# NTSB CEN18LA276: Beech V35, N228Q, Katy, TX, July 17, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 17, 2018, 08:30 local (13:30 UTC) - Place: Katy, TX - Coordinates: 29.868055, -95.794998 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.8681&lon=-95.7950&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards, Continental Motors Inc. - NTSB case key (mKey): 97809 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA276 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97809/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97809 - Page: https://openairdocs.org/ntsb/CEN18LA276 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Beech V35, 2 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=1151538), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Maintenance personnel (probable cause); cases with it: [Beech V35, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1151538), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech V35, 4 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1151538), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/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 V35, 2 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=1151538), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech V35, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151538), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech V35, 9 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151538), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/aircraft/N228Q), registered now, S/N D-8135, built 1966 (OpenAirDocs) - Reported make and model: Beech V35 - Registry model: [Beech V35](https://openairdocs.org/model/beech-v35) (registry code 1151538) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-8135 - Year built: 1966 - Airframe hours: 5959 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; 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 ## 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 20180717011389A](https://openairdocs.org/incident/20180717011389A), Jul 17, 2018: Beech V35, Katy, TX, Substantial damage. [privacy data omitted] Pilot departed TX42 for transition flight to kiws after maintenance. Ten minutes into transition flight, the pilot felt an engine… ## Docket (6 files) The files NTSB released with the investigation on March 27, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97809. 5.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471399&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Engine Examination Photos (item 2, .PDF, 7 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471404&FileExtension=.PDF&FileName=Engine%20Examination%20Photos-Master.PDF - Maintenance Records - Airframe (item 3, .PDF, 518 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471401&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Airframe-Master.PDF - Maintenance Records - Engine (item 4, .PDF, 719 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471402&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine-Master.PDF - Maintenance Records - Propeller (item 5, .PDF, 312 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471403&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Propeller-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471405&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.