CEN17LA286

NTSB accident investigation · Beech V35 · Walters, OK · July 8, 2017

Accident · Minor injuriesLimited investigationFinal report
Date
July 8, 2017, 10:50 local (15:50 UTC)
Place
Walters, OK
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N6257VBeech V35
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO, Continental Engines
FAA report
20170708009809A
Case key
95674

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

Maintenance personnel’s installation of an improper vacuum pump gasket, which resulted in oil starvation to the engine and a subsequent total loss of engine power.

Findings · 3

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.

Misc hardwareAircraft › Fluids/misc hardware · Incorrect service/maintenanceBeech V35: 1 caseAll aircraft: 41 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBeech V35: 2 casesAll aircraft: 371 casesProbable cause
Fluids: oilAircraft › Fluids/misc hardware · Fluid levelBeech V35: 4 casesAll aircraft: 174 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 airline transport pilot was conducting a personal, cross-country flight. He reported that, about 10 minutes after takeoff, the oil pressure decreased to 0, and the engine experienced a loss of all power. The pilot conducted a forced landing on a soft field about 1 mile short of an airport, during which the airplane sustained substantial damage to the firewall and lower fuselage. A review of the airplane's maintenance records revealed that the vacuum pump had been replaced the day before the accident. Examination of the engine revealed that three connecting rods exhibited thermal and impact damage, and three rod journals were found dry and exhibited thermal discoloration, indicative of oil starvation. Disassembly indicated that a gasket typically used for carburetors was installed on the vacuum pump. The installed gasket did not completely cover the high-pressure oil orifice on the vacuum pump mounting fixture, which resulted in oil leakage, subsequent oil starvation to the engine, and the loss of engine power.

Factual narrative

On July 8, 2017, about 1050 central daylight time, a Beech VA airplane, NV, sustained substantial damage during a forced landing after a loss of engine power near Walters, Oklahoma. The airline transport pilot and one passenger sustained minor injuries. Visual meteorological conditions prevailed and no flight plan was filed. The airplane was registered to Gas Corporation of America of Wichita Falls, Texas, and the flight was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The flight originated at 1040 from Kickapoo Downtown Airport (CWC), Wichita, Falls, Texas, and was en route to Lawton, Oklahoma. The pilot reported that about 10 minutes after departing CWC, the oil pressure went to zero and the engine failed. He executed a forced landing to a soft farm field, about one mile south of the Walters Airport (OK12). The pilot and passenger exited the airplane with minor injuries. The airplane sustained substantial damage to the firewall and lower fuselage. A review of the airplane maintenance records showed that the vacuum pump was replaced on July 7, 2017, the day before the accident. The engine was visually examined and disassembled. During the disassembly, it was discovered that a improper gasket (P/N-21051) was installed on the vacuum pump. The gasket was normally used for the installation of a carburetor. The installed gasket did not completely cover the high-pressure oil orifice on the vacuum pump mounting fixture. The proper gasket was (PN-MS9134-01) for the vacuum pump. Three connecting rods showed thermal and impact damage, and three rod journals were observed to be dry and showed thermal discoloration.

Aircraft

Registration
N6257V
Reported as
Beech V35 (UNDESIGNAT)
Category
Airplane
Serial number
D-8587
Built
1967
Airframe hours
3,432
Engine
Continental IO-520-BB6, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 7, 2017 · 10 hours before
Departed
CWC · Wichita Falls, TX
Destination
LAW · Lawton, OK
Airport
OK12 · Jones Farm Field Airport
Equipment
Stall warning system

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
48
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
5,000 total · 26 in this make and model · 20 in the last 90 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
77 °F, dew point 72 °F
Altimeter
30.06 inHg
Observed at
LAW, 20 nm away

Docket · 7

The files NTSB released with the investigation on January 3, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.5 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.

Other investigations on N6257V · 1

Matched to the same aircraft by N-number and date.