# NTSB ERA14LA392: Bellanca 7GCBC, N36236, Itta Bena, MS, August 16, 2014 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 16, 2014, 18:30 local (23:30 UTC) - Place: Itta Bena, MS - Coordinates: 33.495834, -90.322219 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4958&lon=-90.3222&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report June 16, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA - NTSB case key (mKey): 89900 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14LA392 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89900/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89900 - Page: https://openairdocs.org/ntsb/ERA14LA392 ## Probable cause A total loss of engine power during maneuvering due to an obstruction from air intake filter material being ingested into the carburetor, which resulted in a forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Bellanca 7GCBC, 1 case](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=1220601), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Bellanca 7GCBC, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=1220601), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Bellanca 7GCBC, 2 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=1220601), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Bellanca 7GCBC, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=1220601), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Approach-VFR go-around: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Bellanca 7GCBC, 3 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1220601), [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: [Bellanca 7GCBC, 5 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1220601), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bellanca 7GCBC, 26 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1220601), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor and student pilot were practicing simulated forced landings. The flight instructor reported that, during the third simulated forced landing, when the student pilot applied engine power to go around, the engine began to sputter, and it then experienced a total loss of power. The flight instructor assumed control of the airplane and performed a forced landing to a cornfield, which resulted in substantial damage to both wings and the fuselage. Postaccident examination of the engine revealed that a portion of the air intake filter had been ingested into the carburetor and was obstructing the venturi opening, which likely resulted in the loss of engine power. The remaining portion of the air filter was not located, and its preimpact condition could not be determined. The engine examination also revealed that an intake valve inner spring had broken; however, the outer spring remained intact, and the broken inner spring did not contribute to the accident. A review of the maintenance records indicated that the airplane had been operated for about 13 hours since its most recent annual inspection, which was performed about 8 months before the accident. A maintenance logbook entry noted that the induction filter was replaced at that time. The engine had accumulated about 1,265 total flight hours at the time of the accident and had not been overhauled since its manufacture about 41 years before the accident. ## Factual narrative **This report was modified on July 25, 2017. Please see the public docket for this accident to view the original report.** On August 16, 2014, about 1830 central daylight time, a Bellanca 7GCBC, N36236, operated by a private individual, was substantially damaged during a forced landing, after it experienced a total loss of engine power while maneuvering near Itta Bena, Mississippi. The flight instructor and a student pilot were seriously injured. Visual meteorological conditions prevailed and no flight plan had been filed for the local flight that originated at the Greenwood-Leflore Airport (GWO), Greenwood, Mississippi, about 1810. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the flight instructor, the student pilot was practicing simulated forced landings, and had performed two simulated forced landings without incident. During a third simulated forced landing, when the student pilot applied engine power to go-around, the engine began to sputter and lost power. The flight instructor assumed control of the airplane and performed a forced landing to a corn field, which resulted in substantial damage to both wings and the fuselage. According to Federal Aviation Administration (FAA) records, the airplane was purchased by its current owner on February 15, 2014. It was equipped with a Lycoming O-320-A2B, 150-horsepower engine. On site examination of the airplane by an FAA inspector did not reveal any evidence of a catastrophic engine failure. Fuel sampled from the airplane's fuel tanks was consistent with 100-low-lead aviation gasoline and absent of contamination. Subsequent examination of the engine by an investigator from the NTSB and the engine manufacturer revealed that the No. 4 intake valve inner spring was fractured in three locations. The outer spring remained intact. When the propeller was rotated by hand, camshaft, crankshaft, and valve train continuity were confirmed and thumb compression was attained on all cylinders. Both magnetos produced spark from all leads when rotated by hand. The carburetor remained attached to the engine, and the fuel inlet screen was absent of debris. Foam consistent with a portion of air intake filter material was observed obstructing more than half of the carburetor