CHI04LA019

NTSB accident investigation · Beech A36 · Davenport, IA · October 16, 2003

Accident · No injuriesLimited investigationFinal report
Date
October 15, 2003, 22:17 local (Oct 16, 2003, 03:17 UTC)
Place
Davenport, IA
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N25496Beech A36
Weather
Visual (VMC) · Night
Status
Completed · report April 28, 2005
Report
Approved by Office Director
Parties
FAA
FAA report
20031015025879A
Case key
58231

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

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Probable cause

A loss of engine power due to fuel starvation as a result of the improper installation of the fuel nozzle. Also causal was the engine manufacturer's improper installation instructions for the nozzle pressure port plug on the fuel manifold valve. A factor associated with the accident was the corn crop which was contacted during the forced landing.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfClimb - to cruise
Instructions,written/verbal - improperManufacturerCause
Fuel system,fuel flow divider/distributor - leakCause
Maintenance,overhaul - improperManufacturerCause
Fluid,fuel - starvationCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency landing
Terrain condition - cropFactor

Analysis

The airplane collided with a corn crop following a loss of engine power shortly after takeoff. The pilot stated that during another flight earlier on the day of the accident, he noticed an odor of fuel. He was unable to identify the source of the smell. The airplane operated normally and the fuel flow was normal. The pilot reported that during the next flight, he was once again able to smell fuel and when climbing through 3,000 feet, the engine lost power. The pilot was unable to restart the engine. After landing in the corn field, smoke entered the cabin. Post accident inspection of the engine revealed the nozzle pressure port plug on the aft side of the fuel manifold valve was not in place, nor was it located. Blue fuel stains were evident under the left magneto and on the engine case under the right cylinders. The plug hole and the area surrounding the hole were inspected and there was no evidence of torque putty (Loctite) having been used when the plug was installed. The injector line fittings and the fuel inlet fitting had torque putty applied to them. The engine had operated 10.1 hours since it was overhauled. Continental Motors reviewed their build-up procedures for the IO-550 engines and determined that the requirement for applying Loctite to the suspect fitting had been removed from the procedures. Continental Motors subsequently issued a Quality Alert re-inserting the requirement for Loctite to be applied to the nozzle pressure port plug at installation. The procedures manual and build-up instructions for the IO-550 were also revised to include the requirement that Loctite be applied to the plug.

Factual narrative

On October 15, 2003, at 2217 central daylight time, a Beech A36, N25496, operated by Carver Aero collided with a corn crop following a loss of engine power shortly after takeoff from the Davenport Municipal Airport (DVN), Davenport, Iowa. The airline transport rated pilot was not injured. The airplane was substantially damaged. The 14 CFR Part 135 cargo flight was operating in visual meteorological conditions on an instrument flight rules flight plan. The flight originated from DVN at 2210 with an intended destination of Chicago, Illinois.

The pilot stated that during another flight earlier on the day of the accident, he noticed an odor of fuel. He was unable to identify the source of the smell and thought it may have been his hands from having checked the fuel during the aircraft preflight. The pilot stated he monitored the fuel flow during this flight and it was normal. The pilot landed at DNV with "...all systems indicating normal operations with no odor of fuel."

The pilot reported he then departed DNV and was cleared to climb to 5,000 feet. He stated the airplane was "...performing normally and all gauges confirmed normal operations. Again I could smell a strong odor of fuel." He stated that once again he was unable to identify the source of the odor. The pilot reported that as he climbed through 3,000 feet, the engine lost all power. He reported he made several attempts to restart the engine, but to no avail. The pilot reported that after touching down in the corn field, smoke started to enter the cabin. He confirmed that the electrical switches were in the off position and he exited the airplane.

Post accident inspection of the engine revealed the nozzle pressure port plug on the aft side of the fuel manifold valve was not in place, nor was it located. Blue fuel stains were evident under the left magneto and on the engine case under the right cylinders. The plug hole and the area surrounding the hole were inspected and there was no evidence of torque putty (Loctite) having been used when the plug was installed. The injector line fittings and the fuel inlet fitting had torque putty applied to them.

The engine had operated 10.1 hours since it was overhauled. Continental Motors reviewed their build-up procedures for the IO-550 engines and determined that the requirement for applying Loctite to the suspect fitting had been removed from the procedures. Continental Motors subsequently issued a Quality Alert re-inserting the requirement for Loctite to be applied to the nozzle pressure port plug at installation. The procedures manual and build-up instructions for the IO-550 were also revised to include the requirement that Loctite be applied to the plug.

Aircraft

Registration
N25496
Reported as
Beech A36
Category
Airplane
Serial number
E-2305
Airframe hours
6,091
Engine
Continental IO-550-B74, 300 hp, reciprocating
Damage
Substantial damage
Flight
Part 135
Operator
Carver Aero
Registered owner
Roy J. Carver, Jr.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 3, 2003 · 10 hours before
Departed
DVN · Davenport, IA
Destination
MDW · Chicago, IL
Flight plan
IFR
Airport
DVN · Davenport Municipal

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
56
Injuries
None
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Last flight review
April 15, 2003
Seat
Left
Flight hours
2,047 total · 76 in this make and model · 1,834 as pilot in command · 44 in the last 90 days · 15 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Wind
250° at 4 knots
Visibility
10 statute miles
Lowest ceiling
7,500 ft broken
Temperature
52 °F, dew point 45 °F
Altimeter
30.01 inHg
Observed at
MLI, 11 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.

Other investigations on N25496 · 2

Matched to the same aircraft by N-number and date.