CEN18LA276

NTSB accident investigation · Beech V35 · Katy, TX · July 17, 2018

Accident · No injuriesLimited investigationFinal report
Date
July 17, 2018, 08:30 local (13:30 UTC)
Place
Katy, TX
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N228QBeech V35
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards, Continental Motors Inc.
FAA report
20180717011389A
Case key
97809

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 failure to remove a paper towel from the engine during recent maintenance, which resulted in oil starvation, the failure of a connecting rod, and a catastrophic engine failure and 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.

Engine (reciprocating): recip eng cyl sectionAircraft › Aircraft power plant · FailureBeech V35: 2 casesAll aircraft: 373 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Maintenance personnelBeech V35: 2 casesAll aircraft: 792 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 private pilot reported that, as he approached the destination airport, he noted "a sudden and severe noise and vibration" and "a…stream of gray smoke from under the right side of the [engine] cowling," followed by a loss of engine power. The pilot subsequently conducted a forced landing, during which the airplane sustained substantial damage to the fuselage and right wing. Postaccident engine examination revealed two holes in the top of the crankcase near the Nos. 3 and 4 cylinders. A teardown examination of the engine revealed that the No. 4 connecting rod had failed due to oil starvation, which resulted in a catastrophic engine failure. Foreign debris, which was similar to a paper towel, was recovered from the engine oil sump and the oil pickup screen. Most of the screen area was obstructed by the debris, which had interrupted the oil flow from the sump to the engine. The airplane maintenance records noted that the alternator and alternator drive gear were replaced about 8 weeks before the accident. The engine had been operated about 24 hours since the alternator replacement. The starter and starter adapter were replaced the day before the accident flight. The engine had been operated about 15 minutes since the most recent maintenance work was performed. It is likely that maintenance personnel left the paper towel in the engine during the recent maintenance work, which resulted in oil starvation, the failure of the connecting rod, and the catastrophic engine failure and subsequent total loss of engine power.

Factual narrative

On July 17, 2018, about 0830 central daylight time, a Beech V35 airplane, N228Q, was substantially damaged during a forced landing following a loss of engine power near Katy, Texas. The pilot was not injured. The airplane was registered to Pivot Group LLC and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed. The flight was not operated on a flight plan. The flight originated from the Fair Weather Field Airport (TX42), Monaville, Texas, about 0820 and was destined for the West Houston Airport (IWS), Houston, Texas.The pilot reported that "a sudden and severe noise and vibration" and "a brief stream of gray smoke from under the right side of the [engine] cowling" preceded a loss of engine power as he approached the destination airport. He subsequently executed a forced landing to a residential development under construction. The airplane "bounced and skidded" before coming to rest upright. The airplane sustained substantial damage to the fuselage and right wing. A postrecovery engine examination was conducted under oversight of the National Transportation Safety Board (NTSB) investigator-in-charge. A visual examination revealed two holes in the top of the crankcase near the No. 3 and No. 4 cylinders. The crankcase appeared to be otherwise intact. A teardown examination determined that the No. 4 connecting rod had separated from crankshaft journal. The connecting rod remained attached to the piston. The end of the connecting rod common to the crankshaft was deformed consistent with secondary mechanical damage. The No. 4 crankshaft journal was discolored consistent with oil starvation. The No. 4 piston was wedged in the cylinder and portions of the piston skirt had separated. The oil sump contained foreign debris that appeared to be a paper-based shop towel. The oil pickup screen was obstructed by similar debris. Approximately 7 quarts of oil were recovered from the sump in addition to the debris. At the time of the examination, the hour (Hobbs) meter and tachometer indicated 1,414.3 hours and 5,959.54 hours, respectively. The debris recovered from the oil sump and the pickup screen was forwarded to the NTSB materials lab. Microscopic examination revealed that the debris consisted of a fibrous material with the appearance of a textured paper product similar to paper towels. A sample was washed with acetone to remove the engine oil and analyzed using a spectrometer. The cleaned sample displayed a spectrum with a strong match to cellulose, which is found in natural plant fibers such as cotton and wood. Paper products are manufactured with cellulosic material. A review of the airplane maintenance records revealed that the most recent annual inspection was completed on September 22, 2017, at 5,815.4 hours tachometer time. On June 6, 2018, the alternator and alternator drive gear were replaced. The corresponding hour meter and tachometer times were 1,390.3 and 5,935.7hours, respectively. On July 16, 2018, the starter and starter adapter were replaced. The corresponding hour meter and tachometer times were 5,959.33 hours and 1,414.0 hours, respectively. The records contained no subsequent entries.

Aircraft

Registration
N228Q
Reported as
Beech V35
Category
Airplane
Serial number
D-8135
Built
1966
Airframe hours
5,959
Engine
Continental IO-520-BA, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Utility
Last inspection
Annual · September 22, 2017 · 140 hours before
Departed
TX42 · Monaville, TX
Destination
IWS · Houston, TX
Airport
IWS · West Houston
Equipment
Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Onboard weather, Handheld GPS

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
56
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 2, 2018
Seat
Left
Restraint
3-point
Flight hours
441 total · 149 in this make and model · 406 as pilot in command · 29 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 4 knots
Visibility
5 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 79 °F
Altimeter
30.10 inHg
Observed at
TME, 7 nm away

Docket · 6

The files NTSB released with the investigation on March 27, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.9 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.