# NTSB CEN10LA140: Beech A36, N2036Y, Slaton, TX, March 5, 2010 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 5, 2010, 16:30 local (22:30 UTC) - Place: Slaton, TX - Coordinates: 33.490554, -101.587501 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4906&lon=-101.5875&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report April 12, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Teledyne Continental Motors, Inc, FAA Lubbock FSDO - NTSB case key (mKey): 75453 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA140 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75453/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75453 - Page: https://openairdocs.org/ntsb/CEN10LA140 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=1151604), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=1151604), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## 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](https://openairdocs.org/deregistered/N2036Y-2013-08-27), registration cancelled 2013-08-27, S/N E-1366, built 1978 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1366 - Airframe hours: 5834 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: minor; 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 ## 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 20100305028579A](https://openairdocs.org/incident/20100305028579A), Mar 5, 2010: Beech A36, Lorenzo, TX, Substantial damage. On March 5, 2010, at 2152 zulu N2036Y, a BE-36-A36 lost engine power during cruise flight. The pilot of the aircraft declared an emergency and executed an… ## Docket (2 files) The files NTSB released with the investigation on October 26, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75453. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338276&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 2, .PDF, 255 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40338300&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.