# NTSB ERA19FA189: Beech A36, N8014T, Southold, NY, June 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 8, 2019, 09:14 local (13:14 UTC) - Place: Southold, NY - Coordinates: 40.987499, -72.580001 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.9875&lon=-72.5800&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Continental, Textron - NTSB case key (mKey): 99568 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA189 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99568/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99568 - Page: https://openairdocs.org/ntsb/ERA19FA189 ## Probable cause A total loss of engine power due to a main bearing shift and the pilot’s subsequent failure to maintain a proper glide path to the selected forced landing site. Contributing to the accident was the pilot’s decision to operate the airplane with known mechanical deficiencies. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Beech A36, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1151604), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Beech A36, 27 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1151604), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Damaged/degraded (probable cause); cases with it: [Beech A36, 13 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=1151604), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341) (defining event); cases with it: [Beech A36, 56 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=1151604), [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 A36, 47 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=1151604), [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 A36, 78 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=1151604), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed on a cross-country flight when, shortly after takeoff, he announced to air traffic control that the airplane had experienced an engine failure and that he would perform a forced landing in a field. Radar data showed the airplane descending over an area of open fields, and surveillance video near the accident site captured the airplane at low altitude in a steep left bank before it descended out of view behind trees and impacted the ground. A mechanic stated that, several weeks before the accident, the pilot asked him to look at the airplane due to higher-than-normal engine oil temperature and lower than normal oil pressure. The mechanic subsequently discovered metal debris in the oil filter. He stated that he expressed concern to the pilot about operating the airplane multiple times in the weeks and days before the accident, as he felt the engine was rapidly degrading and was susceptible to a catastrophic loss. Postaccident examination of the engine revealed that the No. 1 main aft bearing had shifted, was separated from the crankshaft, and sustained extensive thermal damage. The rear of the crankshaft was no longer connected to the main bearing and there was extensive internal and thermal damage. It is likely that the bearing shift resulted in the loss of engine power. The pilot’s decision to fly the airplane with known engine deficiencies increased the risk of a loss of engine power in flight. Following the loss of engine power, the pilot failed to maintain a proper glidepath to the forced landing site, which resulted in his low altitude maneuvering and impact with terrain. ## Factual narrative According to the mechanic who worked on the airplane, the pilot was concerned that the oil temperature was higher than usual, and the oil pressure was low. The mechanic changed the oil and oil filter and ran the engine. Afterwards, he removed and opened the oil filter and found metal debris. After consulting the pilot, he sent an oil sample for analysis and told him he was not comfortable working on the airplane and suggested replacing the engine. The mechanic stated that he stressed to the pilot on numerous occasions that he felt the visual inspections and results of oil analysis indicated a rapid degradation of the condition of the engine and the potential for immediate catastrophic loss. When asked about specifics and frequency of this conversation, the mechanic noted multiple conversations in the preceding weeks and days before the accident. On June 8, 2019, at 0914 eastern daylight time, a Beech A36, N8014T, was destroyed when it was involved in an accident near Mattituck, New York. The commercial pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The departure airport tower controller approved a radio frequency and transponder code change, which terminated communications with the airplane, as the pilot had not requested flight following services. About 0911:52, at 3,325 ft mean sea level (msl) and 107 knots (kts) groundspeed, about 1 mile north of the shoreline near Northville, New York, the airplane's track turned right from its on-course heading of 060°, and the airplane began a descent. The airplane turned to about 120° and at 0912:41, it crossed the shoreline at Suffolk, New York, at 2,175 ft msl and 88 kts. About that time, the pilot contacted air traffic control and announced that the airplane had experienced "engine failure" and that he would perform a forced landing in a field. Figure 1 shows the airplane’s radar track and descent over open fields. Figure 1. Map showing the airplane's radar track. The controller assigned the airplane a discrete transponder code and requested information from the pilot. During the exchange, the pilot again announced his intention to "land in a field." About 1 minute later, the controller transmitted that radar contact was lost, and there were no further communications from the airplane. The radar track showed that the airplane turned eastbound approximately over New York State Route 48. The airplane continued to descend over SR48 before it entered a tight left turn and reversed course to the west around a commercial farm, where radar contact was lost. The last radar target was depicted at 25 ft msl and 88 knots about 200 ft east of the accident site. Witnesses near the accident site described the airplane as flying "low" and one witness asked another if the airplane "was a crop-duster." One witness stated he heard the engine, and another said he did not. Surveillance video depicted the airplane at low altitude in asteep left bank as it turned from a northerly to a westerly heading, descending out of view behind trees before it impacted the ground. A dark plume of smoke appeared immediately after. Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for carbon monoxide, ethanol, and tested-for drugs. The airplane came to rest inverted on a commercial farm. The wreckage path was oriented on a magnetic heading of 270° and was 105 ft in length. All major components of the airplane were accounted for at the scene. The cockpit, cabin, empennage, and both wings were consumed by post-crash fire. The vertical stabilizer and left horizontal stabilizer were impact damaged but intact. The right horizontal stabilizer was separated by impact. Flight control continuity was confirmed from the cockpit area to all flight control surfaces. The landing gear was in the retracted position. The flaps were consistent with the retracted position; however, the flap actuator was destroyed by fire and the actual pre-accident position could not be confirmed. The propeller was separated from the crankshaft and all three propeller blades were secure in the hub. Each blade exhibited similar aft bending and light chordwise and spanwise scratching. Some leading edge polishing was also observed. The engine was rotated by hand through an accessory drive pad and powertrain continuity was confirmed through the valve train to the accessory section. Thumb compression was confirmed on all but cylinder Nos. 2 and 6. Borescope examination of those cylinders revealed debris around the valves consistent with soot and ash, which prevented full seating of the valves. Examination of the spark plugs revealed normal wear; the electrodes were light grey in color. The magnetos were removed and rotated. The impulse couplings engaged, but no spark was produced. Disassembly of each magneto revealed that the internal components were damaged (melted) by heat exposure. The fuel manifold was removed and disassembled. Examination revealed trace amounts of fuel. The internal spring, diaphragm, and screen were all intact and absent of water and debris. A detailed examination of the engine revealed that the No. 1 main aft bearing had shifted. The crankcase halves exhibited fretting and lock slot elongation. The rear of the crankshaft was no longer connected to the main bearing and there was extensive internal and thermal damage. The severely burned oil filter was cut open and remaining filter media was spread open, big metal flakes of ferrous and non-ferrous materials were consistent with internal catastrophic failure. The aft main bearing was heavily damaged with spun a bearing in the rear main journal. The engine-driven fuel pump was removed and rotated with a drill. Air was drawn into the intake port and exited the output ports when the pump was actuated. The fuel pump drive coupling was sent to the NTSB Materials Laboratory for examination. There were multiple rachet marks andstriations on the fracture surfaces consistent with multiple initiation fatigue cracking and fatigue fracture. Microvoid coalescence was also present on both fracture surfaces, consistent with overstress separation. ## Aircraft - Registration: [N8014T](https://openairdocs.org/deregistered/N8014T-2020-12-05), registration cancelled 2020-12-05, S/N E-2561, built 1990 (OpenAirDocs) - Reported make and model: Beech A36 - Registry model: [Beech A36](https://openairdocs.org/model/beech-a36) (registry code 1151604) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: E-2561 - Year built: 1990 - Airframe hours: 4695 - Engines: Continental IO-550 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Ri Aviation Services Llc - Registered owner: Ri Aviation Services Llc - Airworthiness certificate: Standard, Utility - Last inspection: Annual, February 21, 2019 - Departed: ISP, New York, NY - Destination: BED, Bedford, MA - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 11,090 total ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 55 °F - Altimeter: 30.13 inHg - Observed at: KFOK, 9 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 20190608017409A](https://openairdocs.org/incident/20190608017409A), Jun 8, 2019: Beech A36, Mattituck, NY, Destroyed, 2 fatal. 06/08/2019 Aircraft accident southhold NY. N8014T a beachcraft BE36 departed long island macarthur airport isp, declared an emergency due to engine failure and… ## Other investigations on N8014T (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 IAD05CA140](https://openairdocs.org/ntsb/IAD05CA140), Sep 23, 2005: Beech BE-36 (N8014T), Farmingdale, NY, substantial damage. Probable cause: The pilot's improper recovery from a bounced landing. ## Docket (14 files) The files NTSB released with the investigation on October 27, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99568. 614 MB in all. - Mechanic statement (item 1, PDF, 4 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9732548&FileExtension=pdf&FileName=Mechanic%20statement_Redacted-Rel.pdf - Materials labratory factual report (item 2, PDF, 10 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9113091&FileExtension=pdf&FileName=Fuel%20Pump%20Drive%20Coupling%20(ERA19FA189)-Rel.pdf - FAA inspector's engine teardown examination summary (item 3, PDF, 2 pages, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9712621&FileExtension=pdf&FileName=Engine%20Teardown%20Inspector%27s%20Report_Redacted-Rel.pdf - Maintenance records (item 4, PDF, 49 pages, 570 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11686446&FileExtension=pdf&FileName=Maintenance%20Records_Redacted-Rel.pdf - Memorandum - fuel pump rotation (item 5, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12688526&FileExtension=pdf&FileName=MOR%20Rayner-Rel.pdf - Oil analysis (item 6, PDF, 8 pages, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9711721&FileExtension=pdf&FileName=Blackstone%20Labs%20email_Redacted-Rel.pdf - Radar data - plots (item 7, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9875114&FileExtension=pdf&FileName=Radar%20Data%20Plots-Rel.pdf - Radar data- cvs file (item 8, XLSX, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9875378&FileExtension=xlsx&FileName=Radar%20data%20-%20CSV%20file-Rel.xlsx - Video file (item 9, MP4, 30.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9711595&FileExtension=mp4&FileName=Accident%20video-Rel.mp4 - Toxicological report (item 10, PDF, 1 page, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9113073&FileExtension=pdf&FileName=Toxicology_Redacted-Rel.pdf - Photos (item 11, PDF, 5 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11751551&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Statement of party representatives to NTSB investigation (item 12, PDF, 16 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9731898&FileExtension=pdf&FileName=NTSB%20Investigation%20Party%20Form%20Signed_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12621405&FileExtension=pdf&FileName=2_Signed%20Release_Redacted-Rel.pdf - Autopsy memo (item 14, PDF, 1 page, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11748995&FileExtension=pdf&FileName=Autopsy%20Memo%20for%20Record-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.