# NTSB LAX02FA148: Beech C23, N9180S, Oak Shores, CA, April 28, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 27, 2002, 17:45 local (Apr 28, 2002, 00:45 UTC) - Place: Oak Shores, CA - Coordinates: 35.790832, -120.993614 - Nearby events: https://openairdocs.org/map.md?lat=35.7908&lon=-120.9936&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report September 29, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Beech Raytheon, Textron Lycoming - NTSB case key (mKey): 54595 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX02FA148 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54595/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54595 - Page: https://openairdocs.org/ntsb/LAX02FA148 ## Probable cause the number 1 cylinder exhaust valve fractured and separated resulting in a loss of engine power and an off airport forced landing. A finding in the accident was the owner's failure to maintain the engine in accordance with the manufacturer's recommendations. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(partial) - mech failure/malf, cruise - engine assembly,valve,exhaust - fractured (cause) - engine assembly,valve,exhaust - separation (cause) - maintenance,service bulletin/letter - not complied with, owner/builder - Forced landing, emergency descent/landing - In flight collision with terrain/water, maneuvering - turn to landing area (emergency) - object - tree(s) - terrain condition - mountainous/hilly ## Analysis The airplane collided with trees following a loss of engine power. A passenger heard a "roar" through the four-way intercom. The certified flight instructor (CFI) and the student pilot checked the oil pressure and fuel pressure; both were "good." The CFI pointed to the left and directed the student toward a private strip. During or immediately following the left turn, the CFI said, "I've got it." The student looked back at the two passengers, and motioned with his right hand that they were going to land at the strip. The last thing that the passenger remembered was contact with the trees and coming to rest. The airplane cleared a ridge top, but collided with trees about 1/4 mile from the landing strip. The spark plug for cylinder no. 1 sustained mechanical damage and contained metallic debris. The head of the cylinder no. 1 exhaust valve was missing, and the top of the piston exhibited mechanical damage across its entire surface. Metallurgists examined the valve and cylinder. The valve stem was broken and remained in the valve guide. The stem fractured and there were numerous secondary cracks below the fracture surface. The areas around the valve seats were severely damaged. The fracture surface condition was such that the fracture mechanism could not be determined. The secondary cracks were only in a local area where the material was severely battered and deformed. Many of the cracks were slightly curved and/or did not appear to be perpendicular to the outer or inner surface. These types of cracks are most likely to occur where surfaces have overlapped, or are the result of the excessive local strains in the area. There were no material or dimensional abnormalities that would suggest fatigue. The manufacturer issued maintenance instructions describing methods for determining exhaust valve and guide condition. This maintenance function was optional for the operator, and maintenance records indicated that this had not been done. Although the diameter of the exhaust valve stem was slightly below the specified diameter, this would have a small affect on overall stresses. However, a small change in diameter of the valve stem significantly changes the amount of clearance between the exhaust valve stem and the exhaust valve guide. Excessive clearance can lead to exhaust valve sticking, which can lead to overstress fracture. The engine total time was 2,079 hours, and it had not been overhauled since it was new in 1975. The manufacturer recommended overhaul at 2,000 hours or after 12 years of service life. Given the high hours on this engine and the number of years since overhaul, it was likely that the failure was due to exhaust valve sticking. ## Factual narrative HISTORY OF FLIGHT On April 27, 2002, about 1745 Pacific daylight time, a Beech C23, N9180S, collided with trees following a loss of engine power near Oak Shores, California. The owner was operating the airplane under the provisions of 14 CFR Part 91. The certified flight instructor (CFI) pilot, the student pilot, and one passenger sustained fatal injuries; one passenger sustained serious injuries. The airplane was destroyed. The personal cross-country flight departed Oceano Airport, San Luis Obispo, California, about 1630 en route to Harris Ranch (3O8), California. Visual meteorological conditions prevailed, and no flight plan had been filed. The primary wreckage was at 35 degrees 47.449 minutes north latitude and 120 degrees 59.615 minutes west longitude. The National Transportation Safety Board investigator-in-charge (IIC) interviewed one of the student pilot's sons. The son flew the airplane with the CFI from 0700 to 0900 at the airplane's home base in Oakdale, California. They completed two takeoffs and two landings, and then refueled the airplane. They took off again, and flew about 30 to 45 minutes of practice instrument work. The son reported that he experienced no difficulties with the airplane. The student pilot and the CFI departed Oakdale about 0910, and flew to Modesto to pickup two passengers. They departed Modesto about 0950, and flew to Hanford to visit one passenger's son. At Hanford, the CFI contacted the Rancho Murrieta Automated Flight Service Station (AFSS) to obtain a weather briefing for the San Luis Obispo area. The surviving passenger said that they flew to the Oceano Airport, and went to Pismo Beach for a snack. They planned to stop at Harris Ranch for dinner on the way back to Modesto. After their snack, they departed and flew up the coast. About 1715, they made two circles around Hearst Castle and headed inland. All occupants in the airplane were on a four-way intercom. As they neared Oak Shores the engine sounds changed. The surviving passenger heard a roar, and the CFI asked the student about the oil pressure. It was "good" and both men stated that the fuel pressure was good. The CFI pointed to the left and directed the student to a private strip. During or immediately following the left turn, the CFI said, "I've got it." The student looked back at the two women, and motioned with his right hand that they were going to land at the strip. The last thing that the survivor remembered was contacting trees and coming to rest. The airplane cleared a ridge top, but collided with trees about 1/4 mile from the landing strip. When the airplane did not return at its scheduled time, family members verified that the individual's respective automobiles where still at the originating airports. They notified the Rancho Murrieta AFSS, which issued an alert notice (alnot). The Air Force Rescue Coordination Center (AFRCC) in Langley, Virginia, detected a signal from an emergency locator transmitter (ELT) about 1920. They received two more signals, and with the alnot in effect, they initiated a search mission for the Civil Air Patrol (CAP). The CAP began a ground search about 0200 on April 28, and located the wreckage about 0600. The survivor was sitting next to the wreckage. