# NTSB CEN15LA172: Beech B19, N774TA, Osage Beach, MO, March 11, 2015

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: March 11, 2015, 12:43 local (17:43 UTC)
- Place: Osage Beach, MO
- Coordinates: 38.110553, -92.680557 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.1106&lon=-92.6806&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341)
- Highest injury: Serious injuries
- Injuries: 1 serious, 2 minor
- Status: Completed, report August 25, 2015
- Report: Approved by Office Director
- NTSB office: Central Region
- NTSB case key (mKey): 90874
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA172
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90874/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90874
- Page: https://openairdocs.org/ntsb/CEN15LA172

## Probable cause

The failure of the No. 4 piston wrist pin plug and the subsequent entry of its metal shavings into the oil system, which clogged the oil passages and caused the engine to seize. Contributing to the accident was the installation of engine parts that were not approved by the engine manufacturer.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Beech B19, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151215), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md)
- [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [Beech B19, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1151215), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md)
- [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Related maintenance info (probable cause); cases with it: [Beech B19, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151215), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech B19, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151215), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md)
- [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech B19, 3 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151215), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md)
- [Landing: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Beech B19, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=1151215), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md)

## Analysis

The pilot reported that, shortly after takeoff, he noticed that the oil pressure was dropping. Shortly after the oil pressure dropped, the engine seized, and the pilot subsequently ditched the airplane in a lake. When the airplane was recovered, the oil dipstick was missing. However, more than 4 quarts of oil and only about 1 to 2 cups of water were drained from the engine. If the dipstick had not been in the engine at impact, the engine would have been full of water. Further, the pilot reported that he had replaced the dipstick after checking the oil; so, the dipstick likely was in place at impact. No signs of oil were found in the engine cowling, and no oil streaks were observed underneath the fuselage. A postaccident examination of the engine revealed that the crankshaft middle bearing had seized. The third bearing aft, which was between the two banks of cylinders, and the No. 3 connecting rod bearing had rotated and exhibited severe heat distress and mechanical damage. The No. 4 piston wrist pin plug was deformed, and the deformation had damaged the side of the piston. Aluminum pieces and shavings were found throughout the engine. It is likely that, as the No. 4 wrist pin plug wore down, its shavings entered the oil system and clogged the oil passages, which caused the engine to seize. The examination also revealed that the engine parts installed on the airplane, including the No. 4 piston wrist pin plug, were not approved by the engine manufacturer.

## Factual narrative

On March 11, 2015, at 1243 central daylight time, the pilot of a Beech B19, N774TA, ditched in Lake Ozark, Osage Beach, Missouri, after oil pressure was lost and the engine seized. One passenger was seriously injured, but the pilot and another passenger escaped injury. The airplane was substantially damaged. The airplane was registered to GDS Properties and operated by the pilot, both of St. Charles, Missouri, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight originated from Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri, about 1225, and was en route to Creve Coeur Airport (1H0), St. Louis, Missouri.The pilot told a Federal Aviation Administration (FAA) inspector that everything appeared to be normal when he conducted his preflight inspection, although the oil did appear darker than usual. There was 6 quarts of oil on the dipstick and the oil had just been changed two days before. During the engine run-up, all engine instruments were "in the green." Shortly after takeoff, when the airplane had attained an altitude of about 2,800 feet, he noticed the oil pressure was dropping and he turned back towards K15. Shortly thereafter, the propeller stopped and the engine seized. He ditch in Lake Ozark. The occupants exited the airplane and climbed out on the wing. The pilot said that as they awaited rescue, he thought he smelled a twinge of burnt oil. The FAA inspector examined the airplane and verified there was ample fuel on board, and that it was blue in color. He found the throttle linkage connected. The engine could not be turned by hand. The inspector said he could not find the oil dipstick when the airplane was recovered from the lake. The pilot, however, was adamant that he had replaced the dipstick after checking the oil. On April 15 and 16, 2015, the engine was disassembled and examined at Dawson Aircraft in Clinton, Arkansas. The oil dipstick was missing, but more than 4 quarts of oil and only 1 to 2 cups of water were drained from the engine. There were no signs of oil in the engine cowling, and there were no oil streaks underneath the fuselage. The no. 2 middle bearing on the crankshaft had seized. The third bearing aft between the two banks of cylinders had rotated, and the bearing for the no. 3 connecting rod had rotated. There was evidence of severe heat distress and mechanical damage to the no. 3 rod bearing. The latter had started squeezing out the sides of the connecting rod end. The no. 4 piston wrist pin plug was deformed and had damaged the side of the piston. Aluminum pieces and shavings were noted throughout the engine. The engine parts appeared to have been manufactured by Superior Air Parts, Inc., and not by Textron Lycoming.

