FTW95LA119

NTSB accident investigation · Beech 60 · Santa Rosa, NM · February 23, 1995

Accident · No injuriesLimited investigationFinal report
Date
February 22, 1995, 20:30 local (Feb 23, 1995, 03:30 UTC)
Place
Santa Rosa, NM
Injuries
3 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N100BLBeech 60
Weather
Visual (VMC) · Night/dark
Status
Completed · report November 30, 1995
Report
Approved by Office Director
FAA report
19950222017889A
Case key
19356

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

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Probable cause

The failure of the right engine's turbocharger resulting in oil starvation and subsequent failure of the #5 connecting rod which penetrated the crankcase, and the failure of the left engine's turbocharger resulting in the loss of power on both engines. Factors were the lack of suitable terrain for the forced landing, dark night light conditions, and unapproved turbocharger parts.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of engine power(total) - mech failure/malfClimb - to cruise
1 engine
Exhaust system,turbocharger - failure,totalCause
Exhaust system,turbocharger - unapproved partFactor
Fluid,oil - leak
Fluid,oil - starvationCause
Engine assembly,connecting rod - failure,totalCause
Engine assembly,crankcase - penetrated
Loss of engine power(total) - mech failure/malfDescent - emergency
All engines
Exhaust system,turbocharger - failure,totalCause
Exhaust system,turbocharger - unapproved partFactor
Forced landingDescent - emergency
On ground/water encounter with terrain/waterEmergency descent/landing
Terrain condition - rough/uneven
Terrain condition - none suitableFactor
Light condition - dark nightFactor

Analysis

While the airplane was climbing through FL230 in dark night VMC conditions, the right engine lost power. Seconds after the pilot initiated an emergency descent, the left engine lost power. He then attempted several unsuccessful restarts on both engines until reaching 15,000 MSL, at which time he feathered the right engine propeller. Continued attempts to restart the left engine using various combinations of cross-feed, mixture, and throttle were not successful. The pilot then executed a forced landing to rough terrain with the airplane coming to rest 1/3 miles west of an airport. The airplane was structurally damaged during the emergency landing. Examination of the right engine revealed that the #5 connecting rod failed due to oil starvation, and penetrated the crankcase. Additionally, the turbocharger turbine wheel was found separated from its shaft. Examination of the left engine also revealed a failed turbocharger turbine wheel shaft. Teardown of both turbocharger assemblies revealed evidence of excessively high turbine inlet temperatures and both turbochargers had unapproved parts installed.

Factual narrative

On February 22, 1995, approximately 2030 mountain standard time, a Beech BE-60, N100BL, was substantially damaged during a forced landing after losing power on both engines, near Santa Rosa, New Mexico. The airline transport rated pilot and two passengers sustained minor injuries. The airplane, owned by Agamemnon Operating Inc., was being operated under 14 CFR Part 91 when the accident occurred. The business flight originated at Santa Fe, New Mexico at 2000 and was en route to Dallas, Texas. An instrument flight rules (IFR) plan was filed and dark night visual meteorological conditions prevailed for the personal cross country flight.

The pilot reported that after refueling at Santa Fe Municipal Airport, the airplane departed on an IFR clearance to FL250, en route to Dallas, Tx. Approximately 20 minutes into the flight, and climbing through FL220, the right engine lost power. After initiating an emergency descent, the pilot reported that the left engine lost power. After several unsuccessful restart attempts on both engines, the pilot feathered the right engine propeller. He continued attempts to restart the left engine using various combinations of cross-feed, mixture, and throttle, but was not successful. The pilot then executed a forced landing to rough terrain and came to rest 1/3 miles west of Santa Rosa Airport, New Mexico. The airplane was structurally damaged during the landing.

Fuel samples extracted form the airplane were analyzed by Petroleum Specialist Lab, Floresville, Texas. According to their tests, the fuel samples conformed to standard specifications for aviation gasolines.

Examination of the right engine revealed that the #5 connecting rod penetrated the crankcase and the turbocharger turbine wheel was found separated from it's shaft and found lodged in the exhaust pipe. Examination of the left engine's turbocharger also revealed a separated turbine wheel from it's shaft. Teardown of both right and left turbocharger assemblies revealed evidence of excessively high turbine inlet temperatures (TIT). The TIT probes from both turbochargers displayed excessive heat erosion and according to the manufacturer, "not installed properly." The manufacturer reported that the eroded TIT probes in conjunction with their improper installation, could have allowed the turbine components to operate at temperature above specification.

During an examination of both turbochargers, it was noted that the manufacturer's markings were missing from the journal bearings. The manufacturer documented that the bearings were not an approved part. Additionally, the center housings from both turbochargers had solid anti-rotation pins for the thrust bearings installed. According to the manufacturer, solid pins are used in automotive applications only, and their presence indicates that either an unapproved repair was performed, unapproved parts were used during the repair, or an automotive center housing was installed at one time. (See enclosed turbocharger teardown report).

Aircraft

Registration
N100BL
Reported as
Beech 60
Category
Airplane
Serial number
P-135
Airframe hours
3,262
Engine
Lycoming TIO-541-E1A4, 380 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Registered owner
Agamemnon Operating, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 1, 1994 · 33 hours before
Departed
SAF · Santa Fe, NM
Destination
DAL · Dallas, TX
Flight plan
IFR

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
65
Certificate
Airline transport
Airplane ratings
Single-engine sea, Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left
Flight hours
34,000 total · 25 in this make and model · 36,000 as pilot in command · 40 in the last 90 days · 30 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
Calm
Visibility
100 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 27 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

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