# NTSB CHI08LA154: Beech A36, N7214Y, Grand Rapids, MN, June 9, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 8, 2008, 20:30 local (Jun 9, 2008, 01:30 UTC) - Place: Grand Rapids, MN - Coordinates: 47.211112, -93.509719 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=47.2111&lon=-93.5097&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report March 23, 2009 - Report: Approved by Office Director - Parties: FAA-Minneapolis FSDO - NTSB case key (mKey): 68324 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI08LA154 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68324/pdf - Page: https://openairdocs.org/ntsb/CHI08LA154 ## Probable cause A loss of engine thrust due to the propeller separating from the aircraft as a result of fatigue failure of the propeller attachment bolts caused by the insufficient torque of the bolts during installation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Propeller system: propeller assembly](https://openairdocs.org/ntsb-findings/01046110): Aircraft › Aircraft propeller/rotor · Fatigue/wear/corrosion (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01046110/cases.md?model=1151604), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01046110/cases.md) - [Propeller system: propeller assembly](https://openairdocs.org/ntsb-findings/01046110): Aircraft › Aircraft propeller/rotor · Incorrect service/maintenance (probable cause); cases with it: [Beech A36, 1 case](https://openairdocs.org/ntsb-findings/01046110/cases.md?model=1151604), [All aircraft, 29 cases](https://openairdocs.org/ntsb-findings/01046110/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Not specified (probable cause); cases with it: [Beech A36, 6 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151604), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Beech A36, 10 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=1151604), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Enroute: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338) (defining event); cases with it: [Beech A36, 4 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=1151604), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis The pilot stated that about 40 minutes into the flight he heard a loud noise followed by a rapid deceleration of the engine, and then a "distinct bang." The windshield was immediately covered with a film of oil, completely obstructing forward visibility. He established a descent at best glide airspeed and established a course for the nearest suitable airport. During the descent, the engine continued to run rough and smoke entered the cockpit. It became apparent to the pilot that he did not have enough altitude to reach the airport. He attempted to increase engine power in order to slow the descent; however, the engine seized shortly afterward. He set up for a forced landing to a clearing adjacent to a set of power lines. During the forced landing, the airplane impacted trees and a utility pole, which separated the left tip tank and left aileron from the airframe. The airplane slid approximately 50 feet and came to rest upright. A postaccident inspection revealed that the propeller assembly had separated from the engine propeller flange. The propeller flange appeared intact. The propeller assembly was not recovered. Two propeller bolt fragments and one propeller alignment pin fragment were recovered from the engine cowling. Examination of the fracture surfaces revealed features consistent with reverse bending fatigue cracking. In addition, the washer faces of both nuts were worn and polished consistent with relative movement against the crankshaft flange. Maintenance records indicated that the propeller spinner bulkhead was replaced approximately one year prior to the accident in order to comply with a manufacturer's service letter. At the time of the accident, the propeller assembly had accumulated 1,906 hours total time in service, with 235 hours since replacement of the spinner bulkhead. About 531 hours had accumulated since overhaul of the propeller assembly. ## Factual narrative HISTORY OF FLIGHT On June 8, 2008, about 2030 central daylight time, a Beech model A36 (Bonanza), N7214Y, was substantially damaged during an in-flight collision with trees, a utility pole and terrain near Grand Rapids, Minnesota. The pilot was executing a forced landing at the time of the accident. The flight was being conducted under 14 CFR Part 91 on an instrument flight rules (IFR) flight plan. Visual meteorological conditions prevailed in the vicinity of the accident site. The pilot and two passengers on-board reported no injuries. The flight departed Falls International Airport (INL), International Falls, Minnesota, about 1945. The intended destination was Flying Cloud Airport (FCM), Eden Prairie, Minnesota. The pilot stated that about 40 minutes into the flight, he heard a loud noise followed by a rapid deceleration of the engine, and then a "distinct bang." The windshield was immediately covered with a film of oil, completely obstructing forward visibility. He established a descent at best glide airspeed and declared an emergency with air traffic control. The pilot identified Grand Rapids/Itasca County Airport (GPZ), Grand Rapids, Minnesota, as the nearest suitable airport, and altered course accordingly. The pilot reported that during the descent, the engine continued to run rough and smoke entered the cockpit. It became apparent that they did not have enough altitude to reach the runway. He attempted to increase engine power in order to slow the descent; however, the engine seized shortly afterward. He set up for a forced landing to a clearing adjacent to a set of power lines approximately 2 miles east of GPZ. During the forced landing, the airplane impacted trees and a utility pole, which separated the left tip tank and left aileron from the airframe. The pilot noted that the airplane slid approximately 50 feet after initial impact with the ground. PERSONNEL INFORMATION The pilot held a Private Pilot certificate with single and multi-engine airplane