## Aircraft

- Registration: [N774TA](https://openairdocs.org/deregistered/N774TA-2018-01-09), registration cancelled 2018-01-09, S/N MB825, built 1976 (OpenAirDocs)
- Reported make and model: BEECH B19
- Registry model: [Beech B19](https://openairdocs.org/model/beech-b19) (registry code 1151215) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: MB825
- Year built: 1976
- Airframe hours: 2451
- Engines: Lycoming O-320-E3D 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: GDS Properties
- Registered owner: GDS Properties
- Airworthiness certificate: Standard, Utility; Standard, Normal
- Last inspection: Annual, October 30, 2014, 18 hours before
- Departed: K15, Grand Glaize, MO
- Destination: 1H0, St. Louis, MO
- Airport: K15, Grand Glaize-Osage Beach Arto, runway 32, 3,205 × 60 ft, asphalt
- Equipment: Stall warning system, Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; injuries: none; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 450 total, 375 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 180° at 3 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 66 °F, dew point 63 °F
- Altimeter: 30.28 inHg
- Observed at: KAIZ, 6 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 20150311002739A](https://openairdocs.org/incident/20150311002739A), Mar 11, 2015: Beech B19, Osage Beach, MO, Substantial damage. Aircraft departed runway 32 at grand glaize airport. Upon reaching 2,800 feet MSL, the pilot reported a loss of engine power. The aircraft was over the lake of…

## Docket (17 files)

The files NTSB released with the investigation on May 11, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90874. 14.1 MB in all.

- Record of Conversation (item 1, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426228&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF
- Pilot’s Statement to the Missouri State Patrol (item 2, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426229&FileExtension=.PDF&FileName=Pilot%E2%80%99s%20Statement%20to%20the%20Missouri%20State%20Patrol-Redacted.PDF
- Specialist’s Factual Report, Global Positioning System Device (item 3, .PDF, 6 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426230&FileExtension=.PDF&FileName=Specialist%E2%80%99s%20Factual%20Report,%20Global%20Positioning%20System%20Device-Master.PDF
- Attachment 1 - Tabular Data (GPS) (item 4, .CSV, 4 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426231&FileExtension=.csv&FileName=Attachment%201%20-%20Tabular%20Data%20(GPS)-Master.csv
- Teardown Report from David Hall, President, HyTech Analysis and Laboratory Services, Inc. (item 5, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426232&FileExtension=.PDF&FileName=Teardown%20Report%20from%20David%20Hall,%20President,%20HyTech%20Analysis%20and%20Laboratory%20Services,%20Inc.-Redacted.PDF
- E-Mails from Henry Soderlund, Textron Aviation (item 6, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426233&FileExtension=.PDF&FileName=E-Mails%20from%20Henry%20Soderlund,%20Textron%20Aviation-Redacted.PDF
- Weather Report and Record (item 7, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426326&FileExtension=.PDF&FileName=Weather%20Report%20and%20Record-Master.PDF
- Photo 1 - Wreckage (item 8, .PDF, 725 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426234&FileExtension=.PDF&FileName=Photo%201%20-%20Wreckage-Master.PDF
- Photo 2 - Missing Oil Dipstick (item 9, .PDF, 10.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426235&FileExtension=.PDF&FileName=Photo%202%20-%20Missing%20Oil%20Dipstick-Master.PDF
- Photo 3 - Recovered Oil from Engine (item 10, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426236&FileExtension=.PDF&FileName=Photo%203%20-%20Recovered%20Oil%20from%20Engine-Master.PDF
- Photo 4 - Metal Specks in Oil (item 11, .PDF, 991 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426237&FileExtension=.PDF&FileName=Photo%204%20-%20Metal%20Specks%20in%20Oil-Master.PDF
- Photo 5 - Metal Shavings in the Vernatherm and Housing (item 12, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426238&FileExtension=.PDF&FileName=Photo%205%20-%20Metal%20Shavings%20in%20the%20Vernatherm%20and%20Housing-Master.PDF
- Photo 6 - Aluminum Shavings on Oil Screen (item 13, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426239&FileExtension=.PDF&FileName=Photo%206%20-%20Aluminum%20Shavings%20on%20Oil%20Screen-Master.PDF
- Photo 7 - Aluminum Shavings in bottom of oil pan (item 14, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426240&FileExtension=.PDF&FileName=Photo%207%20-%20Aluminum%20Shavings%20in%20bottom%20of%20oil%20pan-Master.PDF
- Photo 8 - Crankshaft (item 15, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426241&FileExtension=.PDF&FileName=Photo%208%20-%20Crankshaft-Master.PDF
- Photo 9 - Main bearing mounting surface on the crankcase between the two banks of cylinders (item 16, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426242&FileExtension=.PDF&FileName=Photo%209%20-%20Main%20bearing%20mounting%20surface%20on%20the%20crankcase%20between%20the%20two%20banks%20of%20cylinders-Master.PDF
- Photo 10 - Number 4 Piston Wrist Pin Plug (item 17, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40426243&FileExtension=.PDF&FileName=Photo%2010%20-%20Number%204%20Piston%20Wrist%20Pin%20Plug-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.

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