# NTSB CEN20FA096: Beech A36, N3266Q, Rogers, MN, February 22, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: February 22, 2020, 11:11 local (17:11 UTC) - Place: Rogers, MN - Coordinates: 45.198055, -93.652778 - Nearby events: https://openairdocs.org/map.md?lat=45.1981&lon=-93.6528&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: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Continental Aerospace Technologies, Textron Aviation, Flight District Standards Office - NTSB case key (mKey): 100978 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20FA096 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100978/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100978 - Page: https://openairdocs.org/ntsb/CEN20FA096 ## Probable cause Inadequate maintenance that resulted in improper torque to the engine-driven fuel pump inlet fitting, which led to a loss of engine power and forced landing into unsuitable terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fuel system](https://openairdocs.org/ntsb-findings/01022800): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md?model=1151604), [All aircraft, 181 cases](https://openairdocs.org/ntsb-findings/01022800/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on equipment (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=1151604), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151604), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); 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) - [Landing: 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 Radar data indicate that the airplane was in cruise flight about 1,000 ft above ground level (agl) when it climbed about 300 ft and decelerated from about 170 to 110 knots groundspeed. The airplane subsequently turned away from populated areas and descended at 70 to 75 knots groundspeed with a steady vertical speed. About 100 ft agl, the airplane turned right and impacted forested terrain, which resulted in a postcrash fire. The flight profile was consistent with a power loss, followed by a forced landing attempt. Examination at the accident site revealed the flexible fuel hose b-nut connecting the firewall fuel outlet fitting to the inlet fitting on the engine-driven fuel pump was only finger tight, and green ‘torque putty’ did not align between the b-nut shoulder of the outlet fitting and the fuel pump’s inlet. Both findings were consistent with improper torque application during maintenance. The loose b-nut could have resulted in allowing air to enter the fuel line which would result in a loss of engine power. Examination at the recovery facility and an engine test run revealed no other anomalies that would have precluded normal engine operation. The engine was installed about 4 months prior to the accident and had accumulated about 21 hours. No maintenance was recorded after the inspections that were conducted in conjunction with the engine installation. An autopsy revealed the pilot had moderate-to-severe atherosclerosis, but there was no evidence of any acute or past coronary event. While the pilot was at increased risk for an acute cardiac event, there was no evidence this occurred, and the pilot’s coronary artery disease was determined to not be a factor in the accident. ## Factual narrative According to maintenance records, the originally installed IO-550-B engine was removed and a model IO-550-R engine was installed on October 17, 2019, in accordance with supplemental type certificate #SA10145SC-D. After installation a 60-minute engine run was completed, followed by a break-in run for 130 minutes. The engine oil was changed, and filters were inspected, with no defects noted. No maintenance entries were recorded after October 17, 2019. A review of flight data from FlightAware indicated the airplane was airborne about 16.5 hours after the new engine was installed. On February 22, 2020, about 1111 central standard time, a Beech A36 airplane, N3266Q, was destroyed when it was involved in an accident near Rogers, Minnesota. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to air traffic control (ATC) data, the flight departed at 1100 from Flying Cloud Airport (FCM), Eden Prairie, Minnesota and was destined for Breezy Point Airport (8MN3), Breezy Point, Minnesota. After takeoff from FCM, the airplane turned northwest and climbed to 2,000 ft mean sea level (msl). No radio communications occurred after the airplane exited FCM airspace. While in cruise flight, the airplane climbed from 2,000 to 2,300 ft msl and decelerated from about 170 to 110 knots groundspeed. The airplane subsequently turned left away from populated areas and descended with a steady vertical speed at 70 to 75 knots groundspeed. At 1,100 ft msl (200 ft agl), the airplane turned right and the last ATC data recorded was 1,000 ft msl (100 ft agl), 72 knots groundspeed, and 243°. Figure 1 – Flight Path of Accident Airplane A witness observed the airplane flying at low altitude toward the southwest and subsequently noted that the airplane’s bank angle increased, followed by a rapid descent. The airplane impacted forested terrain and a post-crash fire occurred. According to the autopsy report, the cause of death in the pilot was multiple blunt force injuries. The medical examiner identified focally severe atherosclerosis in the pilot’s right coronary artery (75-80%) and left anterior descending coronary artery (75%). No other significant natural disease was identified. FAA Forensic Sciences Laboratory toxicology testing was negative for ethanol and tested for drugs. The airplane came to rest upright, with the cabin area and both wings fire damaged. The left wing was separated by tree impact, with the left-wing outboard section located about 20 ft from the main wreckage. The right-wing outboard section was separated and folded under the main wreckage. The three-blade constant speed propeller