CEN19LA055

NTSB accident investigation · Beech 36 · Fredericksburg, TX · January 17, 2019

Accident · FatalClass 3 · LimitedFinal report
Date
January 17, 2019, 16:50 local (22:50 UTC)
Place
Fredericksburg, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N2021TBeech 36
Defining event
Enroute: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Textron Aviation, Inc, FAA FSDO, Lycoming Engines
FAA report
20190117000249A
Case key
98840

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

The loss of engine power due to fatigue failure of the crankshaft.

Findings · 2

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 · Fatigue/wear/corrosionBeech A36: 6 casesAll aircraft: 233 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 accident pilot was in cruise flight in a single-engine airplane when he declared "mayday" on the radio, stating the airplane's engine was on fire. The accident airplane impacted a field, crossed a road, and came to rest upright. A postcrash fire consumed the majority of the airframe. The airplane was equipped with a turbo-charged reciprocating engine and propeller that had been converted under a Supplemental Type Certificate (STC). The engine had accumulated 412.2 hours between the last overhaul and the last annual inspection. The last inspection was about three months before the accident. An examination of the engine revealed fire damage and limited rotation. Disassembly of the engine revealed a broken camshaft and crankshaft. Metallurgical examination of the crankshaft revealed crack arrest marks in the crankshaft, consistent with fatigue, which initiated in the fillet radius at the forward end of the number 6 connecting rod journal. Multiple crack origins and prominent crack arrest lines were consistent with a relatively high stress associated with crack initiation. However, a reason for the high stress or fatigue initiation could not be determined based on the limited airplane records and the damage to the airplane.

Factual narrative

On January 17, 2019, about 1650 central standard time, a Beech A-36 airplane, N2021T, was destroyed when it impacted terrain in Fredericksburg, Texas. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane was flying from Bulverde Airpark, San Antonio, Texas, to Gillespie County Airport (T82), Fredericksburg, Texas, when another pilot reportedly heard a Bonanza (Beech A-36) pilot announce a "mayday" call on the common traffic advisory frequency, indicating the airplane's engine was on fire. A review of aircraft records revealed the pilot had purchased the airplane in October 2018 and had flown the airplane on two flight that month for a flight time of 5.0 hours. The records noted that the engine was last overhauled on December 9, 2010, at a tachometer time of 1,585.1 hours and had accumulated 412.2 hours at the time of the October 2018 annual inspection. The airplane was equipped with a Lycoming TIO-540 reciprocating engine and a Hartzell propeller under Supplemental Type Certificate SA762NW, Machen Inc. engine and propeller conversion. The airplane's initial impact point was the edge of a field about 1 mile north of T82; the airplane then impacted a slightly elevated country road and came to rest upright. A post-crash fire consumed a majority of the airframe. The airplane was initially recovered to an impound yard. After the government shutdown, the wreckage was then moved to aircraft salvage facility near Lancaster, Texas, where an examination was conducted by the National Transportation Safety Board (NTSB) Investigator-in-Charge (IIC), and technical representatives from the engine and airframe manufacturers. A postaccident examination revealed that the engine exhibited fire damage. An attempt to manually rotate the engine was limited due to internal binding. Disassembly of the engine revealed a broken camshaft and crankshaft. The broken parts, along with the cylinders and pistons were sent to the NTSB Material Laboratory for examination. The laboratory noted crack arrest marks in the crankshaft, consistent with fatigue. The examination also noted that the fatigue initiated in the fillet radius at the forward end of the number 6 connecting rod journal. Multiple crack origins and prominent crack arrest lines were consistent with the relatively high stress associated with crack initiation.

Aircraft

Registration
N2021T
Reported as
Beech 36 (NO SERIES)
Category
Airplane
Serial number
E-1325
Built
1978
Airframe hours
3,940.4
Engine
Lycoming TSIO-540, reciprocating
Damage
Destroyed
Fire
Both
Flight
Personal · Part 91
Operator
Big Fuga LLC
Registered owner
Big Fuga LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 1, 2018
Departed
1T8 · San Antonio, TX
Destination
1T8 · San Antonio, TX
Airport
T82 · Gillespie County Airport

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
50
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
October 28, 2018
Seat
Left
Toxicology
Performed
Flight hours
550 total · 5 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 37 °F
Altimeter
30.11 inHg
Observed at
T82, 1 nm away

Docket · 9

The files NTSB released with the investigation on October 9, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.1 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.