# NTSB CEN20LA288: Beech 36, N630JL, Independence, MO, July 16, 2020 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: July 16, 2020, 17:20 local (22:20 UTC) - Place: Independence, MO - Coordinates: 39.125278, -94.331947 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.1253&lon=-94.3319&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 101617 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA288 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101617/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101617 - Page: https://openairdocs.org/ntsb/CEN20LA288 ## Probable cause Failure of the No. 5 piston head and ring, which resulted in a total loss of engine power and the pilot’s decision to takeoff with a known mechanical issue. ## 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 A36, 5 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=1151604), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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) ## Analysis During the initial climb, the pilot noted a rising cylinder head temperature which shortly after led to the airplane oscillating back and forth and responding slowly. The pilot set up for a forced landing and the airplane began to shake and was unable to hold altitude. During the approach to landing, the engine quit, and the pilot minimized his bank angle to stay out of a stall situation. When the airplane touched down, the pilot lost directional control and the airplane skidded off the road into a grassy area. The airplane sustained substantial damage to the wings and fuselage. The pilot reported that on the previous flight, he was in cruise flight at 8,000 ft when he noted that the airplane began “moving back and forth.” He scanned the instruments and saw the cylinder head temperatures (CHT) for the Nos. 5 and 6 cylinders were “running in the red” along with oil temperature. The pilot diverted and landed uneventfully. During the descent for landing, the engine temperatures returned to normal, and he landed uneventfully. The pilot called the owner and discussed what had occurred. The owner suggested that if the pilot was comfortable, he should return to the home airfield. The pilot agreed to return if the taxi and engine run-up checked normal. The engine run-up was normal, and the pilot departed the airport without incident. Postaccident examination of the engine found that the No. 5 cylinder head and piston ring had failed with signatures of denotation. Additionally, the turbocharger oil seal had failed. The pilot stated that he was not running the engine lean with fuel. ## Factual narrative On July 16, 2020, about 1720 central daylight time, a Beech 36 airplane, N630JL, was substantially damaged when it was involved in an accident near Independence, Missouri. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot recalled that on the previous flight, he was in cruise flight at 8,000 ft when he noted that the airplane began “moving back and forth.” He scanned the instruments and saw the cylinder head temperatures (CHT) for the Nos. 5 and 6 cylinders were “running in the red” along with oil temperature. The pilot diverted to the nearest airport. During the descent for landing, the engine temperatures returned to normal, and he landed uneventfully. The pilot called the owner and discussed what had occurred. The owner suggested that if the pilot was comfortable, he should return to the home airfield. Since the engine temperatures returned to normal during the descent and landing, the pilot agreed to return if the taxi and engine run-up checked normal. The engine run-up was normal, and the pilot departed the airport without incident. During the initial climb, about 4 miles from the airport, the No. 4 CHT increased significantly above the rest of the cylinders. The pilot continued the climb, and the airplane began moving back and forth again and began to respond “sluggishly.” The airplane shook and the pilot was unable to maintain altitude, so he set up for a forced landing to a road. During the approach to landing, the engine quit, and the pilot minimized his bank angle to stay out of a stall situation. When the airplane touched down, the pilot lost directional control and the airplane skidded off the road into a grassy area. The airplane sustained substantial damage to the wings and fuselage. Examination of the engine found that the No. 5 cylinder head and piston ring had failed with signatures of denotation. Additionally, the turbocharger oil seal had failed. The pilot stated that he was not running lean of peak with fuel. ## Aircraft - Registration: [N630JL](https://openairdocs.org/aircraft/N630JL), registered now, S/N E-821, built 1976 (OpenAirDocs) - Reported make and model: Beech 36 (A36) - 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-821 - Year built: 1976 - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Strategos International Llc - Registered owner: Strategos International Llc - Airworthiness certificate: Standard, Normal - Destination: KLXT, Lee's Summit, MO - Airport: GPH, Midwest Ntl Air Center ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: none; commercial, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 1,470 total, 40 in this make and model, 555.6 as pilot in command, 264.4 in the last 90 days, 86.3 in the last 30 days, 4.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 5 knots - Visibility: 10 statute miles - Temperature: 84 °F, dew point 70 °F - Altimeter: 30.04 inHg - Observed at: KLXT, 10 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 20200716010629A](https://openairdocs.org/incident/20200716010629A), Jul 16, 2020: Beech A36, Liberty, MO, Substantial damage. The pilot stated that while enroute from klxt to kalo, he noticed the aircraft beginning to oscillate from side to side, and he saw that cylinders #5 and 6… ## Docket (3 files) The files NTSB released with the investigation on June 16, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101617. 2.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13800866&FileExtension=pdf&FileName=6120%20CEN20LA288_Redacted-Rel.pdf - Case findings (item 2, PDF, 4 pages, 3 photos, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13964183&FileExtension=pdf&FileName=case%20findings%20cen20la288-Rel.pdf - Statement of party representatives to NTSB investigation (item 3, PDF, 1 page, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13963869&FileExtension=pdf&FileName=CEN20LA288%20Hartzell%20Engine%20Tech%20Party%20Form_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.