# NTSB ERA15LA092: Beech V35B, N246JT, Long View, NC, January 6, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: January 6, 2015, 17:10 local (22:10 UTC) - Place: Long View, NC - Coordinates: 35.720001, -81.139999 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.7200&lon=-81.1400&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Serious injuries - Injuries: 1 serious, 3 minor - Status: Completed, report September 8, 2015 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Continental Motors, Cessna Aircraft Company, FAA/FSDO - ADs cited in the narratives: [AD 99-09-17](https://openairdocs.org/ad/99-09-17) (OpenAirDocs) - NTSB case key (mKey): 90574 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90574/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90574 - Page: https://openairdocs.org/ntsb/ERA15LA092 ## Probable cause The improper installation of the lower rear crankshaft counterweight snap rings by unknown maintenance personnel, which resulted in the separation of the counterweight and a subsequent total loss of engine power during initial climb. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151548), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Beech V35B, 2 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151548), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance (probable cause); cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=1151548), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [Engine (reciprocating): recip engine power section](https://openairdocs.org/ntsb-findings/01058520): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Beech V35B, 1 case](https://openairdocs.org/ntsb-findings/01058520/cases.md?model=1151548), [All aircraft, 233 cases](https://openairdocs.org/ntsb-findings/01058520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Beech V35B, 2 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=1151548), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech V35B, 10 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151548), [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 V35B, 8 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151548), [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: [Beech V35B, 20 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151548), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that, during initial climb, he heard a big "bang," which was followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees. Teardown examination of the engine revealed that the lower rear crankshaft counterweight had separated. During a subsequent examination, all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings was found broken in half. Three of the lower rear counterweight retaining plates were found, but the fourth retaining plate was not recovered. Two snap rings that were still in place on the upper rear crankshaft counterweight were examined. The examination revealed that the width between the snap ring ears on one of the snap rings did not meet the manufacturer-prescribed width, indicating that the snap ring was not properly seated. After that snap ring was removed and its groove was cleaned of deposits with a wire brush, it seated properly when reinstalled. A review of maintenance records revealed that, about 16 years before the accident, the engine had been rebuilt and had accumulated about 1,600 hours since it was rebuilt and that, about 8 years before the accident, a top overhaul was performed on the engine. The crankshaft was inspected about 6 months after the factory rebuild in accordance with an airworthiness directive (AD); however, there likely would have been little to no deposits in the crankshaft so soon after the factory rebuild. Before the issuance of the AD, the engine manufacturer had issued a mandatory service bulletin, which included a warning that the "failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure." It is likely that the lower rear crankshaft counterweight snap rings were not properly installed; however, it could not be determined when or by whom they were improperly installed. ## Factual narrative On January 6, 2015, about 1710 eastern standard time, a Beech V35B, N246JT, operated by a private individual, was substantially damaged during a forced landing into trees in Long View, North Carolina, following a total loss of engine power during initial climb from Hickory Regional Airport (HKY), Hickory, North Carolina. The commercial pilot was seriously injured and the three passengers incurred minor injuries. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Pitt-Greenville Airport (PGV), Greenville, North Carolina.The pilot stated that during initial climb, about 300 feet above ground level, he heard a loud bang followed by a total loss of engine power. He subsequently performed a forced landing straight ahead into trees. Examination of the wreckage by a Federal Aviation Administration inspector revealed substantial damage to the fuselage. The inspector also noted a hole in the engine case near the No. 2 cylinder. A teardown examination of the engine was performed at a recovery facility, under the supervision of an NTSB investigator. The examination revealed that the lower rear crankshaft counterweight had separated and the No. 1 connecting rod separated. Oil was present throughout the engine and there was no evidence of lack of lubrication. The No. 2 cylinder, crankshaft, and camshaft could not be separated from the engine case half for examination due to rotational damage that occurred following the separation of the crankshaft counterweight. Those components were then forwarded to the manufacturer's facility for further examination as the teardown examination could not be completed at the recovery facility. The subsequent examination at the manufacturer's facility was also performed under the supervision of an NTSB investigator. The examination revealed that all four snap rings from the lower rear crankshaft counterweight were found loose in the engine, and one of the rings had separated in half. Three of the lower rear counterweight retaining plates were found, but the fourth was not recovered. For comparison purposes, two snap rings were examined on the upper rear crankshaft