venturi opening. The carburetor heat air box was crushed and the air intake filter was not located amongst the recovered wreckage. Examination of the fractured No. 4 intake valve inner spring and the material recovered from the carburetor was performed by an NTSB Materials Engineer. Fracture features consistent with fatigue, and pitting were present through the inner surfaces of the spring. In addition, Fourier-transform infrared (FTIR) spectrometer examination of the material found in the carburetor was consistent with polyurethane. [Additional information can be found in the NTSB Materials Laboratory Factual Report located in the public docket] According to maintenancerecords, at the time of the accident, the airplane had been operated for about 1,265 total hours, which included about 13 hours since its most recent annual inspection, which was performed on December 2, 2013. According to an entry in the airframe maintenance logbook, the annual inspection was "owner assisted" by the previous owner and included "Replaced induction filter." According to engine logbook entries, the No. 4 cylinder was replaced on August 9, 2001, about 70 hours prior to the accident, and the "Bracket air filter" was replaced on October 12, 2011, about 25 hours prior to the accident. In addition, there was no indication that the engine had been overhauled since it was manufactured in 1973. Lycoming Service Instruction No. 1009AW recommended that engines which have not accumulated the recommended hourly time in service be overhauled in the 12th year since the last overhaul. According to the Bracket Aero Filters polyurethane foam information manual, "…All Brackett Air Filter elements are required to be replaced each 12 calendar months regardless of actual flight time…." ## Aircraft - Registration: [N36236](https://openairdocs.org/deregistered/N36236-2017-03-31), registration cancelled 2017-03-31, S/N 549-73, built 1973 (OpenAirDocs) - Reported make and model: BELLANCA 7GCBC - Registry model: [Bellanca 7GCBC](https://openairdocs.org/model/bellanca-7gcbc) (registry code 1220601) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 549-73 - Year built: 1973 - Airframe hours: 1265 - Engines: Lycoming O-320-A2B 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 2, 2013, 13 hours before - Departed: GWO, GREENWOOD, MS - Destination: GWO, GREENWOOD, MS - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 71; injuries: serious; flight instructor, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 19, 2014; seat: rear; restraint: 3-point; flight hours: 7,432 total, 317 in this make and model, 6,367 as pilot in command, 25 in the last 90 days, 11 in the last 30 days, 0 in the last 24 hours - Student pilot; age 44; injuries: serious; student; medical: class 3, without waivers/limitations; seat: front; restraint: 3-point; flight hours: 7 total, 7 in this make and model, 0 as pilot in command, 4 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 73 °F - Altimeter: 29.93 inHg - Observed at: GWO, 12 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 20140816014209A](https://openairdocs.org/incident/20140816014209A), Aug 16, 2014: Bellanca 7GCBC, Itta Bena, MS, Substantial damage. Insructional flight. Practicing forced landing procedures. First attempt, the student did'nt do well. Second attempt at a different location, student did… ## Other investigations on N36236 (1) 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 NYC94LA083](https://openairdocs.org/ntsb/NYC94LA083), May 17, 1994: Bellanca 7GCBC (N36236), Lewisburg, WV, substantial damage. Probable cause: THE PILOT'S INADEQUATE INFLIGHT DECISION, INADVERTENT VFR FLIGHT INTO IMC, AND FAILURE TO MAINTAIN ADEQUATE TERRAIN CLEARANCE WHICH RESULTED IN INFLIGHT COLLISION WITH TREES. A FACTOR WAS INADEQUATE… ## Docket (9 files) The files NTSB released with the investigation on May 5, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89900. 10.2 MB in all. - Aircraft Bill of Sale (item 1, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439699&FileExtension=.PDF&FileName=Aircraft%20Bill%20of%20Sale-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 2, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439700&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector Statement and NTSB Memorandum (item 3, .PDF, 554 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439701&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20and%20NTSB%20Memorandum-Master.PDF - Materials Laboratory Factual Report (item 4, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439786&FileExtension=.PDF&FileName=Materials%20Laboratory%20Factual%20Report-Master.PDF - NTSB Evidence Control Form (item 5, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439702&FileExtension=.PDF&FileName=NTSB%20Evidence%20Control%20Form-Master.PDF - Maintenance Records (excerpts) (item 6, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439703&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Master.PDF - Brackett Polyurethane Aero Filters Information Manual (excerpt) (item 7, .PDF, 349 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439704&FileExtension=.PDF&FileName=Brackett%20Polyurethane%20Aero%20Filters%20Information%20Manual%20(excerpt)%20-Master.PDF - NTSB Party Guidance and Form (item 8, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439705&FileExtension=.PDF&FileName=NTSB%20Party%20Guidance%20and%20Form-Master.PDF - Photo Array (item 9, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439706&FileExtension=.PDF&FileName=Photo%20Array-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.