CEN12LA501

NTSB accident investigation · Beech H35 · Holly Lake Ranch, TX · August 1, 2012

Accident · Serious injuriesLimited investigationFinal report
Date
August 1, 2012, 11:20 local (16:20 UTC)
Place
Holly Lake Ranch, TX
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4684DBeech H35
Defining event
Enroute-descent: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2013
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Dallas FSDO
FAA report
20120801021009A
Case key
84539

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

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Probable cause

The incomplete maintenance performed by maintenance personnel, which resulted in a total loss of engine power.

Findings · 2

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.

Maintenance: repairPersonnel issues › Task performance · Maintenance personnelBeech H35: 1 caseAll aircraft: 99 casesProbable cause
Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect service/maintenanceBeech H35: 1 caseAll aircraft: 497 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

The airplane’s engine lost power during the descent to the destination airport, and the airplane struck trees during the ensuing forced landing attempt. A postaccident examination of the engine revealed that the idler gear pin was not in position and no retaining bolts were found. Additionally, the nuts from the forward left, lower through bolt on the crankcase half and the forward left engine mount bolt were missing. A logbook entry indicated that the engine had been reassembled and re-installed on the airplane about 1 week before the accident due to a previous propeller strike. Based on the available information, it is likely that the improper assembly of the engine, specifically the omission of the idler gear pin retaining bolts, resulted in the idler gear falling out of its position and a subsequent complete loss of engine power.

Factual narrative

On August 1, 2012, about 1120 central daylight time, a Beech H35 airplane, N4684D, sustained substantial damage when it struck trees following a loss of engine power near Holly Lake Ranch, Texas. The pilot received serious injuries. The aircraft was registered to an individual and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a business flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan. The flight originated from the Wood County Airport (JDD), Mineola, Texas, about 1100, and was destined for the Gilmer Municipal Airport (JXI), Gilmer, Texas. The pilot reported that he performed a pre-flight run-up with no anomalies noted. He then departed JDD and climbed to 7,500 feet altitude en route to JXI. During the descent to JXI, at 6,500 feet altitude, the engine experienced a total loss of engine power. The pilot reported that he turned the airplane toward the Holly Lake Ranch Airport (16TE), and attempted an engine restart to no avail. The airplane struck trees off the end of runway 27 at 16TE. Examination of the airplane’s engine after recovery from the accident scene revealed that the idler gear pin was missing from the rear of the engine, and both nuts and washers were missing from the idler gear pin attachment studs. The idler gear pin was found in a plastic trash bag that contained smaller parts recovered from the wreckage site. The idler gear had fallen in to the rear crankshaft gear and damaged the rear crankshaft gear teeth. The nut was missing from the forward left side lower through bolt on the crankcase half. The nut was also missing from the forward left side engine mount bolt. Examination of the maintenance records revealed a piece of paper attached to the log book indicating that the engine was disassembled and inspected after a propeller strike. The crankshaft was turned 0.010 inches undersize and the engine was re assembled. The entry was dated July 25, 2012 and was signed by the pilot, who also held a mechanic certificate with airframe and powerplant ratings issued by the Federal Aviation Administration. According to manufacturer drawings, the aft crankshaft gear engaged the idler gear which in turn engaged both magneto drive gears. Without the idler gear in place the magnetos would cease to operate.

Aircraft

Registration
N4684D
Reported as
Beech H35
Category
Airplane
Serial number
D-4867
Engine
Cont Motor O-470 SERIES, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
July 25, 2012
Departed
JDD · Mineola, TX
Destination
JXI · Gilmer, TX
Airport
16TE · Holly Lake Ranch Airport, runway 27, 2,700 × 30 ft, asphalt

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
63
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 12, 2012
Seat
Left
Flight hours
3,915 total · 162 in this make and model · 3,915 as pilot in command · 16 in the last 90 days · 9 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 68 °F
Altimeter
29.97 inHg
Observed at
JXI, 13 nm away

Docket · 5

The files NTSB released with the investigation on August 26, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.9 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.