# NTSB ERA09FA093: Beech 36, N7472N, Louisville, KY, December 18, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 18, 2008, 03:55 local (08:55 UTC) - Place: Louisville, KY - Coordinates: 38.288612, -85.561111 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.2886&lon=-85.5611&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report October 21, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Teledyne Continental Motors, Inc., FAA/FSDO - NTSB case key (mKey): 69588 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09FA093 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69588/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69588 - Page: https://openairdocs.org/ntsb/ERA09FA093 ## Probable cause The pilot’s continued operation of the aircraft with known deficiencies. Contributing to this accident was the improper sealing of the engine case during overhaul. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech 36, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151602), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Malfunction; cases with it: [Beech 36, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151602), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech 36, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=1151602), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Beech 36, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=1151602), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Approach-IFR final approach: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech 36, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151602), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Beech 36, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151602), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Beech 36, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151602), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was cleared for the Area Navigation (RNAV) Global Positioning System (GPS) approach for runway 24 at his destine airport. The weather at the airport was reported as visibility, 6 statute miles; mist, overcast clouds at 800 feet. When the airplane was about 9 miles from the airport, the pilot reported an emergency; advising of an “engine failure”. A witness on the ground observed the airplane flying low over the golfing community. The witness reported the weather was cold, with little wind, cloudy, and misty at the time, and the street lights and a car dealership across the highway were the only illumination for the area that dark morning. The airplane was on an approximate course of 340 degrees and about a height of 30 feet above ground level (agl) when the right wing made contact with a tree at the beginning of the fairway, which was located between a row of residential homes and a row of tall trees. The right wing and the gear separated at the wheel well inboard section, the airplane contacted the ground inverted and came to rest 175 feet down the fairway from the initial contact point. Examination of the engine revealed the crankshaft and counterweight assembly was fractured through at the forward fillet radius of the number 2 main bearing journal. The number 2 main bearing journal exhibited scoring consistent with bearing rotation. The number 2 main bearings’ fragments were located in the oil sump. The number 3 main bearing journal was fractured at the rear fillet area. Examination of the crankcase halves, revealed the presence of silk thread patterns and gasket making material on the sealing surfaces of the main bearing bosses, which is not part of the engine’s manufacturer maintenance instructions that resulted in improper torque valves obtained during the crankcase halves assembly. The number 2 main bearing boss was severely damaged on both the left and right case halves. The damage included rotational mechanical gouging and deformation of the boss area behind the bearing, including mushrooming deformation of the boss. The engine was overhauled 58 hour before the accident. Witnesses reported the pilot mentioned having oil pressure problems with the overhaul engine prior to the accident. ## Factual narrative HISTORY OF FLIGHT On December 18, 2008, about 0355 eastern standard time, a Beech 36, N7472N, registered to the TFB Aviation LLC and operated by an individual, crashed in an open field within a golfing community in Louisville, Kentucky, during an instrument flight rules (IFR) flight from the Chicago Midway International Airport (MDW), Chicago, Illinois, to Bowman Field Airport(LOU), Louisville, Kentucky. Night instrument meteorological conditions prevailed at the time and an IFR flight plan was filed for the Title 14 Code of Federal Regulations Part 91 personal flight. The airplane incurred substantial damage and the pilot/owner was killed. A mechanic at LOU stated to a Federal Aviation Administration FAA inspector that he had seen the airplane on the field and had seen it fly on several occasions. He was also aware of the recent overhaul engine and propeller installation to the accident airplane. Several weeks before the accident, the mechanic talked to the pilot when the pilot was conducting a ground run of the airplane. The pilot stated that he was having an oil pressure problem. The pilot asked the mechanic about oil pressure adjustments. The mechanic explained the system to the pilot and advised him to have the problem checked out, especially if the engine was recently overhauled. About a week later the mechanic was informed the oil pressure problem was related to the oil filter and that it seemed to be ok. A witness, working at a fixed base operator (FBO) at MDW, stated that the airplane arrived on December 17, 2008, about 2330 and the pilot requested fuel. When the airplane was going to depart, it returned back to the FBO. The pilot stated that there was a problem with the airplane and it was placed in the hangar. The pilot contacted a