# NTSB CHI04LA019: Beech A36, N25496, Davenport, IA, October 16, 2003 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: October 15, 2003, 22:17 local (Oct 16, 2003, 03:17 UTC) - Place: Davenport, IA - Coordinates: 41.610279, -90.588333 - Nearby events: https://openairdocs.org/map.md?lat=41.6103&lon=-90.5883&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 28, 2005 - Report: Approved by Office Director - Parties: FAA - NTSB case key (mKey): 58231 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI04LA019 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58231/pdf - Page: https://openairdocs.org/ntsb/CHI04LA019 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, climb - to cruise - instructions,written/verbal - improper, manufacturer (cause) - fuel system,fuel flow divider/distributor - leak (cause) - maintenance,overhaul - improper, manufacturer (cause) - fluid,fuel - starvation (cause) - Forced landing, emergency descent/landing - In flight collision with terrain/water, emergency landing - terrain condition - crop (contributing factor) ## 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](https://openairdocs.org/aircraft/N25496), registered now, S/N E-2305, built 1986 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane - Serial number: E-2305 - Airframe hours: 6091 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; 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 (OpenAirDocs). - [Accident 20031015025879A](https://openairdocs.org/incident/20031015025879A), Oct 15, 2003: Beech A36, Davenport, IA, Substantial damage. (-23) Shortly after N25496 departed Davenport, the pilot reported he "lost his engine". He landed in a cornfield approximately 2 miles east of Davenport… ## Other investigations on N25496 (2) 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. - [NTSB CHI91LA263](https://openairdocs.org/ntsb/CHI91LA263), Aug 15, 1991: Beech 36 (N25496), Davenport, IA, substantial damage. Probable cause: THE INADEQUATE VISUAL LOOKOUT AND POOR INFLIGHT PLANNING AND DECISION MAKING BY THE PILOT OF N97867. FACTORS IN THE ACCIDENT ARE INOPERATIVE EXTERIOR LIGHTS AND RADIO COMMUNICATION NOT POSSIBLE. - [NTSB MKC88LA130](https://openairdocs.org/ntsb/MKC88LA130), Jul 8, 1988: Beech A-36 (N25496), Marion, IA, substantial damage 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.