CEN10LA140

NTSB accident investigation · Beech A36 · Slaton, TX · March 5, 2010

Accident · Minor injuriesLimited investigationFinal report
Date
March 5, 2010, 16:30 local (22:30 UTC)
Place
Slaton, TX
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N2036YBeech A36
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 12, 2011
Report
Approved by Office Director
NTSB office
Central Region
Parties
Teledyne Continental Motors, Inc, FAA Lubbock FSDO
FAA report
20100305028579A
Case key
75453

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 loss of engine power due to the insufficient clamping force between the two crankcase halves and each cylinder to the crankcase.

Findings · 1

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · MalfunctionBeech A36: 5 casesAll aircraft: 373 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

While at 5,500 feet mean sea level, the pilot heard a loud explosion and the left front engine cowling blew open. Shortly thereafter the engine stopped producing power and the pilot executed a forced landing to a flat plowed field. The No. 2 cylinder was found separated from the engine crankcase. A postaccident engine teardown examination revealed that there had been an insufficient clamping force between the crankcase halves and between each cylinder and the crankcase. In particular, the No. 2 crankcase cylinder deck exhibited signatures consistent with the No. 2 cylinder vibrating back and forth before it exited the engine case. At the time of the accident, the engine had accumulated approximately 1,072 hours since major overhaul and 641 hours since a top overhaul.

Factual narrative

On March 5, 2010, about 1630 central standard time, a single-engine, Beech A36 airplane, N2036Y, was substantially damaged during a forced landing following a total loss of engine power while in cruise fight near Slaton, Texas. The private pilot, the sole occupant, sustained minor injuries. The airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed and a flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The 256 mile cross-country flight departed the Lubbock Preston Smith International Airport (LBB), Lubbock, Texas, about 1620 with the Dallas Executive Airport (RBD), Dallas, Texas, as the intended destination. According to the pilot, while at 5,500 feet, he heard a “loud explosion” and the left front engine cowling blew open. Shortly thereafter, oil appeared on the windscreen and the engine stopped producing power. The pilot executed a forced landing to a flat plowed field. The airplane’s left wing separated at impact and the airplane came to rest in a nose down, but upright position. The pilot was able to exit the airplane unassisted. The Federal Aviation Administration (FAA) inspector who responded to the accident site reported, that the engine’s #2 cylinder was found separated from the engine crankcase. The engine, a Teledyne Continental Motors (TCM), IO-550-B-12B, serial number 271728-R, was examined at TCM in Mobile, Alabama. Oversight was provided by the NTSB investigator-in-charge (IIC). The examination revealed that all crankcase main bearing surfaces, except for #5, exhibited fretting wear. In addition, the crankcase cylinder decks exhibited wear patterns consistent with movement between all cylinders and the crankcase. Additionally, the crankcase exhibited signatures consistent with the #2 cylinder rocking back and forth before it exited the engine case. The #2 piston to crankshaft connecting rod cap was found separated from the connecting rod. The #2 piston pin had been pulled through the lower section of piston, suggesting that the connecting rod to crankshaft separation was a secondary failure. A review of the engine logbook revealed that the engine was overhauled on March 29, 2002. At the time of the accident, the engine had accumulated approximately 1,072 hours since major overhaul and 641 hours since a top overhaul. On May 29, 1992, TCM issued Service Bulletin (SB) M92-9, which was applicable to all Continental 470’s, 520’s, and 550’s. This SB instructed that “at overhaul or when necessary … a 12 point nut must be used … and torqued to 790 – 810 inch lbs.” The accident engine was equipped with the earlier 6 point nuts which had a required torque of 690 – 710 in lbs. This nut is used on the crankcase through bolts and to secure the cylinders to the crankcase. It was also noted that the SB was not mandatory since the airplane was being operated under 14 Code of Federal Regulations Part 91.

Aircraft

Registration
N2036Y
Reported as
Beech A36
Category
Airplane
Serial number
E-1366
Airframe hours
5,834
Engine
Cont Motor IO 550-B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Gale Donald H
Registered owner
Gale Donald H
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 1, 2009 · 77 hours before
Departed
LBB · Lubbock, TX
Destination
RBD · Dallas, TX

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
69
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
March 28, 2009
Seat
Left
Flight hours
3,500 total · 1,800 in this make and model · 30 in the last 90 days · 11 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 36 °F
Altimeter
29.88 inHg
Observed at
LBB, 16 nm away

Docket · 2

The files NTSB released with the investigation on October 26, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.