# NTSB CEN18LA084: Beech A36, N3600A, Abilene, TX, January 22, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: January 22, 2018, 08:45 local (14:45 UTC) - Place: Abilene, TX - Coordinates: 32.448612, -99.733055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.4486&lon=-99.7331&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Continental Motors, Federal Aviation Administration; FSDO SW-13 - NTSB case key (mKey): 96651 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96651/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96651 - Page: https://openairdocs.org/ntsb/CEN18LA084 ## Probable cause Maintenance personnel’s improper maintenance of the engine, which resulted in a catastrophic engine failure due the shifting/slipping of the No. 2 bearing and the subsequent oil starvation and total loss of engine power during cruise flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: repair](https://openairdocs.org/ntsb-findings/02062015): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech A36, 2 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md?model=1151604), [All aircraft, 99 cases](https://openairdocs.org/ntsb-findings/02062015/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Beech A36, 13 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=1151604), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1151604), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=1151604), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/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: [Beech A36, 7 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=1151604), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-climb to cruise: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=1151604), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=1151604), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The private pilot was conducting a cross-country, personal flight. He stated that, upon leveling off at cruise altitude, there was a "severe vibration" coming from the engine compartment, followed by a sound of the engine "coming apart." Oil covered the windshield, and the smoke entered the cockpit. The pilot was unable to return to the departure airport because it was beyond gliding distance, so he performed a forced landing on a field with the landing gear and flaps retracted. The pilot sustained serious injuries. Postaccident examination of the engine revealed a large hole in the left crankcase half over the No. 2 cylinder attachment point and a small hole in the right crankcase half over the No. 5 cylinder attachment point. The No. 2 main bearing had shifted in the bearing saddle, which cut off the oil supply to the No. 2 rod cap bearing. Shifting/slipping of the bearing can result from either improper torque application during cylinder replacement or improper grinding of the bearing journal during maintenance. The engine had been disassembled twice before the accident. An engine logbook entry showed that the No. 2 cylinder had been removed and replaced about 328 hours before the accident. It is likely that maintenance personnel did not conduct proper maintenance on the No. 2 cylinder during reassembly of the engine and that this ultimately led to the catastrophic engine failure due the shifting/slipping of the No. 2 bearing and the subsequent oil starvation and total loss of engine power. ## Factual narrative On January 22, 2018, at 0845 central standard time, a Beech A36, N3600A experienced a total loss of engine power during climb after departing from Abilene Regional Airport (ABI), Abilene, Texas. The private pilot then performed a forced landing to a field near Abilene, Texas. The pilot sustained serious injuries and the airplane sustained minor damage. The airplane was registered to and operated by the pilot under Title 14 Code of Federal Regulations Part 91 as a personal flight that was operating on a visual flight rules flight plan. Day visual meteorological conditions prevailed at the time of the accident. The flight originated from ABI at 0835 and was destined to Sierra Blanca Regional Airport (SRR), Ruidoso, New Mexico. The pilot stated that upon level off at cruise altitude, there was a "severe vibration" from the engine compartment followed by a sound of the engine "coming apart." Oil covered the windshield and the smoke entered the cockpit. The pilot stated that he was unable to return to ABI due to its distance from his position and attempted a forced landing to Dyess Air Force Base (AFB), Texas. The pilot was unable to attain Dyess AFB due to the airplane's altitude. The pilot performed a forced landing to a field about one mile southwest of Dyess AFB with the landing gear and flaps retracted. Post-accident examination revealed the engine was intact with all the accessories attached. A large hole was observed in the left crankcase half over the number two-cylinder attachment point, and a small hole was observed in the right crankcase half over the number five-cylinder attachment point. Cylinders two, four, and six were Continental cylinders and had chrome markings. Cylinders one, three, and five were ECI cylinders. The number 2 main bearing shifted in the bearing saddle, which cut off the oil supply to the number 2 rod cap bearing. The number 2 connecting rod separated from the connecting rod journal on the crankshaft. The number 2 rod journal on the crankshaft was very dry and partly melted. The number 2 rod cap bearing was melted and most of it was found in the oil sump. The engine logbook had an entry dated January 23, 2015, at a tachometer time of 4,173 hours, for the removal and replacement of the number two cylinder. The most recent entry for disassembly of the engine, as part of an annual inspection, was dated February 12, 2016, at a tachometer time of 4,299.6 hours and 1,796.0 hours since overhaul. The entry states, "#4 and #6 cylinders were removed due to exhaust leaks." The mechanic who performed the annual inspection dated February 12, 2016 performed the most recent annual dated February 9, 2017, at a tachometer time of 4,442.7 hours. The tachometer indication at the time of the accident was 4,501.0 hours. ## Aircraft - Registration: [N3600A](https://openairdocs.org/deregistered/N3600A-2020-08-02), registration cancelled 2020-08-02, S/N E-1328, built 1978 (OpenAirDocs) - Reported make and model: BEECH A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-1328 - Year built: 1978 - Airframe hours: 4501 - Engines: Continental IO-520-BA 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Pilot - Registered owner: Pilot - Airworthiness certificate: Standard, Utility - Last inspection: Annual, February 9, 2017, 58 hours before - Departed: ABI, Abilene, TX - Destination: DYS, Abilene, TX - Flight plan: VFR - Airport: DYS, Dyess Air Force Base ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 2, 2016; seat: left; restraint: 3-point; flight hours: 702 total, 350 in this make and model, 702 as pilot in command, 7 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 41 °F, dew point 18 °F - Altimeter: 30.12 inHg - Observed at: DYS, 2 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 20180122001119A](https://openairdocs.org/incident/20180122001119A), Jan 22, 2018: Beech A36, Abilene, TX, Substantial damage. On January 22, 2018, at approximately 0845 local, N3600A, a Beech A36 aircraft experienced engine failure at Abilene, Texas. The aircraft was being operated on… ## Docket (5 files) The files NTSB released with the investigation on March 25, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96651. 4.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471344&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Examination (item 2, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471345&FileExtension=.PDF&FileName=Record%20of%20Examination-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 3, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471346&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Maintenance Logbook Entry 1 of 2 (item 4, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471347&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Entry%201%20of%20%202-Master.PDF - Maintenance Logbook Entry 2 of 2 (item 5, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471348&FileExtension=.PDF&FileName=Maintenance%20Logbook%20Entry%202%20of%202-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.