# NTSB DFW05LA105: Beech A36, N4311S, Early, TX, April 17, 2005 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 17, 2005, 07:10 local (12:10 UTC) - Place: Early, TX - Coordinates: 31.793611, -98.961112 - Nearby events: https://openairdocs.org/map.md?lat=31.7936&lon=-98.9611&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Fort Worth FSDO - NTSB case key (mKey): 61337 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DFW05LA105 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/61337/pdf - Page: https://openairdocs.org/ntsb/DFW05LA105 ## Probable cause A loss of engine power due to the improper installation of the oil filter resulting in oil starvation and eventual seizure of the engine. A contributing factor was the lack of suitable terrain for the forced landing. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, climb - fluid,oil - starvation/exhaustion (cause) - maintenance,installation - improper, owner/pilot mechanic (cause) - Forced landing, emergency descent/landing - On ground/water encounter with terrain/water - terrain condition - high vegetation ## Analysis A 7,378-hour Airline Transport Pilot (ATP) reported that they had just departed the airport and established a cruise-climb, with a 752-hour private pilot at the controls, and one passenger in the rear of the airplane. During the cruise-climb the engine went to full rpm, and then the ATP noticed that the engine oil pressure indicated zero. During the attempted return to the airport, the engine seized and the private pilot turned the controls over to the ATP. The ATP executed a forced landing in a field 4-miles east of the departure airport. Examination of the engine by an NTSB investigator revealed that the oil filter was improperly installed, and the O-ring at the base of the filter was broken. Additionally, the oil filter's adapter plate was found cracked, which allowed the engine oil to be pumped overboard while in flight. ## Factual narrative On April 17, 2005, at 0710 central daylight time, a Beech A36 single-engine airplane, N4311S, was substantially damaged when it impacted terrain during a forced landing following a loss of engine power during takeoff from the Brownwood Regional Airport (BWD), near Brownwood, Texas. The airplane was registered to, and operated by AIT Services, Inc., of Brownwood, Texas. The airline transport rated pilot and two occupants of the airplane were not injured. Visual meteorological conditions prevailed, and a flight plan was not filed for the 672-nautical mile cross-country flight conducted under the 14 Code of Federal Regulations Part 91. The business flight was originating at the time of the accident, with the Murfreesboro Municipal Airport (MBT), near Murgreesboro, Tennasse, as its intended destination. The 7,378-hour airline transport pilot reported to the NTSB (via NTSB Form 6120.1/2) that they had just departed the airport and established a cruise-climb, with a 752-hour private pilot at the controls, and one passenger in the rear of the airplane. During the cruise-climb, the engine went to full rpm, and then the Airline Transport Pilot (ATP) noticed that the engine oil pressure indicated zero. During the attempted return to the airport, the engine seized and the private pilot turned the controls over to the AT P. The ATP executed a forced landing in a field located approximately 4 miles east of BWD The Federal Aviation Administration (FAA) inspector, who responded to the accident site, reported that he did not see any evidence of oil on the engine oil dipstick. He added that the oil cap was secured in place. Additionally, he observed a significant amount of fresh oil on the engine firewall and belly of the airplane. The inspector also noted that the left and right wings experienced extensive structural damage and the vertical stabilizer was also damaged. The wreckage of the airplane was recovered to Air Salvage of Dallas (ASOD) near Lancaster, Texas, where a examination of the engine was conducted on April 27, 2005. The examination revealed that the spin-on oil filter was over torqued, and that the O-ring seal at the base of the oil filter was broken. Additionally, the metal oil filter adapter housing was cracked, so that engine oil could be pumped through the crack and overboard. A review of the engine logbook revealed that the engine oil and filter had been changed the day prior to the accident date. At 0705, the automated weather observing system at BWD, located three miles from the accident site, reported wind from 140 degrees at 4 knots, 10 statute miles visibility, a clear sky, temperature 59 degrees Fahrenheit, dew point 57 degrees Fahrenheit, and an altimeter setting of 30.23 inches of Mercury. ## Aircraft - Registration: [N4311S](https://openairdocs.org/deregistered/N4311S-2013-01-28), registration cancelled 2013-01-28, S/N E-684, built 1975 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-684 - Airframe hours: 5806 - Engines: Continental IO-520 285 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 9, 2005, 60 hours before - Departed: BWD, Brownwood, TX - Destination: MBT, MURFREESBORO, TN - Airport: BWD, Brownwood Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: none; commercial, flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review February 9, 2004; seat: right; flight hours: 7,378 total, 416 in this make and model, 6,094 as pilot in command, 33 in the last 90 days, 21 in the last 30 days - Other flight crew; age 28; injuries: none; private; airplane ratings: single-engine land; medical: class 2, valid medical--no waivers/lim.; last flight review August 31, 2004; seat: left; flight hours: 752 total, 389 in this make and model, 697 as pilot in command, 28 in the last 90 days, 94 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 57 °F - Altimeter: 30.22 inHg - Observed at: BWD, 3 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 20050417005849A](https://openairdocs.org/incident/20050417005849A), Apr 17, 2005: Beech A36, Brownwood, TX, Substantial damage. (-23) On April 17, 2005, at approximately 0710 local time, pilot in command, [privacy data omitted] operated Beech, BE-36-A36, N4311S, while executing an… 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.