maintenance facility on the airport, but the airplane could not be seen until the morning of December 18, 2008. The airplane was pulled out of the hanger, and the pilot tried to start the engine several times. He managed to start the engine and departed about 0220 on December 18, 2008. A witness, a resident in the golfing community, stated to the responding FAA inspectors that she was out walking her dog early that morning. The weather was cold, with little wind, cloudy, and misty. It was dark, but the street lights and the car dealership across the highway were illuminating the area. The witness noticed an airplane flying overhead low; it was about 500 feet above the ground, did not have any lights on, and looked like it was coming in for a landing. She observed the airplane turn right as it descended lower. She believed that the airplane would continue flying below her line of site. She subsequently heard a “thud and a boom,” but did not think much of them as she was accustomed to hearing loud noises from the traffic on the nearby highway. According to the Louisville Approach controller located at the Louisville International Airport-Standiford Field (SDF) Louisville, Kentucky, he cleared the pilot toland, when the airplane was about 9 miles out, for the Area Navigation (RNAV) Global Positioning System (GPS) approach for runway 24 at LOU. Shortly after that, the pilot communicated an emergency, advising of an “engine failure.” The local authorities were notified of a possible downed airplane in the area of the last radar contact, and the airplane was discovered later that morning, around 0600, by the local fire department community. PERSONNEL INFORMATION The pilot, age 25, held a commercial pilot certificate with ratings for airplane single engine land, multiengine airplane land, and instrument airplane. He held a flight instructor certificate with ratings for airplane single engine and instrument airplane. He was issued an FAA first-class medical certificate on February 21, 2008, with no limitations. He had documented 2,300 total hours at that time. AIRCRAFT INFORMATION The Beech 36, a six place all metal low wing, single-engine airplane, variable-pitch propeller, with retractable landing gear, serial number E-32,was manufactured in 1968, and issued a standard airworthiness certificate, in the utility category. The airplane was powered by a Continental IO-520-BA, 285-horsepower engine. The airplane’s engine was overhauled in December of 2007. The engine’s last inspection was performed on February 2, 2008, which the airplane had a total hours of 6,216 at that time. The airplane’s propeller was overhauled in August of 2008, which the airplane had a total hours of 6,247 at that time. The pilot purchased the airplane in July of 2008 and had accumulated 40 total flight hours in it before the accident. The engine had a total of 58 hours since the overhaul. METEOROLOGICAL INFORMATION The closest official weather observation was at Bowman Field Airport (LOU), Louisville, Kentucky, 7 miles southwest of the accident site. The LOU 0353 METAR, was winds from 330 degrees at 3 knots; visibility, 6 statute miles; mist, overcast clouds at 800; temperature 0 degrees Celsius (C); dew point minus 2 degrees C; altimeter 30.33 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was on a golf course fairway located between a row of residential homes and a row of tall trees. Impact marks and ground scars indicated that the airplane was on an approximate course of 340 degrees and about a height of 30 feet above ground level (agl) when the right wing made contact with a tree at the beginning of the fairway. The right wing and the gear separated at the wheel well inboard section. The ground impact markings were consistent with the airplane contacting the ground inverted. The main impact ground scar contained windshield and the vertical fin anti collision light debris, which was 119 feet north of the tree. The airplane came to rest approximately 175 feet from the tree down the fairway inverted, with the left and nose wheel landing gear extended, and the front section of the cabin roof crushed in. A post recovery examination of the wreckage establishedflight control continuity. The left wing was observed with fuel leaks from impact damage. Six gallons of aviation fuel was recovered from the left wing fuel bladder. The right wing fuel bladder was ruptured when the wing separated. Aviation fuel was observed at the engine’s driven fuel pump from the firewall fuel supply hose. Initial examination of the engine revealed the engine would not rotate and was retained for further examination. An engine teardown examination was conducted at the Teledyne Continental Motors (TCM) Facility with National Transportation Safety Board (NTSB) oversight. The examination revealed that the crankshaft and counterweight assembly were fractured through at the forward fillet radius of the number 2 main bearing journal. The number 2 main bearing journal exhibited scoring consistent with bearing rotation. The number 2 main bearings’ fragments were located in the oil sump. The number 3 main bearing journal was fractured at the rear fillet area. The crankshaft, crankcase halves, metal materials collected in the oil sump, and main bearing through bolts were sent to the NTSB for further examination. According to the Materials Laboratory Factual Report, examination of the crankcase halves revealed the presence of silk thread patterns and gasket making material on the sealing surfaces of the main bearing bosses which is not part of the engine’ manufacturer maintenance instructions, TCM Service Information Letter (SIL) 99-2B. The number 2 main bearing boss was severely damaged on both the left and right case halves. The damage included rotational mechanical gouging and deformation of the boss area behind the bearing, including mushrooming deformation of the boss. MEDICAL AND PATHOLOGICAL INFORMATION