# NTSB ERA18LA227: Beech 35, N1330Z, Mayport, FL, August 17, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: August 17, 2018, 13:20 local (17:20 UTC) - Place: Mayport, FL - Coordinates: 30.418333, -81.3675 - Nearby events: https://openairdocs.org/map.md?lat=30.4183&lon=-81.3675&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Continental Motors - NTSB case key (mKey): 98129 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA227 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98129/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98129 - Page: https://openairdocs.org/ntsb/ERA18LA227 ## 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 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 N35, 1 case](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=1151528), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine fuel and control: fuel distribution](https://openairdocs.org/ntsb-findings/01057310): Aircraft › Aircraft power plant · Incorrect service/maintenance (probable cause); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-findings/01057310/cases.md?model=1151528), [All aircraft, 55 cases](https://openairdocs.org/ntsb-findings/01057310/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Beech N35, 3 cases](https://openairdocs.org/ntsb-events/191/sequence.md?model=1151528), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Enroute-cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Beech N35, 6 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151528), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Ditching](https://openairdocs.org/ntsb-events/441); cases with it: [Beech N35, 1 case](https://openairdocs.org/ntsb-events/441/sequence.md?model=1151528), [All aircraft, 186 cases](https://openairdocs.org/ntsb-events/441/sequence.md) ## 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](https://openairdocs.org/deregistered/N1330Z-2018-09-20), registration cancelled 2018-09-20, S/N D-6768 (OpenAirDocs) - Reported make and model: Beech 35 (N35) - Registry model: [Beech N35](https://openairdocs.org/model/beech-n35) (registry code 1151528) (OpenAirDocs) - Registry engine: [Continental I0-470 series](https://openairdocs.org/engine/continental-i0-470-series) (registry code 17027, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-6768 - Year built: 1961 - Airframe hours: 4693 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 77; injuries: none; 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 ## 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 20180817021179A](https://openairdocs.org/incident/20180817021179A), Aug 17, 2018: Beech N35, Mayport, FL, Destroyed. Pilot states he was at cruise with ATC flight following approx 6 miles off the coast of NE FL when his engine began to sputter. Went through appropriate… ## Docket (12 files) The files NTSB released with the investigation on April 26, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98129. 19.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 12 pages, 875 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9130468&FileExtension=pdf&FileName=6120%20LA227_Redacted-Rel.pdf - Witness statements (item 2, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132416&FileExtension=pdf&FileName=Memorandum%20for%20Record%20witness%20statement-Rel.pdf - Memorandum of record - FAA inspector (item 3, PDF, 1 page, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132921&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20FAA%20airframe%20and%20engine%20examination%20summary%20%20LA227-Rel.pdf - Memorandum of record FAA logbook review (item 4, PDF, 2 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132912&FileExtension=pdf&FileName=Memorandum%20Of%20Record%20FAA%20Lobbook%20review%20summary%20%20LA227_Redacted-Rel.pdf - Insight installation instructions (item 5, PDF, 5 pages, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132849&FileExtension=pdf&FileName=Insight%20installation%20instructions-Rel.pdf - Maintenance records (item 6, PDF, 4 pages, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132737&FileExtension=pdf&FileName=1330Z%20logbook%20excerpts%20LA227_Redacted-Rel.pdf - Photo array (item 7, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9145153&FileExtension=pdf&FileName=Photo%20array%20LA227-Rel.pdf - Engine monitor device - specialist's factual report (item 8, PDF, 2 pages, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12198154&FileExtension=pdf&FileName=Engine%20Monitor%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Materials laboratory (item 9, PDF, 7 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9130576&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2018-077-Rel.pdf - Statement of party representatives to NTSB investigation (item 10, PDF, 10 pages, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9132407&FileExtension=pdf&FileName=Signed%20NTSB%20Party%20Letter-ERA18LA227%20Alleyne_Redacted-Rel.pdf - Evidence control form (item 11, PDF, 2 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9145321&FileExtension=pdf&FileName=Evidence%20Control%20Form%20LA227_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 2 pages, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9145583&FileExtension=pdf&FileName=Wreckage%20Release%20N1330Z_Redacted-Rel.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.