# NTSB CEN19LA055: Beech 36, N2021T, Fredericksburg, TX, January 17, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: January 17, 2019, 16:50 local (22:50 UTC) - Place: Fredericksburg, TX - Coordinates: 30.260555, -98.906944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.2606&lon=-98.9069&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Textron Aviation, Inc, FAA FSDO, Lycoming Engines - NTSB case key (mKey): 98840 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98840/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98840 - Page: https://openairdocs.org/ntsb/CEN19LA055 ## Probable cause The loss of engine power due to fatigue failure of the crankshaft. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151604), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Fatigue/wear/corrosion (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151604), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: 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) - [Maneuvering: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150); cases with it: [Beech A36, 3 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=1151604), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) - [Enroute: 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) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N2021T-2021-07-10), registration cancelled 2021-07-10, S/N E-1325, built 1978 (OpenAirDocs) - Reported make and model: Beech 36 (NO SERIES) - 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-1325 - Year built: 1978 - Airframe hours: 3940.4 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; 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 ## 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 20190117000249A](https://openairdocs.org/incident/20190117000249A), Jan 17, 2019: Beech A36, Fredericksburg, TX, Destroyed, 1 fatal. During VFR personal flight the private pilot declared an emergency and continued to fly towards T82. N2021T attempted an off field landing approximately 1/2… ## Docket (9 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98840. 10.1 MB in all. - Site location (item 1, PDF, 2 pages, 630 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9441505&FileExtension=pdf&FileName=Radar%20data%20maps-Rel.pdf - Pilot record (excerpt) (item 2, PDF, 1 page, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9440832&FileExtension=pdf&FileName=A36%20time-Rel.pdf - Maintenance records (excerpt) (item 3, PDF, 4 pages, 838 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9441647&FileExtension=pdf&FileName=MX_Redacted-Rel.pdf - Toxicological report (item 4, PDF, 1 page, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9440760&FileExtension=pdf&FileName=Pilot%20tox%202_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 5, PDF, 2 pages, 683 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9441656&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 6, PDF, 1 page, 194 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9441271&FileExtension=pdf&FileName=Wreckage%20Release%20Form%20(02-10-2010)_Redacted-Rel.pdf - Materials laboratory factual report 20-013 (item 7, PDF, 7 pages, 8 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9844945&FileExtension=pdf&FileName=20-013-Rel.pdf - Materials laboratory factual report 20-013 errata (item 8, PDF, 1 page, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9908703&FileExtension=pdf&FileName=Lab%20Report%20errata-Rel.pdf - Photos (item 9, PDF, 7 pages, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9847442&FileExtension=pdf&FileName=Photos-Rel.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.