CEN22LA250

NTSB incident investigation · Beech 58 · Evansville, IN · June 8, 2022

Incident · No injuriesClass 3 · LimitedFinal report
Date
June 8, 2022, 11:00 local (16:00 UTC)
Place
Evansville, IN · Propeller blade separation in flight
Injuries
5 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N78KLBeech 58
Defining event
Enroute: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA Indianapolis FSDO, Hartzell Propeller
FAA report
20220608009879I
Case key
105266

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

On this page

Probable cause

The failure of the propeller blade due to high-cycle fatigue that originated from damage that occurred at an unknown time. Contributing to the accident was the failure to identify the damage before the accident flight.

Findings · 7

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.

Maintenance: repairPersonnel issues › Task performance · Maintenance personnelBeech 58: 2 casesAll aircraft: 99 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · Maintenance personnelBeech 58: 2 casesAll aircraft: 226 casesProbable cause
Maintenance: unauthorized maint/repairPersonnel issues › Task performance · Unknown/Not determinedBeech 58: 1 caseAll aircraft: 14 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Fatigue/wear/corrosionBeech 58: 1 caseAll aircraft: 51 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Inadequate inspectionBeech 58: 1 caseAll aircraft: 51 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · FailureBeech 58: 1 caseAll aircraft: 51 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Incorrect service/maintenanceBeech 58: 1 caseAll aircraft: 51 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 airplane was about 1 hour into the cross-country flight when the pilot heard a “boom” noise. The airframe began vibrating, and the airplane yawed to the left. The pilot contacted approach control and stated that he needed to land the airplane immediately. The pilot was directed to divert, and he landed the airplane without incident. After exiting the airplane, the pilot noticed that one of the aluminum propeller blades on the left engine had separated about midspan, resulting in minor damage. The “boom” that the pilot heard was likely the blade separating in flight. Examination of the fracture surface revealed signatures consistent with high-cycle fatigue failure. The fatigue origin area was coincident with an area of damage that was covered with a thick black paint. The paint had a slightly different composition than the thinner layer of black paint on the rest of the blade. No evidence indicated any repair in the area of the damage and investigators were unable to determine when the damage was painted. Although the investigation could not determine, based on the available evidence for this incident, when the damage that led to the fracture occurred, or when the damage was painted, it is likely the damaged area was present at the airplane’s most recent 100-hour inspection, which occurred 28 hours before the incident. The presence of the black paint could have made it difficult to detect the damage during the mechanic’s visual inspection of the blade surface during the airplane’s most recent 100-hour inspection. Had the damage been detected during the 100-hr inspection it should have triggered maintenance of the propeller blade. The damage was also hidden but detectable during the preflight inspection conducted by the pilot before the accident flight. Had the damage been detected by the pilot, it should have triggered further examination and maintenance of the propeller blade.

