CHI07LA127

NTSB accident investigation · Beech S35 · Brookfield, MO · April 30, 2007

Accident · No injuriesLimited investigationFinal report
Date
April 30, 2007, 16:43 local (21:43 UTC)
Place
Brookfield, MO
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N8820MBeech S35
Weather
Visual (VMC) · Day
Status
Completed · report February 28, 2008
Report
Approved by Office Director
Parties
Teledyne Continental Motors, Kansas City, FSDO
FAA report
20070430008299A
Case key
65745

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

Improper maintenance by maintenance personnel by not properly torquing cylinder thru-bolts. The loose stud nuts which resulted in the separation of the cylinder and the crop and ditch were factors.

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/malfCruise
Maintenance,installation - improperCompany maintenance personnelCause
Engine assembly,cylinder - separationFactor
Engine assembly,cylinder - loose part/bolt/nut/clamp/etcFactor
Engine assembly - undertorquedCause
Forced landingEmergency descent/landing
In flight collision with terrain/waterEmergency descent/landing
Terrain condition - cropFactor
Terrain condition - ditchFactor

Analysis

he pilot reported that the engine was "operating normally" as he was flying at 6,500 feet mean sea level when the "engine blew up." He elected to execute a gear up forced landing to a corn field about two miles from the airport, but the airplane impacted a ditch during the emergency landing. The engine teardown inspection revealed a hole in the crankcase approximately 3 inches by 3 inches above the number 4 cylinder, which included the 11 and 1 o'clock deck studs. The number 4 cylinder had separated from the crankcase and the number 4 connecting rod was not attached to the number 4 crankshaft pin. The number 4 connecting rod and rod cap exhibited signatures that were consistent with an overload event that deformed and/or sheared the threads on the nuts and bolts. Cylinder number 4 deck stud nuts 6, 7, and 8 were reported missing from the engine at the accident scene, and subsequently found inside the engine cowling of the aircraft. Cylinder number 4 deck studs 6, 7, and 8 were securely attached to the engine crankcase and the threads were clean and undamaged. The 2 o'clock cylinder deck stud was fractured and missing. The remaining deck studs and thru-bolts all exhibited ductile fractures indicative of tensile overload. The other five cylinders' thru-bolt and deck stud break-away torque measurements were recorded for each thru-bolt and deck stud. The inspection revealed that numerous thru-bolts and studs had break-away torque values that did not comply with the manufacturer's limitations. The aircraft engine's logbook indicated that the engine received an annual maintenance inspection on February 16, 2005. The engine logbook entry stated, "Removed and overhauled all 6 cylinders. Installed new rings, ground valves, cleaned and gapped spark plugs." The tach time indicated 5380.5 hours at the time of the annual inspection. At the time of the accident, the tach time was 5,662.24 hours, 281.74 hours since the cylinders had been replaced.

Factual narrative

On April 30, 2007, at 1643 central daylight time, a Beech S35, N8820M, sustained substantial damage during a forced landing to a cornfield after a loss of engine power near North Central Missouri Regional Airport (MO8), Brookfield, Missouri. The commercial pilot, the only occupant, was not injured. The 14 Code of Federal Regulations Part 91 flight departed John Bell Williams Airport (M16), Raymond, Mississippi at an unknown time and was en route to Fort Dodge Regional Airport (FOD), Fort Dodge, Iowa. Visual meteorological conditions prevailed at the time of the accident. No flight plan was filed.

The pilot reported that the engine was "operating normally" as he was flying at 6,500 feet mean sea level when the "engine blew up." He made a MAYDAY call and flew best glide speed as he navigated to the nearest airport located about 15 nautical miles away. The pilot elected to execute a gear up forced landing to a field about two miles from the airport, but the airplane impacted a ditch during the emergency landing. The pilot exited the airplane with no injuries.

A Federal Aviation Administration airworthiness inspector examined the airplane at the accident site. The inspection revealed that the engine had two holes in the crankcase. One of the holes was on the number 4 cylinder side of the crankcase. The number 4 cylinder had separated from the crankcase and the number 4 connecting rod was not attached to the number 4 crankcase pin. The number 4 rod cap, bolts, and nuts were found lying loose in the engine cowling. The number 4 cylinder top left stud and three cylinder deck stud nuts were also found lying loose in the engine cowling.

The engine was sent to Teledyne Continental Motors for an engine teardown inspection. The inspection revealed a hole in the crankcase approximately 3 inches by 3 inches above the number 4 cylinder, which included the 11 and 1 o'clock deck studs. The number 4 connecting rod and rod cap exhibited signatures that were consistent with an overload event that deformed and/or sheared the threads on the nuts and bolts. The number 4 cylinder exhibited skirt damage between the 5 and 6 o'clock position and fretting signatures on the base flange. Cylinder number 4 deck stud nuts 6, 7, and 8 were reported missing from the engine at the accident scene, and subsequently found inside the engine cowling of the aircraft. Cylinder number 4 deck studs 6, 7, and 8 were securely attached to the engine crankcase and the threads were clean and undamaged. The 2 o'clock cylinder deck stud was fractured and missing. The remaining deck studs and thru-bolts all exhibited ductile fractures indicative of tensile overload.

The remaining five cylinders were removed from the crankcase. The thru-bolt and deck stud break-away torque measurements were recorded for each thru-bolt and deck stud. The acceptable torque limits for the deck studs was 490 - 510 inch/pounds, and the limits for the thru-bolts was 690 - 710 inch/pounds. The inspection revealed that numerous thru-bolts and studs had break-away torque values that did not comply with the manufacturer's limitations.

The aircraft engine's logbook indicated that the engine received an annual maintenance inspection on February 16, 2005. The engine logbook entry stated, "Removed and overhauled all 6 cylinders. Installed new rings, ground valves, cleaned and gapped spark plugs." The tachometer time indicated 5,380.5 hours at the time of the annual inspection. The engine logbook indicated that the engine received an annual maintenance inspection on May 3, 2006. At the time of the accident on April 30, 2007, the tachometer time was 5,662.24 hours, 281.74 hours since the cylinders had been replaced.

Aircraft

Registration
N8820M
Reported as
Beech S35
Category
Airplane
Serial number
D-7331
Airframe hours
5,662
Engine
Continental IO-520-BA3B, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Marc Incorporated
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2006 · 137 hours before
Departed
M16 · Raymond, MS
Destination
FOD · Fort Dodge, IA
Flight plan
Unknown

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
46
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
7,000 total · 1,000 in this make and model · 7,000 as pilot in command · 500 in the last 90 days · 100 in the last 30 days · 10 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 16 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 52 °F
Altimeter
29.86 inHg
Observed at
IRK, 35 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.