ratings, and an instrument airplane rating. He was issued a Third-Class Airman Medical certificate on April 28, 2008, with a limitation for corrective lenses. The pilot reported a total flight experience of 1,232 hours, with 162 hours in the same make and model as the accident airplane. He noted 209 hours of instrument flight time. His most recent flight review was completed on March 28, 2008. AIRCRAFT INFORMATION The accident airplane was a 1984 Beech model A36 (Bonanza), serial number E-2169. It was powered by a 300-horsepower Continental IO-550-B1F reciprocating engine, serial number 296821-R, and a McCauley D3A32C409-C three-blade, controllable pitch propeller assembly, serial number 982568. Aircraft maintenance records indicated that the most recent annual inspection was completed on March 21, 2008, at 3,164.4 hours total airframe time. The recording hour (Hobbs) meter indicated 855 hours at the time of that inspection. The propeller had accumulated 1,226.8 hours total time and 482.3 hours since overhaul. The maintenance records noted that the propeller spinner bulkhead was replaced on May 23, 2007, in accordance with McCauley Service Letter 2000-5A. McCauley Service Bulletin 227B, Alert Service Bulletin 248, and Service Letter 1991-11A were also complied with at that time. The propeller had accumulated 1,671.4 hours total time, and 296.5 hours since overhaul. The airplane recording hour meter indicated 669.2 hours, according to the records. The propeller assembly was overhauled on December 1, 2005, and subsequently re-installed on the accident airplane on December 12, 2005. METEOROLOGICAL INFORMATION At 2035, the GPZ Automated Weather Observing System (AWOS) recorded weather conditions as: Calm winds; 10 miles visibility; overcast clouds at 6,500 feet above ground level (agl); temperature 15 degrees Celsius; dew point 12 degrees Celsius; altimeter 29.75 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest upright near the edge of a tree line running along a set of power lines. The left wing tip fuel tank and left aileron had separated from the airframe when it impacted one of the power line support poles during the landing. Impact marks on the utility pole were about 6 feet above ground level. The components were recovered from the debris path. The remaining flight controls remained attached to the airframe. The landing gear was in the retracted (up) position. The flaps were extended. The recording hour (Hobbs) meter indicated 904.1 when observed at the accident site. A post accident inspection revealed that the propeller assembly had separated from the engine propeller flange. The propeller flange appeared intact. The propeller assembly was not recovered. Two propeller bolt fragments and one propeller alignment pin fragment were recovered from the engine cowling. The mating portions of the fragments were not recovered. A teardown inspection of the engine revealed damage consistent with oil starvation. The crankshaft bearings and bearing journals were discolored and extruded. The oil sump contained remnants of a connecting rod bolt, and metal fragments consistent with bearing material. The spark plugs exhibited normal burn signatures. The magnetos produced spark across all leads when tested. TESTS AND RESEARCH The recovered propeller bolt fragments were forwarded to the National Transportation Safety Board Materials Laboratory for examination. Both bolts were fractured through near the center of the bolt at the first or second full thread common to the propeller hub. The nylon insert self-locking nuts were attached to both bolts. The washer faces of both nuts were worn and polished consistent with relative movement against the crankshaft flange. The threads common to the nuts were flattened and damaged consistent with contact to the crankshaft flange holes. The fracture surfaces exhibited ratchet markings on opposing sides of the bolt stud, indicative of multiple initiation sites. In addition, opposing sets of crack arrest markings was consistent with reverse bending fatigue cracking. The arrest markings were coarsely spaced with some intervening ductile features consistent with high-stress propagation. Fatigue propagation was approximately 80-percent one bolt and about 20-percent on the second bolt. The remaining portion of the bolt stud cross-sections exhibited features consistent with overstress separation. The propeller hub alignment pin was fractured near the mid-point at a circumferential groove in the part. The fracture surface exhibited beach marks adjacent to the groove. After the initial radial propagation toward the center of the pin, the beach marks had a coarse appearance consistent with high-stress propagation. The fatigue area comprised approximately 50-percent of the pin cross-section. The material and plating properties met the manufacturer's drawing specifications. ## Aircraft - Registration: [N7214Y](https://openairdocs.org/deregistered/N7214Y-2010-07-08), registration cancelled 2010-07-08, S/N E-2169, built 1984 (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-2169 - Airframe hours: 3214 - Engines: Continental IO-550-B1F 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 21, 2008, 49 hours before - Departed: INL, International F, MN - Destination: FCM, Minneapolis, MN - Flight plan: IFR - Airport: GPZ, Grand Rapids/Itasca County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 28, 2008; seat: left; flight hours: 1,232 total, 162 in this make and model, 1,119 as pilot in command, 28 in the last 90 days, 15 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft overcast - Temperature: 59 °F, dew point 54 °F - Altimeter: 29.75 inHg - Observed at: GPZ, 2 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 20080608838869A](https://openairdocs.org/incident/20080608838869A), Jun 8, 2008: Beech A36, Grand Rapids, MN, Substantial damage. (-23) Zmp ARTCC report: aircraft reported mechanical problem and diverted to gpz. Aircraft reported the engine causing trouble and the pilot landed 5 miles… 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.