ERA23LA173

NTSB accident investigation · Beech P35 · Perry, FL · March 5, 2023

Accident · No injuriesClass 3 · LimitedFinal report
Date
March 5, 2023, 16:45 local (21:45 UTC)
Place
Perry, FL · Open farmland
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N9777YBeech P35
Defining event
Enroute: 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
FAA/FSDO
FAA report
20230305009489A
Case key
106979

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

Maintenance personnel’s incorrect torquing of the oil filter adapter jam nut, resulting in the failure of the adapter threads, a complete loss of oil, and 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.

Engine (reciprocating): recip eng oil sysAircraft › Aircraft power plant · Incorrect service/maintenanceBeech P35: 2 casesAll aircraft: 130 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelBeech P35: 1 caseAll aircraft: 167 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

About an hour into the flight, while cruising at 8,500 ft, light smoke entered the cabin momentarily, and the engine oil pressure dropped to zero. The pilot turned toward a nearby airport and shortly thereafter the engine lost power. Unable to glide to the airport, he saw a cleared field and set up for a forced landing. The airplane touched down on sandy soil, the nose gear dug in and separated, and the airframe was substantially damaged. The pilot was not injured. A postaccident examination of the engine revealed that the oil filter adapter separated at the engine case which likely resulted in a depletion of the engine’s oil supply and the subsequent total loss of engine power due to lack of lubrication. Residual oil covered the area around the adapter-to-engine case opening and below. The adapter threads appeared stripped. The adapter was safety wired in position and there was red torque putty applied as well. A review of the maintenance logbooks revealed that an annual inspection of the airframe and engine was completed about 29 hours before the accident. The logbook entries noted that an airworthiness directive that addressed security of the connection between the oil filter adapter and the engine case, including checking for proper torque, had been complied with during the inspection. The separation of the filter and stripping of the adapter threads were likely indicative of the oil filter adapter threads having failed due to improper torquing of the jam nut.

Factual narrative

On March 5, 2023, about 1645 eastern daylight time, a Beech P35 airplane, N9777Y, was substantially damaged when it was involved in an accident near Perry, Florida. The private pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he was on a cross-country flight from Peter O Knight Airport (TPF), Tampa, Florida, to Apalachicola Regional Airport (AAF), Apalachicola, Florida. About an hour into the flight, while cruising at 8,500 ft, light smoke entered the cabin momentarily and the engine oil pressure dropped to zero. The pilot turned toward Perry-Foley Airport (FPY), Perry, Florida, and shortly thereafter, the engine lost power. Unable to glide to the airport, he saw a cleared field and set up for a forced landing. He lowered flaps to full and lowered the landing gear. The airplane touched down on sandy soil. The nose landing gear dug in and separated. The airplane came to rest upright and the pilot egressed the cockpit and was met by first responders. An initial examination of the wreckage by a Federal Aviation Administration inspector revealed that the lower, forward fuselage had structural damage. The pilot initially reported that the air hose to the oil-air separator failed, and the separator’s canister was split open and empty of oil. The engine crankcase did not contain any oil and the engine was seized. Oil covered the lower fuselage surfaces. Further examination of the engine by an airframe and powerplant mechanic revealed that the oil filter adapter was separated at the engine case. There was residual oil covering the area around the adapter-to-engine case opening and below. The adapter threads appeared stripped. The adapter was safety wired in position, and there was red torque putty applied as well. A review of the maintenance logbooks revealed that an annual inspection of the airframe and engine was completed on December 9, 2022. At the time of the accident, about 29 hours had accrued on the engine since the last annual inspection. The logbook entries noted that Airworthiness Directive (AD) 96-12-22 had been complied with. The AD addressed security of the connection (jam nut) between the oil filter adapter and the engine case, including checking for proper torque. An article from AOPA [Aircraft Owners and Pilots Association] Pilot Magazine, dated May 5, 2005, addressed the oil filter adapter AD. The article stated that, “If the proper torque isn’t applied to the jam nut, the weight of the oil-filled filter combined with normal vibrations will soon cause thread damage to the adapter. In a few cases maintenance practices have been so mindless that the threads got in bad enough shape that the adapter was blown completely out of the engine.”

Aircraft

Registration
N9777Y
Reported as
Beech P35
Category
Airplane
Serial number
D-7160
Built
1963
Airframe hours
5,364
Engine
Cont Motor I0-470 SERIES, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 9, 2022 · 29 hours before
Departed
TPF · Tampa, FL
Destination
AAF · Apalachicola, FL
Airport
None
Equipment
Electronic flight bag or handheld device, ADS-B, Satellite tracking device

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
38
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
February 14, 2023
Seat
Left
Restraint
Lap only
Flight hours
70 total · 16 in this make and model · 31 as pilot in command · 30 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 63 °F
Altimeter
30.08 inHg
Observed at
KAAF, 73 nm away
METAR
METAR KAAF 052053Z AUTO 13009KT 10SM CLR 24/17 A3008 RMK AO2 SLP186 T02440172 56008 $

Docket · 11

The files NTSB released with the investigation on June 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.5 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.