CEN17LA328

NTSB accident investigation · Beech A36 · Gonzales, LA · August 17, 2017

Accident · No injuriesLimited investigationFinal report
Date
August 17, 2017, 09:27 local (14:27 UTC)
Place
Gonzales, LA
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N48TZBeech A36
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report March 18, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Flight Standards District Office
FAA report
20170817015829A
Case key
95883

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

On this page

Probable cause

A partial loss of engine power due to inadequate maintenance, including worn spark plugs and a leaking fuel hose fitting.

Findings · 4

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.

Engine (reciprocating)Aircraft › Aircraft power plant · Incorrect service/maintenanceBeech A36: 13 casesAll aircraft: 497 casesProbable cause
MaintenancePersonnel issues › Task performance · Maintenance personnelBeech A36: 1 caseAll aircraft: 143 casesProbable cause
Ignition system: spark plugs/ignitersAircraft › Aircraft power plant · Fatigue/wear/corrosionBeech A36: 1 caseAll aircraft: 38 casesProbable cause
Fuel systemAircraft › Aircraft systems · Damaged/degradedBeech A36: 6 casesAll aircraft: 181 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

During the initial climb on an instructional flight, the private pilot and instructor noticed a partial loss of engine power. The pilot performed a forced landing into a hay field and the airplane nosed over. Following the accident, the mechanic who normally performed maintenance removed and discarded all twelve spark plugs, as several were worn. A subsequent examination and test run of the engine revealed a leaking fuel hose due to a loose B-nut. The loss of engine power was consistent with an inadequate fuel supply due to a fuel line leak. Further, it is likely that the worn spark plugs would also have contributed to the loss of engine power.

Factual narrative

On August 17, 2017, about 0927 central daylight time, a Beech A36 airplane, N48TZ, was substantially damaged during a forced landing after departing from the Louisiana Regional Airport (REG), Gonzales, Louisiana. The pilot and flight instructor were not injured. The airplane was registered to and operated by Gulf Central Aviation LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed for the local flight, which departed without a flight plan about 0926. According to the pilot, he departed from Runway 17, following a normal engine run up and takeoff roll. After reaching about 150 ft agl, the pilot noticed the airplane was no longer climbing and lowered the airplane's nose. Based on his perceptions of a partial engine power loss, the pilot checked the throttle and mixture lever positions, both of which were full forward. After maneuvering to avoid trees, the pilot initiated a forced landing into a hay field. During the landing roll, the airplane impacted a small ridge and nosed over, which damaged the engine firewall. Examination at the recovery location revealed the ignition harness connecting the magnetos to each of the top sparkplugs had been disconnected from the sparkplugs. All twelve sparkplugs appeared new, with no combustion deposits noted. Without authorization, a mechanic who normally performed maintenance on the airplane stated he had removed and discarded the spark plugs due to several having a worn-out condition. Not realizing the airplane should not be disturbed during the investigation, the mechanic had also removed the fuel screen. Examination of the throttle and mixture control cables revealed proper attachment to their respective control arms. Borescope inspection of piston domes, cylinder wall surfaces, and intake and exhaust valves revealed normal wear patterns and combustion signatures, except for the No. 5 cylinder exhaust valve, which had a green crescent-shaped discoloration on the bottom of the valve face. After the fuel screen was returned by the mechanic, an engine test run was performed. The engine rotated and ran on the first attempt but stopped after several seconds. A fuel leak was observed adjacent to the fuel pump, with a flexible fuel hose leaking at a B-nut. The nut was tightened about ¼ turn, which seated the nut onto the fitting. The engine driven fuel pump and the adjacent oil filter adapter were stained with a blue color. A second fuel leak was observed at the throttle body/metering unit, with the fuel mixture arm and shaft bent in a manner consistent with impact damage. A second engine test run was conducted, during which power was not increased above 1,100 rpm, due to a damaged propeller. The engine was operated at varying speeds and a magneto check was accomplished, with no anomalies. The throttle was reduced to idle power and the engine ran smoothly. The oil on the oil rod was very dark in color. A logbook reviewrevealed the engine had accumulated 163.7 hours since the last oil and oil filter change. The manufacturer recommends oil change intervals of 50 hours for an engine equipped with external filters installed.

Aircraft

Registration
N48TZ
Reported as
Beech A36
Category
Airplane
Serial number
E-1804
Built
1980
Airframe hours
6,184
Engine
Continental IO-520, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Gulf Central Aviation LLC
Registered owner
Gulf Central Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 8, 2016 · 163 hours before
Departed
REG · Gonzales, LA
Destination
REG · Gonzales, LA
Airport
REG · Louisiana Rgnl, runway 17, 5,003 × 100 ft, asphalt
Equipment
Satellite tracking device, Stall warning system, Auto-pilot, Onboard weather, Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
September 19, 2016
Seat
Left
Restraint
3-point
Flight hours
302 total · 165 in this make and model · 148 as pilot in command · 18 in the last 90 days · 11 in the last 30 days · 3 in the last 24 hours
Role
Flight instructor
Age
58
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 12, 2017
Seat
Right
Restraint
3-point
Flight hours
18,100 total · 3,000 in this make and model · 17,200 as pilot in command · 100 in the last 90 days · 25 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 6 knots
Visibility
10 statute miles
Temperature
86 °F, dew point 79 °F
Altimeter
30.09 inHg
Observed at
KREG, 1 nm away

Docket · 3

The files NTSB released with the investigation on September 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 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.