CEN20LA292

NTSB accident investigation · Beech A23-24 · Burns Flat, OK · July 19, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
July 18, 2020, 22:45 local (Jul 19, 2020, 03:45 UTC)
Place
Burns Flat, OK
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N3412CBeech A23-24
Defining event
Enroute-cruise: Loss of engine power (partial)
Weather
Visual (VMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration, Oklahoma City
FAA report
20200718019159A
Case key
101629

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 mechanic’s improper maintenance when he reinstalled the fuel servo during the last annual inspection, which resulted in a loss of engine power during cruise flight when the throttle control rod-end disconnected from the fuel servo throttle linkage.

Findings · 4

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 controls: power leverAircraft › Aircraft power plant · InoperativeBeech A23-24: 1 caseAll aircraft: 95 casesProbable cause
Engine controls: power leverAircraft › Aircraft power plant · Incorrect service/maintenanceBeech A23-24: 1 caseAll aircraft: 95 casesProbable cause
Misc hardware: fastenersAircraft › Fluids/misc hardware · Incorrect service/maintenanceBeech A23-24: 1 caseAll aircraft: 58 casesProbable cause
Maintenance: installationPersonnel issues › Task performance · Maintenance personnelBeech A23-24: 1 caseAll aircraft: 371 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 pilot and his 3 passengers were on a personal night flight when the airplane had a gradual loss of engine power. The pilot was unable to restore engine power and a forced landing was completed to a grass field. The airplane’s main landing gear collapsed when the pilot intentionally swerved the airplane to avoid a tree after landing, which resulted in substantial damage to the horizontal stabilizer and both wings. A postaccident examination revealed that the throttle control rod-end was not connected to the fuel servo throttle linkage. Additionally, the required retaining bolt, washer, and self-locking nut were not located during the investigation. The airplane had accumulated 8.72 flight hours since the last annual inspection, during which the fuel servo had been removed from the engine and overhauled. It is likely that the mechanic who reinstalled the fuel servo did not adequately torque the self-locking nut that secured the retaining bolt, which allowed the self-locking nut to back-off the retaining bolt. The airplane had a partial loss of engine power when the throttle control rod-end disconnected from the unsecured retaining bolt. The pilot did not have the ability to control engine power after the throttle control rod-end disconnected from the fuel servo throttle linkage.

Factual narrative

On July 18, 2020, about 2245 central daylight time, a Beech A23-24 airplane, N3412V, was substantially damaged when it was involved in an accident near Burns Flat, Oklahoma. The pilot and his 3 passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while established in cruise flight the airplane had a gradual loss of engine power. He was unable to restore engine power by switching fuel tanks, turning on the fuel boost pump, and advancing the throttle, mixture, and propeller controls full forward. The pilot made a forced landing in a grass field. After touchdown the airplane traversed over 3 large terraces, and the main landing gear collapsed when the pilot tried to swerve the airplane to avoid a tree. The horizontal stabilizer and both wings were substantially damaged during the forced landing. The airplane was examined at the accident site by a Federal Aviation Administration airworthiness inspector. Both wing fuel tanks contained about 25 gallons of 100 low-lead aviation fuel. The throttle control was very loose when moved by hand in the cockpit. A visual examination revealed that the throttle control rod-end was not connected to the fuel servo throttle linkage. (Figure 1) The required retaining bolt, washer, and self-locking nut were not located during the investigation. Figure 1. Throttle control rod-end found disconnected from the fuel servo throttle linkage. The airplane had accumulated 8.72 flight hours since the last annual inspection that was completed on October 22, 2019. The inspection authorized (IA) mechanic who had completed the annual inspection stated that the fuel servo had been removed from the engine and overhauled in conjunction with the annual inspection. The IA mechanic stated that he personally reinstalled the overhauled fuel servo on the engine, while another individual moved the throttle and mixture controls in the cockpit. The IA mechanic stated that it is his standard practice to connect both the throttle and mixture controls to the fuel servo at the same time. The IA mechanic stated that he likely reused the bolt and washer to connect the throttle control rod-end to the fuel servo throttle linkage, and that it is also possible that he reused the self-locking nut. However, he would not have reused the self-locking nut if it had fully engaged the bolt threads by hand. The IA mechanic stated that he used two wrenches to secure the self-locking nut and that he did not use a torque wrench. A review of the Beech A23-24 Maintenance Manual revealed no specific assembly instructions on how to physically connect the throttle control rod-end to the fuel servo throttle linkage. The Beech A23-24 Illustrated Parts Catalog specified that the throttle control rod-end be attached to the fuel servo throttle linkage with a 169-910021 bolt, AN960-10 washer, and MS20365-1032 self-locking nut.

Aircraft

Registration
N3412C
Reported as
Beech A23-24
Category
Airplane
Serial number
MA-357
Built
1969
Airframe hours
1,717.76
Engine
Lycoming IO-360-A1B, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 22, 2019 · 8.72 hours before
Departed
ELK · Elk City, OK
Equipment
Stall warning system, Handheld GPS

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
27
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 3, 2020
Seat
Left
Restraint
Lap only
Flight hours
309.6 total · 8.4 in this make and model · 267.6 as pilot in command · 8.4 in the last 90 days · 8.4 in the last 30 days · 1.5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
160° at 17 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 66 °F
Altimeter
29.98 inHg
Observed at
CSM, 2.5 nm away

Docket · 8

The files NTSB released with the investigation on February 24, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.9 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.