counterweight. According to the manufacturer's mandatary service bulletin (MSB 99-3C), the minimum width between the snap ring ears must be 0.179 inch or more; a smaller width was indicative of a snap ring that was not properly seated in its groove. For one of the two upper rear counterweight snap rings, a 0.179 inch gap gauge could not be inserted as there was less than the prescribed space between the snap ring ears. However, when that snap ring was removed and its groove was cleaned of deposits by a wire brush, the snap ring then seated properly when reinstalled. Subsequently, the 0.179 inch gap gauge fit between the ears of the reinstalled snap ring. Review of maintenance records revealed that the airplane's mostrecent annual inspection was completed on July 16, 2014. At that time, the airframe had accumulated 3,394 total hours of operation. The engine was a factory rebuild in 1998 and had accumulated 1,561 total hours at the time of the annual inspection. The airplane flew about 46 hours from the time of the inspection, until the accident. Maintenance records show the engine received a top overhaul in 2006. The maintenance records also revealed that the crankshaft was inspection in June, 1999 in accordance with airworthiness directive 99-09-17. Continental Engines Service Bulletin MSB 99-3C states, "WARNING Do not use plates that have a loose fit. Failure to properly install counterweight retaining plates and snap rings may result in engine damage and possible failure." ## Aircraft - Registration: [N246JT](https://openairdocs.org/deregistered/N246JT-2018-04-24), registration cancelled 2018-04-24, S/N D-10079, built 1978 (OpenAirDocs) - Reported make and model: BEECH V35B - Registry model: [Beech V35B](https://openairdocs.org/model/beech-v35b) (registry code 1151548) (OpenAirDocs) - Category: Airplane - Serial number: D-10079 - Year built: 1978 - Airframe hours: 3440 - Engines: Continental IO-520 285 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Jayson Jarvis - Registered owner: J & J Air LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 16, 2014, 46 hours before - Departed: HKY, Hickory, NC - Destination: PGV, Greenville, NC - Airport: HKY, Hickory Regional Airport, runway 24, 6,400 × 150 ft, asphalt - Equipment: Electronic multifunction display, Electronic primary flight display, Handheld GPS, Onboard weather, Electronic flight bag or handheld device, Stall warning system, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review February 12, 2014; seat: left; restraint: 3-point; flight hours: 1,381 total, 862 in this make and model, 1,318 as pilot in command, 37 in the last 90 days, 10 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 8 knots - Lowest ceiling: none - Temperature: 48 °F, dew point 18 °F - Altimeter: 30.10 inHg - Observed at: HKY, 1 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 20150106000049A](https://openairdocs.org/incident/20150106000049A), Jan 6, 2015: Beech V35B, Long View, NC, Destroyed. Upon departure from rwy 24 at hky, pilot described a loud 'bang' and engine power loss. Aircraft crashed approximately 1/2 mile from airport in residential… ## Docket (14 files) The files NTSB released with the investigation on July 31, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90574. 8.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430202&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Memorandum For Record (item 2, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430203&FileExtension=.PDF&FileName=Memorandum%20For%20Record-Master.PDF - Manufacturer Field Report of Engine Teardown Examination (item 3, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430204&FileExtension=.PDF&FileName=Manufacturer%20Field%20Report%20of%20Engine%20Teardown%20Examination-Redacted.PDF - Excerpts From Engine Logbook (item 4, .PDF, 767 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430205&FileExtension=.PDF&FileName=Excerpts%20From%20Engine%20Logbook-Redacted.PDF - Continental Mandatory Service Bulletin MSB 99-3C (item 5, .PDF, 817 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430206&FileExtension=.PDF&FileName=Continental%20Mandatory%20Service%20Bulletin%20MSB%2099-3C-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430207&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430208&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1 – Main Wreckage (Photo Courtesy of FAA) (item 8, .PDF, 292 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430210&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Main%20Wreckage%20(Photo%20Courtesy%20of%20FAA)%0D%0A-Master.PDF - Photo 2 – Engine Case (Photo Courtesy of FAA) (item 9, .PDF, 387 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430211&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Engine%20Case%20(Photo%20Courtesy%20of%20FAA)%0D%0A-Master.PDF - Photo 3 – Rear Lower Crankshaft Counterweight (item 10, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430212&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Rear%20Lower%20Crankshaft%20Counterweight-Master.PDF - Photo 4 – Rear Lower Crankshaft Counterweight Snap Rings And Retaining Plates (item 11, .PDF, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430213&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Rear%20Lower%20Crankshaft%20Counterweight%20Snap%20Rings%20And%20Retaining%20Plates-Master.PDF - Photo 5 – No. 2 Connecting Rod Witness Mark (item 12, .PDF, 238 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430214&FileExtension=.PDF&FileName=Photo%205%20%E2%80%93%20No.%202%20Connecting%20Rod%20Witness%20Mark-Master.PDF - Photo 6 – Snap Rings on Rear Upper Counterweight When Gauge Did Not Fit (item 13, .PDF, 245 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430215&FileExtension=.PDF&FileName=Photo%206%20%E2%80%93%20Snap%20Rings%20on%20Rear%20Upper%20Counterweight%20When%20Gauge%20Did%20Not%20Fit-Master.PDF - Photo 7 – Snap Rings on Rear Upper Counterweight When Cleaned And Gauge Did Fit (item 14, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40430216&FileExtension=.PDF&FileName=Photo%207%20%E2%80%93%20Snap%20Rings%20on%20Rear%20Upper%20Counterweight%20When%20Cleaned%20And%20Gauge%20Did%20Fit%0D%0A-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.