item 18, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40002078&FileExtension=.PDF&FileName=Photo%206.%20%20Right%20side%20of%20main%20wreckage.-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.