remained attached to the crankshaft propeller flange, with no damage to the leading edges of the blades. All three blades had rearward bending that began about 12” outboard of the blade roots. The propeller spinner had no spiral damage. A tree branch near the wreckage had 45-degree cuts consistent withpropeller chopping. The engine’s top cowling was separated and exposed the engine. The flexible fuel hose b-nut that connected the firewall fuel outlet fitting to the fuel inlet fitting on the engine-driven fuel pump was found to be finger tight. The green torque putty did not align between the fuel pump’s inlet fitting and the b-nut shoulder of the outlet fitting. The fuel hose b-nut and outlet fitting were disassembled, with no anomalies noted. The fuel mixture control on the engine driven fuel pump was at the full rich stop, with the assembly hardware secure. The throttle control cable was secured to the throttle arm located on the throttle body. The engine driven fuel pump drive coupling was intact and the pump operated smoothly when manually rotated. The fuel system was fire damaged, and the fuel boost pump switch was not located. Disassembly of the fuel selector valve revealed it to be in the left tank position and no obstructions were found in the fuel strainer screen. Both fuel filler caps were installed in their respective filler neck in the wings. The horizontal stabilizers, elevators, vertical stabilizer, and rudder remained attached. Flight control continuity was confirmed to the extent possible due to fire damage. Both flap actuators were in the retracted position and all landing gear were retracted. Cockpit instruments were fire damaged and no readings were possible. An engine test run was conducted at the manufacturer’s facility with NTSB oversight. Nominal parameters were observed during the engine run, which was abbreviated to 3-minute intervals based on concerns of an observed fatigue crack in the propeller flange. During cylinder compression testing after the engine run, #1 to #6-cylinder compression was measured at 60/80, 65/80, 70/80, 69/80, 70/80, 72/80 psi respectively. ## Aircraft - Registration: [N3266Q](https://openairdocs.org/deregistered/N3266Q-2022-10-03), registration cancelled 2022-10-03, S/N E-2966, built 1995 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2966 - Year built: 1995 - Airframe hours: 2921.9 - Engines: Continental IO-550-R 310 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 17, 2019, 18 hours before - Departed: FCM, Minneapolis, MN - Destination: 8MN3, Breezy Point, MN - Equipment: Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review June 1, 2018; seat: left; toxicology performed; flight hours: 4,507 total, 207 in this make and model, 7 in the last 90 days, 3 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 34 °F, dew point 27 °F - Altimeter: 29.96 inHg - Observed at: KMIC, 14 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 20200222002289A](https://openairdocs.org/incident/20200222002289A), Feb 22, 2020: Beech A36, Rogers, MN, Destroyed, 1 fatal. On February 22, 2020, about 1111 central standard time, a Beech A36 airplane, N3266Q, was destroyed after impacting terrain near Rogers, Minnesota. The pilot… ## Docket (14 files) The files NTSB released with the investigation on December 20, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100978. 12.7 MB in all. - Record of conversation with witness (item 1, PDF, 1 page, 140 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12736533&FileExtension=pdf&FileName=Record%20of%20Conversation%20with%20Witness-Rel.pdf - FAA interview record - maintenance facility (item 2, PDF, 2 pages, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12728689&FileExtension=pdf&FileName=FAA%20interview%20--_Redacted-Rel.pdf - Maintenance logs - excerpt (item 3, PDF, 5 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12734126&FileExtension=pdf&FileName=Maintenance%20Logs%20-%20Excerpt_Redacted-Rel.pdf - Air traffic control - flight path information (item 4, PDF, 1 page, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12729091&FileExtension=pdf&FileName=Air%20Traffic%20Control%20-%20Flight%20Path%20Information-Rel.pdf - Air traffic control - adsb data (item 5, PDF, 14 pages, 454 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12729248&FileExtension=pdf&FileName=Air%20Traffic%20Control%20-%20ADS-B%20Data-Rel.pdf - Air traffic control report - excerpt (item 6, PDF, 2 pages, 615 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12729258&FileExtension=pdf&FileName=Air%20Traffic%20Control%20Report%20-%20Excerpt-Rel.pdf - Flight history - flightaware (item 7, PDF, 1 page, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12734407&FileExtension=pdf&FileName=Flight%20History%20-%20FlightAware-Rel.pdf - Photos (item 8, PDF, 4 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12756369&FileExtension=pdf&FileName=Photos-Rel.pdf - Aircraft examinations (item 9, PDF, 6 pages, 736 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12723277&FileExtension=pdf&FileName=Aircraft%20Examinations%20Summary-Rel.pdf - Engine run - operational test log (item 10, PDF, 1 page, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12725346&FileExtension=pdf&FileName=Engine%20Operational%20Test%20Log-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12723012&FileExtension=pdf&FileName=Tox_Redacted-Rel.pdf - Autopsy memorandum (item 12, PDF, 1 page, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12735811&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 2 pages, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12723002&FileExtension=pdf&FileName=Party%20Member%20Statements--_Redacted-Rel.pdf - Wreckage release (item 14, PDF, 1 page, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12748418&FileExtension=pdf&FileName=Wreckage%20release_Redacted-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.