CEN18LA159

NTSB accident investigation · Beech A36 · Shullsburg, WI · May 5, 2018

Accident · No injuriesLimited investigationFinal report
Date
May 4, 2018, 19:30 local (May 5, 2018, 00:30 UTC)
Place
Shullsburg, WI
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N36LPBeech A36
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report May 29, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors Inc., FAA Flight Standards
FAA report
20180504004629A
Case key
97174

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 catastrophic engine failure due to improper torque on the engine through-bolt nuts, which resulted in relative movement between the crankcase halves, damage to a main journal bearing, and a loss of oil lubrication.

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.

Engine (reciprocating): recip engine power sectionAircraft › Aircraft power plant · Incorrect service/maintenanceBeech A36: 6 casesAll aircraft: 233 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBeech A36: 2 casesAll aircraft: 320 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 commercial pilot reported that he heard an unusual noise from the engine during cruise flight and shortly afterward, the engine experienced a total loss of power. The pilot performed a forced landing to an open field. Visual examination of the engine revealed a hole in the crankcase. A teardown examination revealed fretting on the crankcase mating surfaces, shifting of the No. 2 main bearing within the journal support, thermal damage consistent with a loss of oil lubrication, and separation of the crankshaft. The observed fretting damage was consistent with relative movement of the crankcase halves during operation due to a lack of through-bolt torque. The main journal bearing damage, the separation of the crankshaft, and the crankcase damage were secondary and a result of the loss of lubrication. An engine overhaul was completed in about 11 years 5 months before the accident; about 849 flight hours had accumulated since the overhaul. Two cylinders were replaced 6 years before the accident, and one cylinder was replaced during the most recent annual inspection about 9 months before the accident. It is likely that improper torque of the through-bolt nuts was applied during one of the cylinder replacement events, though it could not be determined which event.

Factual narrative

On May 4, 2018, about 1930 central daylight time, a Beech A36 airplane, N36LP, was substantially damaged during a forced landing following a loss of engine power near Shullsburg, Wisconsin. The pilot was not injured. The airplane was registered to and operated by a private individual as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and the flight was operating on an instrument flight rules flight plan. The flight originated from the Okmulgee Regional Airport (OKM), Okmulgee, Oklahoma, about 1537. The intended destination was Bucky's Airport (WN09), Plainfield, Wisconsin.The pilot reported that the airplane was in cruise flight at 7,000 ft mean sea level when he heard an unusual noise from the engine. Shortly afterward, the engine lost power and he executed a forced landing to an open field. He recalled thinking that oil may have escaped from the engine because he observed smoke. The airplane sustained substantial damage to the lower fuselage/nose landing gear wheel well structure. A postaccident engine examination revealed a hole in the crankcase above the no. 1 cylinder. A teardown examination revealed wear on the mating crankcase surfaces consistent with fretting of the case halves. The no. 2 main journal bearing was shifted within the bearing support, the lock tab was elongated, and the bearing was extruded. Bearing fragments were recovered from the oil sump. The crankshaft was separated between the no. 2 main bearing journal and the no. 2 connecting rod journal. The crankshaft was discolored adjacent to the separation consistent with thermal damage due to a lack of oil lubrication. The remaining portions of the crankshaft displayed normal operating and lubrication signatures. The no. 2 connecting rod bearing exhibited damage consistent with lubrication distress. The oil pump housing and impellers exhibited scoring consistent with hard particle passage. Airplane maintenance records indicated that an engine overhaul was completed in November 2006. The no. 2 and no. 4 cylinders were replaced in June 2012. The most recent annual inspection was completed in August 2017. The no. 5 cylinder was replaced during the annual inspection. At the accident site, the airplane recording hour (Hobbs) meter and tachometer indicated 4,698.4 hours and 7.951.79 hours, respectively. At the time of the accident, the engine had accumulated 848.9 hours since overhaul and 9.8 hours since the annual inspection. The time between overhaul (TBO) interval recommended by the engine manufacturer was 1,700 hours or 12 years, whichever came first. In October 2016, the NTSB issued a safety alert regarding improper torque of engine fasteners during maintenance activities.

Aircraft

Registration
N36LP
Reported as
Beech A36 (UNDESIGNAT)
Category
Airplane
Serial number
E-894
Built
1976
Airframe hours
7,951.8
Engine
Continental IO-520-BB, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · August 19, 2017 · 10 hours before
Departed
OKM · Okmulgee, OK
Destination
WN09 · Plainfield, WI
Flight plan
IFR
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device

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
49
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 2, 2018
Seat
Left
Restraint
3-point
Flight hours
994 total · 281 in this make and model · 942 as pilot in command · 299 in the last 90 days · 111 in the last 30 days · 8 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 46 °F
Altimeter
29.97 inHg
Observed at
PVB, 12 nm away

Docket · 4

The files NTSB released with the investigation on September 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.0 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.