CEN22LA233

NTSB accident investigation · Beech A36 · Amarillo, TX · June 4, 2022

Accident · No injuriesClass 3 · LimitedFinal report
Date
June 4, 2022, 09:00 local (14:00 UTC)
Place
Amarillo, TX
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N9087SBeech A36
Defining event
Approach-IFR final approach: Powerplant sys/comp malf/fail
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration, Lubbock FSDO
FAA report
20220604009659A
Case key
105201

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 loss of engine power due to a leak in the fuel control assembly. Contributing to the accident was the inadequate maintenance of the fuel control assembly.

Findings · 3

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 fuel and control: fuel control/carburetorAircraft › Aircraft power plant · Not serviced/maintainedBeech A36: 1 caseAll aircraft: 195 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBeech A36: 2 casesAll aircraft: 320 casesProbable cause
Record-keeping: aircraft/maintenance logsPersonnel issues › Task performance · Not specifiedBeech A36: 1 caseAll aircraft: 21 cases

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 stated that during a nonprecision instrument approach to the destination airport, he applied full engine power when he noticed that the airplane airspeed was decreasing. He realized that the engine lost power and was unsuccessful in attempts at regaining engine power. He performed a forced landing on a pasture during which the airplane sustained substantial damage that included damage to the right wing. A postaccident examination of the wreckage revealed streaks fuel on the left side of the engine cowling. An examination of the engine revealed the fuel control assembly was leaking at the mixture control shaft’s O-ring. The O-ring was intact and did not exhibit separation. However, the outside diameter of the O-ring was less than the diameter of the mixture control shaft consistent with wear. A leak within the fuel control assembly would have allowed air to enter/fuel to exit the assembly resulting in improper fuel metering and a loss of engine power. No other mechanical anomalies were noted with the airframe and engine that would have precluded normal operations. Maintenance records showed that the last overhaul of the fuel control assembly was performed during an engine overhaul in 1996. There were no subsequent records or evidence that indicated the assembly was overhauled after 1996. The engine manufacturer’s recommended time between overhaul (TBO) was 12 years. The engine manufacturer’s standard practice manual stated that engine accessories must be overhauled at the time of engine overhaul. The engine and fuel control assembly exceeded the engine manufacturer’s recommended TBO.

Factual narrative

On June 4, 2022, at 0900 central daylight time, a Beech A36, N9087S, was involved in an accident near Amarillo, Texas. The airplane sustained substantial damage. The pilot and pilot-rated passenger were uninjured. The airplane was operated under Title 14 Code of Federal Regulations Part 91 as a personal flight. The pilot stated that during an RNAV approach to runway 35 at the destination airport, he attempted to apply full engine power when he noticed that the airspeed was decreasing. He realized that the engine lost power and he was unsuccessful in his attempts at regaining engine power. He performed a forced landing on a pasture about 2-3 miles from the airport, during which the airplane sustained substantial damage that included damage to the right wing. Postacccident examination of the airplane revealed that the left side of the engine cowl had a blue stain, consistent in color with 100 low lead aviation fuel, that extended in the aft direction. A postaccident engine run was attempted but could not be completed due to fuel leaking from the fuel control assembly. The fuel control assembly was removed from the engine for bench testing. An attempt was made to bench test the fuel control assembly, but due to fuel leaking from the control arm shaft, the bench test could not be performed. The safety wire around the fuel control assembly had a metal stamp with “TCM,” which indicated that the last assembly of the fuel control assembly was performed by Teledyne Continental Motors (TCM). Disassembly of the fuel control assembly revealed that the leak was at the mixture control arm shaft O-ring, which was intact and did not exhibit separation. The outside diameter of the O-ring was less than the diameter of the mixture control shaft. TCM records showed that in 1996 the engine and engine accessories were overhauled, which included the fuel control assembly. An engine logbook entry dated July 15, 1996, stated that the engine was installed onto the airplane. An engine logbook entry dated April 1, 2013, noted a tachometer and an engine total time of 772.0 hours. The time since major overhaul (TSMOH) was recorded as “NA.” The logbook entry stated that all work was done in accordance with the TCM IO-520 overhaul manual and that an annual inspection was performed. The entry did not state that an engine overhaul was performed. Subsequent logbook entries referenced the TSMOH of the April 1, 2013, entry. No evidence could be found to indicate that the fuel control assembly had been overhauled since 1996. TCM’s recommended time between overhaul, as stated in Continental Motors Aircraft Engine Service Information Letter SIL98-9C, was 12 years. Several sections in TCM’s Standard Practice Manual stated that the engine accessories must be overhauled at the time of engine overhaul.

Aircraft

Registration
N9087S
Reported as
Beech A36
Category
Airplane
Serial number
E-1299
Built
1978
Airframe hours
5,148.04
Engine
Continental Motors IO 520-BA, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Cda Ventures LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 2021
Departed
OJC · Olathe, KS
Destination
TDW · Amarillo, TX
Flight plan
IFR
Airport
TDW · Tradewind Airport, runway 35, 5,098 × 60 ft, asphalt
Equipment
Electronic primary flight display, Auto-pilot, ADS-B, Stall warning system

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
57
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
June 4, 2020
Seat
Left
Restraint
Lap only
Flight hours
529 total · 21 in this make and model · 500 as pilot in command · 17 in the last 90 days · 12 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
210° at 10 knots
Visibility
10 statute miles
Lowest ceiling
400 ft overcast
Temperature
61 °F, dew point 59 °F
Altimeter
29.95 inHg
Observed at
AMA, 7 nm away

Docket · 6

The files NTSB released with the investigation on January 31, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.0 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.