# NTSB FTW95LA119: Beech 60, N100BL, Santa Rosa, NM, February 23, 1995 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: February 22, 1995, 20:30 local (Feb 23, 1995, 03:30 UTC) - Place: Santa Rosa, NM - Coordinates: 34.940063, -104.670104 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.9401&lon=-104.6701&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 3 uninjured - Status: Completed, report November 30, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 19356 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95LA119 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19356/pdf - Page: https://openairdocs.org/ntsb/FTW95LA119 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, climb - to cruise - 1 engine - exhaust system,turbocharger - failure,total (cause) - exhaust system,turbocharger - unapproved part (contributing factor) - fluid,oil - leak - fluid,oil - starvation (cause) - engine assembly,connecting rod - failure,total (cause) - engine assembly,crankcase - penetrated - Loss of engine power(total) - mech failure/malf, descent - emergency - all engines - exhaust system,turbocharger - failure,total (cause) - exhaust system,turbocharger - unapproved part (contributing factor) - Forced landing, descent - emergency - On ground/water encounter with terrain/water, emergency descent/landing - terrain condition - rough/uneven - terrain condition - none suitable (contributing factor) - light condition - dark night (contributing factor) ## 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](https://openairdocs.org/deregistered/N100BL-2002-04-10), registration cancelled 2002-04-10, S/N P-135, built 1970 (OpenAirDocs) - Reported make and model: BEECH 60 - Registry model: [Beech A60](https://openairdocs.org/model/beech-a60) (registry code 1153604) (OpenAirDocs) - Registry engine: [Lycoming TI0-541 series](https://openairdocs.org/engine/lycoming-ti0-541-series) (registry code 41536, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: P-135 - Airframe hours: 3262 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; 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 (OpenAirDocs). - [Accident 19950222017889A](https://openairdocs.org/incident/19950222017889A), Feb 22, 1995: Beech A60, Santa Rosa, NM, Substantial damage. Left engine thru rod. Right one quit also. Landed rough area. Both engine turbo broke. High temp. Bogus parts. 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.