ERA18LA181

NTSB accident investigation · Beech 35B33 · Berlin, MD · June 29, 2018

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
June 29, 2018, 09:15 local (13:15 UTC)
Place
Berlin, MD · Golf course
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9745YBeech 35B33
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
CMI, FAA/FSDO, Textron
FAA report
20180629013029A
Case key
97641

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The failure of the No. 3 cylinder exhaust valve, which resulted in the total loss of engine power during takeoff.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Maintenance/inspectionsAircraft › Aircraft handling/service · Not serviced/maintainedBeech 35-B33: 1 caseAll aircraft: 103 cases
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelBeech 35-B33: 1 caseAll aircraft: 167 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot stated that, shortly after he retracted the landing gear during the initial climb after takeoff, the airplane began to vibrate and the engine lost power. The pilot initiated a 180° return to the runway, but unable to reach it, performed a forced landing to a golf course. Postaccident examination of the airplane’s engine revealed that the No. 3 cylinder sustained catastrophic damage, including heavy mechanical damage to the piston and separation of the exhaust valve, a portion of which was lodged under the intake valve. Numerous pieces of metal consistent with material from the No. 3 piston head were found in the oil sump. Given this information, it is likely that the loss of engine power was due to the failure of the No. 3 exhaust valve. The engine manufacturer's maintenance manual recommended that this engine be overhauled at 1,500 hours of operation or every 12 years, whichever occurred first. The maintenance manual also recommended that a borescope be used to inspect the engine’s cylinders during every 100-hour/annual inspection in conjunction with a compression test. The engine maintenance records listed the compression test results during previous annual inspections but did not indicate whether the cylinders had been inspected with a borescope. At the previous annual inspection, about 1 month before the accident, the engine total time was 1,769.1 hours. Additionally, the engine was manufactured about 37 years prior to the accident and had not been overhauled. The investigation did not determine if the impending failure of the exhaust valve could have been detected and corrected had the borescope inspections been performed and/or the engine had been overhauled.

Factual narrative

On June 29, 2018, about 0915 eastern daylight time, a Beech 35-B33, N9745Y, was substantially damaged when it was involved in an accident near Berlin, Maryland. The private pilot was seriously injured, and the passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that the preflight inspection and the engine runup were normal. After takeoff, he retracted the landing gear, and the airplane began to vibrate. He checked his cockpit gauges, but the “plane was losing power and the vibration increased.” The pilot transmitted via radio that he was returning to the airport; however, unable to reach the runway, the pilot performed a forced landing on a golf course. After landing, a small postcrash engine compartment fire ensued. A Federal Aviation Administration (FAA) inspector examined the airplane where it came to rest about 1/3 mile west of the departure airport. The left wing displayed leading edge damage and was canted upward from midspan to the wingtip. The engine was partially separated from the airframe, and the landing gear and wing flaps were retracted. Further examination revealed fire damage to the aft section of the engine. The fuel selector valve was in the right tank position. The fuel selector valve screen was removed and inspected; no debris was found. The fuel line from the firewall to the fuel pump inlet was fracture-separated at the inlet fitting. The fuel line from the fuel pump to the fuel metering unit was intact, and the fuel line from the metering unit to the manifold valve was separated at the metering unit. All other B-nuts remained attached to their fittings. Flight control cable continuity was established from the control surfaces to the cockpit controls. Continuity of the crankshaft and camshaft were confirmed when the propeller was rotated by hand, and thumb compression was obtained on all cylinders except No. 3. Borescope examination of the No. 3 cylinder revealed catastrophic damage, including heavy mechanical damage to the piston and separation of the exhaust valve, a portion of which was lodged under the intake valve. The No. 3 pushrods did not display any visible damage or bending. Numerous pieces of metal consistent with material from the No. 3 piston head were found in the oil sump. No other engine anomalies were observed. The most recent annual inspection was completed on May 7, 2018, at a tachometer time of 1,162.5 hours and a recorded engine total time of 1,769.1 hours. Additionally, the engine was manufactured during March 1981 and had not been overhauled. The Continental Motors M-0 Maintenance Manual recommended that IO-470-K engines with serial numbers before 1006000, which included the accident engine, be overhauled at 1,500 hours or every 12 years, whichever occurred first. Additionally, the Maintenance Manual recommends a borescope inspection of the cylinders during every 100-hour/annual inspection in conjunction witha compression test. The engine maintenance records listed the compression test results during the annual inspections but did not indicate whether the borescope inspections were conducted.

Aircraft

Registration
N9745Y
Reported as
Beech 35B33 (NO SERIES)
Category
Airplane
Serial number
CD-681
Built
1963
Airframe hours
3,553.8
Engine
Continental IO-470, 225 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 7, 2018
Departed
OXB · Berlin, MD
Destination
PSK · Dublin, VA
Flight plan
IFR
Airport
OXB · Ocean City Muni
Equipment
Video recording device, ADS-B, Auto-pilot, Electronic flight bag or handheld device, Onboard weather

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
60
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
May 24, 2018
Seat
Left
Flight hours
1,191 total

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
OXB

Docket · 8

The files NTSB released with the investigation on October 21, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 29.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.