The Jefferson County Coroner’s Office, Louisville, Kentucky, conducted a postmortem examination. The cause of death for the pilot was blunt force trauma. The FAA Civil Aeromedical Institute (CAMI) conducted toxicology testing on specimens from the pilot. No carbon monoxide, cyanide, ethanol, or drugs were detected ## Aircraft - Registration: [N7472N](https://openairdocs.org/deregistered/N7472N-2009-01-22), registration cancelled 2009-01-22, S/N E-32, built 1968 (OpenAirDocs) - Reported make and model: BEECH 36 - Registry model: [Beech 36](https://openairdocs.org/model/beech-36) (registry code 1151602) (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-32 - Airframe hours: 6274 - Engines: CONT MOTOR IO 520 SERIES 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Annual, February 2, 2008, 58 hours before - Departed: MDW, Chicago, IL - Destination: LOU, Louisville, KY - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 25; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: left; toxicology performed; flight hours: 2,300 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 330° at 3 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 28 °F - Altimeter: 30.32 inHg - Observed at: LOU, 7 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 20081218852649A](https://openairdocs.org/incident/20081218852649A), Dec 18, 2008: Beech 36BEECH, Louisville, KY, Destroyed, 1 fatal. Aircraft returning from mdw was cleared RNAV GPS 24 approach to lou. Pilot declared emergency and stated the nature of the problem as his engine. The pilot set… ## Docket (19 files) The files NTSB released with the investigation on August 11, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69588. 11.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330804&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements (item 2, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40333567&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Reports from Federal Agencies: Airport Traffic Control Tower Transcripts. (item 3, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330825&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20Airport%20Traffic%20Control%20Tower%20Transcripts.-Redacted.PDF - Weather Reports and Records (item 4, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330808&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Redacted.PDF - Miscellaneous: Excerpts From the Engine Overhaul Facility. (item 5, .PDF, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330809&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20From%20the%20Engine%20Overhaul%20Facility.-Redacted.PDF - Miscellaneous: Excerpts from the Airplane's Engine Maintenance Records. (item 6, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330810&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20from%20the%20Airplane%27s%20Engine%20Maintenance%20Records.-Redacted.PDF - Reports from Parties to the Investigation: Excerpts from Teledyne Continental Motors, Inc. Report. (item 7, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330811&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%3A%20Excerpts%20from%20Teledyne%20Continental%20Motors,%20Inc.%20Report.-Redacted.PDF - Materials Laboratory 15 - Factual Report 09-072 (item 8, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321138&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2009-072-Master.PDF - Miscellaneous: Excerpts from Teledyne Continental Motors, Inc. Service Information Letter SIL99-2B. (item 9, .PDF, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330812&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20from%20Teledyne%20Continental%20Motors,%20Inc.%20Service%20Information%20Letter%20SIL99-2B.-Master.PDF - Toxicological Report (item 10, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330813&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330835&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 220 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330815&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1) View of the Wreckage on the Fairway. Photo Provided by the Federal Aviation Administration (FAA). (item 13, .PDF, 569 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330816&FileExtension=.PDF&FileName=Photo%201)%20View%20of%20the%20Wreckage%20on%20the%20Fairway.%20Photo%20Provided%20by%20the%20Federal%20Aviation%20Administration%20(FAA).-Master.PDF - Photo 2) Close-up View of the Wreckage. Photo Provided by FAA. (item 14, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330819&FileExtension=.PDF&FileName=Photo%202)%20Close-up%20View%20of%20the%20Wreckage.%20Photo%20Provided%20by%20FAA.-Master.PDF - Photo 3) Front View of the Wreckage. (item 15, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330818&FileExtension=.PDF&FileName=Photo%203)%20Front%20View%20of%20the%20Wreckage.-Master.PDF - Photo 4) View of the Separated Right Wing. Photo Provided by the FAA. (item 16, .PDF, 623 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330821&FileExtension=.PDF&FileName=Photo%204)%20View%20of%20the%20Separated%20Right%20Wing.%20Photo%20Provided%20by%20the%20FAA.-Master.PDF - Photo 5) View of the Accident Site. Photo Provided by the FAA. (item 17, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330822&FileExtension=.PDF&FileName=Photo%205)%20View%20of%20the%20Accident%20Site.%20Photo%20Provided%20by%20the%20FAA.-Master.PDF - Photo 6) View of the Tree the Right Wing Impacted. (item 18, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330823&FileExtension=.PDF&FileName=Photo%206)%20View%20of%20the%20Tree%20the%20Right%20Wing%20Impacted.-Master.PDF - Photo 7) View of the Fairway and Adjacent Trees, and Houses. (item 19, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40330824&FileExtension=.PDF&FileName=Photo%207)%20View%20of%20the%20Fairway%20and%20Adjacent%20Trees,%20and%20Houses.-Master.PDF 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.