# NTSB CEN22LA037: Beech K35, N899RW, Hammond, LA, October 28, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: October 28, 2021, 16:26 local (21:26 UTC) - Place: Hammond, LA - Coordinates: 30.478889, -90.384167 - Nearby events: https://openairdocs.org/map.md?lat=30.4789&lon=-90.3842&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA - FSDO - NTSB case key (mKey): 104258 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22LA037 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104258/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104258 - Page: https://openairdocs.org/ntsb/CEN22LA037 ## Probable cause A complete loss of engine power due to oil starvation as a result of the oil filter safety wire fracturing and the oil filter becoming loose in flight for a reason that could not be determined given the evidence available during the investigation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=1151524), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) - [Fluids: oil](https://openairdocs.org/ntsb-findings/01071020): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01071020/cases.md?model=1151524), [All aircraft, 174 cases](https://openairdocs.org/ntsb-findings/01071020/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Owner/builder; cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=1151524), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Engine (reciprocating): recip eng oil sys](https://openairdocs.org/ntsb-findings/01058550): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Beech K35, 1 case](https://openairdocs.org/ntsb-findings/01058550/cases.md?model=1151524), [All aircraft, 130 cases](https://openairdocs.org/ntsb-findings/01058550/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech K35, 5 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151524), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Approach: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech K35, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151524), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing-flare/touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech K35, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151524), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that while on approach to the airport, smoke filled the cockpit and the oil pressure gauge indicated zero. Unable to make the runway, the pilot declared an emergency and turned toward a nearby interstate. During descent, the engine lost total power. The airplane touched down between traffic, and as the airplane slowed, the right wing struck a truck. The airplane swerved off the pavement and it came to rest nose down in the median. During an on-scene examination, oil was observed along the bottom and right side of the airplane. The engine cowling was removed, and oil was noted inside the cowling and on the engine components near the oil filter. The oil filter safety wire was fractured and separated allowing the oil filter to rotate freely when turned by hand. The pilot who was not a licensed mechanic performed his own oil and oil filter changes on this airplane. When asked about safety wire and how to apply it, he said he was unaware of specific safety wire guidance, he “just installed it.” It was evident that the loss of engine power resulted due to oil starvation as a result of the loose oil filter. Given the available evidence it it could not be determined why the oil filter safety wire fractured or if it was properly installed. ## Factual narrative On October 28, 2021, about 1626 central daylight time, a Beech K35, N899RW, was substantially damaged when it was involved in an accident near Hammond, Louisiana. The pilot and two passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that shortly after being cleared to land at the Hammond Northshore Regional Airport (HDC), Hammond, Louisiana, smoke filled the cockpit and the oil pressure gauge indicated zero. Unable to make it to the runway, the pilot declared an emergency and turned toward a nearby interstate. During the descent, the engine lost total power. The airplane touched down between traffic, and as the airplane slowed, the right wing struck a truck. The airplane swerved right, then left, and exited the pavement. It came to rest came to rest nose down against the median fence. The right wing sustained substantial damage. A Federal Aviation Administration (FAA) Inspector went on scene and observed oil along the bottom and right side of the airplane. The engine cowling was removed, and oil was noted inside the cowling and on the engine components near the oil filter. The oil filter safety wire was fractured and separated allowing the oil filter to rotate freely when turned by hand. A portion of the safety wire remained attached to the oil filter. The remainder of the safety wire was lost in the high vegetation at the accident site. The pilot reported that he conducted the airplane’s most recent oil and oil filter change, about one year prior. He estimated that he had flown the airplane about 60 hours since the oil change. He further reported that he was not a mechanic, but he has done maintenance and oil changes on this airplane for a “very long time.” When asked about safety wire and how to apply it, he said he was unaware of specific safety wire guidance, he “just installed it.” A representative from Textron Aviation reported the aircraft manual does not contain safety wire procedures. It is considered a basic knowledge item for a mechanic. In 2005, the FAA Safety Team (FAASTeam) released a fact sheet titled Safety Wire. It states in part: “if you’re doing owner-performed maintenance, make sure that you know what you’re doing, and get a second set of eyes to look at your work after you’re done.” ## Aircraft - Registration: [N899RW](https://openairdocs.org/deregistered/N899RW-2022-12-24), registration cancelled 2022-12-24, S/N D-6064 (OpenAirDocs) - Reported make and model: BEECH K35 - Registry model: [Beech K35](https://openairdocs.org/model/beech-k35) (registry code 1151524) (OpenAirDocs) - Category: Airplane - Serial number: D-6064 - Year built: 1959 - Airframe hours: 3200 - Engines: Continental IO-470 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: None - Last inspection: Annual, June 15, 2021 - Departed: TME, Houston, TX - Destination: Same as departure - Airport: HDC, Hammond Northshore Regional Airport, runway 31, 2,502 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed, with waivers/limitations; seat: left; restraint: 4-point; flight hours: 6,000 total, 4,000 in this make and model, 20 in the last 90 days, 5 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 9 knots, gusting 16 - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft overcast - Temperature: 64 °F, dew point 46 °F - Altimeter: 29.64 inHg - Observed at: KHDC, 3 nm away - METAR: KHDC 282123Z AUTO 28009G16KT 10SM OVC055 18/08 A2964 RMK AO2 ## 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 20211028023079A](https://openairdocs.org/incident/20211028023079A), Oct 28, 2021: Beech K35, Hammond, LA, Substantial damage. On October 28th, a Beechcraft bonanza [privacy data omitted]was flying from katy, Texas (iws) to Hammond, Louisiana (hdc) with 3 soles onboard. While on… ## Docket (4 files) The files NTSB released with the investigation on June 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104258. 3.8 MB in all. - Record of conversation - pilot/owner/mechanic (item 1, PDF, 2 pages, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13060326&FileExtension=pdf&FileName=ROC%20Pilot-Rel.pdf - Record of conversation and on scene photos - FAA inspector (item 2, PDF, 6 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13060061&FileExtension=pdf&FileName=ROC%20FAA%20with%20on%20scene%20photos%20%20%2099999%20again-Rel.pdf - Record of email - Textron aviation representative (item 3, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13059990&FileExtension=pdf&FileName=roe%20textron-Rel.pdf - Safety wire fact sheet from the federal aviation administration safety team (item 4, PDF, 2 pages, 550 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13060258&FileExtension=pdf&FileName=safety%20wire%20fast%20team%20sheet-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.