Factual narrative

On June 8, 2022, about 1100 central daylight time, a Beech 58 airplane, N78KL, sustained minor damage when it was involved in an incident near Evansville, Indiana. The pilot and four passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that no anomalies were noted during the preflight inspection of the airplane. The airplane departed from Kirk Field Airport (PGR), Paragould, Arkansas, with a destination of James M. Cox Dayton International Airport (DAY), Dayton, Ohio. When the airplane was about 1 hour into the flight, while at an altitude of about 9,000 ft mean sea level and an airspeed of about 180 knots, the pilot heard a “boom” noise. The airframe began vibrating, and the airplane yawed to the left. The pilot contacted approach control and reported that he needed to land the airplane immediately. The pilot was directed to divert to Evansville Regional Airport (EVV), Evansville, Indiana. The pilot then reduced the power on the right engine and maneuvered the airplane for landing on runway 18 at EVV. The pilot was able to land the airplane without incident. After the pilot exited the airplane, he noticed that one of the aluminum propeller blades on the left engine had separated about mid-span. The separated blade segment was not recovered. No other damage was observed on the propeller, engine, or airframe. The airplane had two Hartzell Propeller model HC-C4YF-2E/FC7063Q propellers that each had four blades. The propellers were installed on the airplane via Federal Aviation Administration (FAA) Supplemental Type Certificate SA1762SO on November 12, 2002. The fractured blade was manufactured on September 6, 2000. Airplane registration records indicate that the airplane was sold on May 13, 2021. The airplane’s previous 100-hour inspection, completed before the airplane was sold, occurred on December 17, 2020, when the propeller had accumulated 1,097 hours of time since overhaul (TSO). The most recent 100 hour inspection of the propeller occurred on January 10, 2022, when the propeller had accumulated 1,172 hours of TSO. The propeller had accumulated 1,200 hours of TSO at the time of the incident. The fractured blade (design number FC7063Q and serial number J51843) was removed from its hub and was provided to the National Transportation Safety Board Materials Laboratory for further examination. The examination of the fracture surface revealed signatures consistent with high-cycle fatigue failure. The blade fractured was about 16.9 inches from the blade butt. The deice boot was severed at the fracture and was partially debonded on both the camber and face sides. The fatigue origin area was coincident with an area of damage that was covered with a thick black paint that had a slightly different composition than the thinner layer of black paint on the rest of the blade. No evidence indicated any repair in the area of the damage. The pilot reported that he was notaware of any paint work performed on the blades or any previous propeller blade impacts. The mechanic who performed the most recent 100-hour inspection reported that he performed a visual examination of the blades and recalled that only normal damage was observed on the blades, such as small nicks, which he dressed. He did not remember if he did any paint work on the blades. FAA Advisory Circular 20-37E, Aircraft Propeller Maintenance, discusses propeller blade failures and states in part the following: A propeller is one of the most highly stressed components on an aircraft. During normal operation, 10 to 25 tons of centrifugal force pull the blades from the hub while the blades are bending and flexing due to thrust and torque loads and engine, aerodynamic and gyroscopic vibratory loads. A properly maintained propeller is designed to perform normally under these loads, but when propeller components are damaged by corrosion, stone nicks, ground strikes, etc., an additional unintended stress concentration is imposed, and the design margin of safety may not be adequate. The result is excessive stress and the propeller may fail. Additional causes of overstress conditions are exposure to overspeed conditions, other object strikes, unauthorized alterations, engine problems, worn engine vibration dampers, lightning strike, etc. Most mechanical damage takes the form of sharp-edged nicks and scratches created by the displacement of material from the blade surface and corrosion that forms pits and other defects in the blade surface. This small-scale damage tends to concentrate stress in the affected area and eventually, these high-stress areas may develop cracks. As a crack propagates, the stress becomes increasingly concentrated, increasing the crack growth rate. The growing crack may result in blade failure. Many types of damage cause propellers to fail or become unairworthy. FAA data on propeller failures indicates that the majority of failures occur in the blade at the tip region, usually within several inches from the tip and often due to a crack initiator such as a pit, nick, or gouge. However, a blade failure can occur along any portion of a blade, including the mid-blade, shank, and hub, particularly when nicks, scratches, corrosion, and cracks are present. Therefore, during propeller inspection and routine maintenance, it is important to inspect the entire blade. FAA Special Airworthiness Bulletin NE-08-22, Propeller Search Inspection (General Visual Inspection), discusses cosmetic repairs and states in part the following: For exposed aluminum surfaces, an exposed defect can be inspected while a hidden defect cannot be inspected. A cosmetic repair that creates a hidden defect in an exposed surface is an unacceptable practice.

Aircraft

Registration
N78KL
Reported as
Beech 58 (UNDESIGNATED SERIES)
Category
Airplane
Serial number
TH-1578
Built
1990
Airframe hours
2,969.6
Engines
Continental Motors IO-550 Series, 300 horsepower, reciprocatingContinental Motors IO-550 Series, 300 horsepower, reciprocating
Damage
Minor damage
Flight
Personal · Part 91
Operator
Nea Industrial LLC, doing business as None
Registered owner
Nea Industrial LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 10, 2022 · 27.8 hours before
Departed
PGR · Paragould, AR
Destination
DAY · Dayton, OH
Flight plan
IFR
Equipment
ADS-B, Auto-pilot, Onboard weather, 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
61
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
March 21, 2021
Seat
Left
Restraint
3-point
Flight hours
3,734 total · 270 in this make and model · 3,178 as pilot in command · 120 in the last 90 days · 35 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 11 knots
Visibility
9 statute miles
Lowest ceiling
1,600 ft broken
Temperature
77 °F, dew point 70 °F
Altimeter
29.82 inHg
Observed at
KEVV, 1 nm away
METAR
KEVV 081554Z 17011KT 9SM BKN016 25/21 A2982 RMK AO2 SLP092 T02500206

Docket · 11

The files NTSB released with the investigation on January 30, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 31.8 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.