ERA18LA227

NTSB accident investigation · Beech 35 · Mayport, FL · August 17, 2018

Accident · No injuriesClass 3 · LimitedFinal report
Date
August 17, 2018, 13:20 local (17:20 UTC)
Place
Mayport, FL
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N1330ZBeech 35
Defining event
Enroute-cruise: Fuel starvation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Continental Motors
FAA report
20180817021179A
Case key
98129

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 a fuel line due to improper installation of a fuel flow sensor, which resulted in fuel starvation and a subsequent total loss of engine power.

Findings · 2

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: installationPersonnel issues › Task performance · Maintenance personnelBeech N35: 1 caseAll aircraft: 371 casesProbable cause
Engine fuel and control: fuel distributionAircraft › Aircraft power plant · Incorrect service/maintenanceBeech N35: 1 caseAll aircraft: 55 casesProbable cause

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 reported that he was in cruise flight when the engine lost total power. The pilot's attempts to restart the engine were unsuccessful. He contacted air traffic control and reported that he was unable to make it to the closest airport and ditched the airplane into the Atlantic Ocean. Postaccident examination of the airplane revealed that both elevators had separated from the horizontal stabilizer during the ditching. Examination of the engine revealed that a fuel line that had been attached to the fuel flow sensor was broken. Detailed examination of the fracture surfaces on the broken fuel line fitting revealed features that were consistent with high-stress, low-cycle fatigue crack propagation. The crack initiated at the outside, progressing through the thickness of the aluminum fuel line and partially along its circumference until final overstress fracture. A review of the installation drawings and instructions revealed that the fuel flow sensor was installed without a mounting bracket per installation instructions. Given this information, it is likely that the fuel line fractured in fatigue due to the improper installation, and lack of support that would have been provided by the required bracket. The failure of the fuel line subsequently resulted in fuel starvation, and the total loss of engine power. While the available maintenance records detailed the installation of an engine monitoring device and accompanying cylinder head temperature probes, there were no records that indicated when the fuel flow sensor was installed.

Factual narrative

On August 17, 2018, about 1320 eastern daylight time, a Beech N35, N1330Z, sustained substantial damage when it was involved in an accident near Mayport, Florida. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight departed Rutherford County Airport (FQD), Rutherfordton, North Carolina, about 0930 and was destined for Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida. The pilot reported that he was in cruise flight with the airplane at an altitude of 4,500 ft when the engine lost total power. The pilot's attempts to restart the engine were unsuccessful. He contacted air traffic control and was advised that Mayport Naval Station (NRB), Mayport, Florida, was the closet airport to his current location. The pilot responded that he was unable to make it to the airport and ditched the airplane into the Atlantic Ocean, about 3 miles east of NRB. The crew of a nearby ship rescued the pilot. Postaccident examination of the airplane after recovery revealed that both elevators were separated from the horizontal stabilizers. Due to the saltwater immersion, the continuity of the engine’s valvetrain and powertrain could not be established. Visual examination of the engine revealed that a fuel line that had been attached to the fuel flow sensor was broken; the fuel flow sensor and the broken fuel line were removed and sent to the National Transportation Safety Board Materials Laboratory for further examination. Examination of the fracture surfaces on the broken fuel line revealed the features were consistent with high-stress, low-cycle fatigue crack propagation. The crack initiated at the outside, progressing through the thickness of the aluminum fuel line and partially along its circumference until final overstress fracture. A review of the installation drawings and instructions revealed that the fuel flow sensor was installed without a mounting bracket per Insight drawing 1000-303 (bracket type 3), which depicts installation using a metal plumbing fitting for support directly to the engine fuel distributor. Insight drawing 1000-303 (bracket type 1) depicts the fuel sensor attached to the engine top case bolts and the fuel flow sensor plumbed with flexible hoses, and Insight drawing 1000-303 (bracket type 2) depicts the fuel sensor attached to the firewall and the fuel flow sensor plumbed with flexible hoses. The Insight Avionics installation manual states that the installing mechanic should determine which type of mounting is best for their installation, as all three types are approved. A review of the maintenance logbook entries revealed no record of the fuel flow sensor installation. However, an Insight G-2 installation record dated January 18, 2016, indicated that the Insight G-2 engine monitor was installed with six exhaust gas and six cylinder head temperature probes only.

Aircraft

Registration
N1330Z
Reported as
Beech 35 (N35)
Category
Airplane
Serial number
D-6768
Built
1961
Airframe hours
4,693
Engine
Continental IO-470N, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 15, 2017 · 37 hours before
Departed
FQD · Rutherfordton, NC
Destination
OMN · Ormond Beach, FL
Airport
NRB · Mayport Ns (Adm David L Mcdona
Equipment
Stall warning system, Handheld GPS

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
77
Injuries
None
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
July 13, 2018
Seat
Left
Restraint
3-point
Flight hours
1,566 total · 515 in this make and model · 1,447 as pilot in command · 12 in the last 90 days · 6 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 12 knots
Visibility
10 statute miles
Temperature
88 °F, dew point 77 °F
Altimeter
30.18 inHg
Observed at
NRB, 3 nm away

Docket · 12

The files NTSB released with the investigation on April 26, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 19.5 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.