# NTSB CEN12LA558: Beech A36, N262EA, Ruleton, KS, August 17, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 17, 2012, 13:45 local (18:45 UTC) - Place: Ruleton, KS - Coordinates: 39.340473, -101.699836 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.3405&lon=-101.6998&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report May 9, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 84733 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA558 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84733/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84733 - Page: https://openairdocs.org/ntsb/CEN12LA558 ## Probable cause The improper installation of the wastegate controller O-ring, which resulted in a partial loss of engine power. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Raytheon A36, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7150001), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Turbocharging (recip only)](https://openairdocs.org/ntsb-findings/01058100): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Raytheon A36, 1 case](https://openairdocs.org/ntsb-findings/01058100/cases.md?model=7150001), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/01058100/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Raytheon A36, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7150001), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Raytheon A36, 3 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7150001), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Raytheon A36, 12 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7150001), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Raytheon A36, 17 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7150001), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Shortly after leveling off at a cruise altitude of 8,500 feet mean sea level, the pilot noted that the engine rpm increased to above its red line limit (2,700 rpm). The pilot was able to reduce power to 2,500 rpm but was unable to restore thrust and maintain altitude, so he made a forced landing in a nearby wheat field. During postaccident examination, the engine turbocharger controller was found covered with oil. Examination of an elbow fitting on the turbocharger wastegate control revealed that an O-ring was improperly installed and flattened, which allowed oil to seep out. When the O-ring was reseated and the elbow fitting torqued, no seepage was observed. ## Factual narrative On August 17, 2012, about 1345 mountain daylight time, the pilot of a Beech A36, N262EA, made a forced landing in a field near Ruleton, Kansas. The pilot and two passengers were not injured. The airplane was substantially damaged. The airplane was registered to KABAKY, LLC, Rapid City, South Dakota, and operated by 21st Century Equipment, Bridgeport, Nebraska, under the provisions of 14 Code of Federal Regulations Part 91 as a corporate/executive flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The local flight originated from Goodland, Kansas (KGLD), approximately 1330. According to the pilot's accident report, there was 9 quarts of oil in the engine crankcase (12 quarts maximum capacity) prior to his departure from Sidney, Nebraska. He arrived in KGLD about 1230. He did not indicate whether he checked the oil. After boarding two passengers, he departed KGLD at 1330, en route to Fort Morgan (KFMM), Colorado. Shortly after leveling off at a cruising altitude of 8,500 feet, the pilot heard engine RPM (revolutions per minute) increase and he noted that the tachometer was at the top of the gauge. The pilot was able to reduce power to 2,500 RPM, but was unable to restore thrust or maintain altitude. He extended the landing gear and made a forced landing in a wheat field near County Roads 74 and 9, about 12 miles northwest of KGLD. Post-accident examination revealed the right wing rear spar was broken. FAA inspectors went to the accident site and reported finding the turbocharger controller covered with oil. After the airplane was recovered to a hangar, they drained 5 quarts of oil from the crankcase. On September 27, 2012, the turbocharger controller was examined by the NTSB at Beegles Aircraft Service in Greeley, Colorado. Oil covered the controller piping. When shop air (35-95 psi) was introduced via the oil pressure inlet hose, the wastegate control valve opened and closed normally. A soapy solution was applied to all fittings. Air bubbles were noted at the elbow fitting of the outlet hose going to the wastegate controller. The outlet fitting was loosened and removed. The O-ring was discovered flattened. It was reseated and the elbow fitting re-torqued. Shop air and a soapy solution were reapplied. No more bubbles were observed. Examination of the airplane’s maintenance records revealed the last annual/100-hour inspection was performed on October 10, 2011. On that date, the engine, turbocharger, controller and wastegate were overhauled. The units were reinstalled on the airplane on November 12, 2011, at a Hobbs meter time of 1,907.6 hours. Routine oil changes followed on February 1, 2012 (1,909.8 hours0, April 26, 2012 (1.962.8 hours), and June 12, 2012 (38.5 hours, after the Hobbs meter was changed on April 26). ## Aircraft - Registration: [N262EA](https://openairdocs.org/aircraft/N262EA), registered now, S/N E-3417, built 2001 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Raytheon A36](https://openairdocs.org/model/raytheon-a36) (registry code 7150001) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-3417 - Airframe hours: 2032 - Engines: Continental IO-550-B 310 horsepower reciprocating - Damage: Substantial damage - Flight: Executive/Corporate, Part 91 - Operator: 21st Century Equipment - Registered owner: Kabajk, LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 11, 2011, 124 hours before - Departed: KGLD, Goodland, KS - Destination: KFMM, Fort Morgan, CO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 34; injuries: none; flight instructor, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review September 22, 2011; seat: left; flight hours: 2,940 total, 130 in this make and model, 2,510 as pilot in command, 80 in the last 90 days, 35 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 9 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 43 °F - Altimeter: 30.12 inHg - Observed at: KGLD, 7 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 20120817022349A](https://openairdocs.org/incident/20120817022349A), Aug 17, 2012: Raytheon Aircraft Company A36, Ruleton, KS, Substantial damage. After departure from gdl experienced engine over speed and no forward thrust. Landed in field. A/c has substantial damage. A/c was moved to beegles a/c in… ## Docket (8 files) The files NTSB released with the investigation on March 20, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84733. 5.7 MB in all. - NTSB Form 6120.1-2, Pilot-Operator Aircraft Accident Report (item 1, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40379115&FileExtension=.PDF&FileName=NTSB%20Form%206120.1-2,%20Pilot-Operator%20Aircraft%20Accident%20Report-Redacted.PDF - FAA Inspector's Statement (item 2, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384537&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF - Excerpt from Engine Maintenance Records (item 3, .PDF, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380316&FileExtension=.PDF&FileName=Excerpt%20from%20Engine%20Maintenance%20Records-Redacted.PDF - Photo 1 - Oil drained from the engine crankcase measured 5 quarts (item 4, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384459&FileExtension=.PDF&FileName=Photo%201%20-%20Oil%20drained%20from%20the%20engine%20crankcase%20measured%205%20quarts-Master.PDF - Photo 2 - Turbocharger controller after removal from engine. Note oil coating the piping. (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380443&FileExtension=.PDF&FileName=Photo%202%20-%20Turbocharger%20controller%20after%20removal%20from%20engine.%20Note%20oil%20coating%20the%20piping.-Master.PDF - Photo 3 - Wastegate control valve is in open position (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384419&FileExtension=.PDF&FileName=Photo%203%20-%20Wastegate%20control%20valve%20is%20in%20open%20position-Master.PDF - Photo 4 - Red hose is outlet to wastegate controller. Blue hose is oil pressure inlet. Open drain plug is visible at bottom. (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380445&FileExtension=.PDF&FileName=Photo%204%20-%20Red%20hose%20is%20outlet%20to%20wastegate%20controller.%20Blue%20hose%20is%20oil%20pressure%20inlet.%20Open%20drain%20plug%20is%20visible%20at%20bottom.-Master.PDF - Photo 5 - Red hose is the outlet to the wastegate controller (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384420&FileExtension=.PDF&FileName=Photo%205%20-%20Red%20hose%20is%20the%20outlet%20to%20the%20wastegate%20controller-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.