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the instructor pilot held a commercial certificate with ratings for airplane singe engine land, multiengine land, and instrument airplane. He also held a certified flight instructor certificate with ratings for airplane single engine land, multiengine land, and instrument airplane. The instructor pilot held a second-class medical certificate issued on March 3, 2001. It had the limitations that the pilot must wear corrective lenses. The medical application indicated that the pilot had accumulated about 3,500 hours at the time of the application with 274 hours in the previous 6 months. The pilot's logbooks were not recovered. The student pilot did not hold a medical certificate; however, he had petitioned the FAA for a medical certificate. All of his flight time was dual. The IIC reviewed his logbook and estimated his total flight time at 230 hours (all single engine time) with 200 in this make and model. AIRCRAFT INFORMATION The airplane was a Beech C23, serial number M-1801. The airplane and engine did not have the original logbooks. A mechanic created new logbooks in 1993, and noted that the total time on the airframe and engine was 1,445 hours. A review of the airplane's logbooks revealed a total airframe time of 2,097 hours. The logbooks contained an entry for an annual inspection dated April 6, 2001, at a total time of 1,976 hours. The engine was a Textron Lycoming O-360-A4K engine, serial number L-20956-36A. Total time on the engine at the annual inspection was 1,976 hours. The tachometer read 2,097.5 at the accident scene. METEOROLOGICAL INFORMATION The nearest reporting weather station was Paso Robles, California. An aviation routine weather report (METAR) for Paso Robles was issued at 1753. It stated: skies clear; visibility 10 miles; winds 220 degrees at 11 knots; temperature 54 degrees Fahrenheit; dew point 41 degrees Fahrenheit; altimeter 30.01 inHg. WRECKAGE AND IMPACT INFORMATION Investigators from the Safety Board, the FAA, Raytheon Beech, and Textron Lycoming inspected the wreckage at the accident scene. The accident area was in hilly terrain with a mixture of cultivated land, open grassland, and clusters of oak trees. The first identified point of contact (FIPC) was just over the crest of a ridge. Oak tree limbs with shiny debarked surfaces lay strewn along the ground. One limb that was about 1 inch in diameter exhibited a smooth fracture surface along about 12 inches of its length. The debris path was along a magnetic heading of 330 degrees. The debris path went downhill and through trees from the FIPC to the main wreckage. Looking along the debris path, about 42 feet left of the FIPC lay the right aileron. The aileron bent down, and the fracture surfaces were irregular and on an angular plane. Along the debris path centerline and 150 feet from the FIPC lay the portion of the right wing that was outboard of the right main landing gear. It separated along a jagged angular fracture surface. About 230 feet from the FIPC was a splintered oak tree stump that was about 12 inches in diameter. The main wreckage was intertwined with oak tree limbs just beyond this stump. The airplane was inverted, and the nose of the airplane was on a magnetic heading of 180 degrees. The main wreckage was about 270 feet from the FIPC. The fuselage fractured around 270 degrees of its circumference at the aft part of the cabin. The tail section rotated 180 degrees around that fracture surface so that the empennage was lying inboard of the right main landing gear, parallel to the fuselage, and on top of the inverted right wing stub. The vertical stabilizer and rudder folded over so that their tops were pointing toward the right wing tip. The right horizontal stabilizer and right elevator pointed toward the ground, and sustained the most mechanical damage. The left horizontal stabilizer and elevator pointed toward the nose of the airplane. All of the major components of the airplane remained attached together except the previously mentioned right aileron and outboard right wing. The propeller and engine remained attached to the airframe. Rescue personnel reported that all of the victims had their seat belts fastened, and the front seat occupants utilized their shoulder harness restraints. The survivor released herself, but stayed in the airplane overnight for warmth. MEDICAL AND PATHOLOGICAL INFORMATION The San Luis Obispo County Coroner completed autopsies of both pilots. The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Ok ## Aircraft - Registration: [N9180S](https://openairdocs.org/deregistered/N9180S-2002-08-28), registration cancelled 2002-08-28, S/N M-1801, built 1976 (OpenAirDocs) - Reported make and model: Beech C23 - Registry model: [Beech C23](https://openairdocs.org/model/beech-c23) (registry code 1151242) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: M-1801 - Airframe hours: 2097 - Engines: Lycoming O-360-A4K 180 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Registered owner: Stephen W. Meester - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 6, 2001, 118 hours before - Departed: L52, SAN LUIS OBISPO, CA - Destination: 3O8, HARRIS RANCH, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 52; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: right; toxicology performed; flight hours: 3,542 total - Student pilot; age 64; injuries: fatal; seat: left; toxicology performed; flight hours: 225 total ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 39 °F - Altimeter: 30.01 inHg - Observed at: PRB, 21 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 20020427006239A](https://openairdocs.org/incident/20020427006239A), Apr 27, 2002: Beech C23, Pasorobles, CA, No damage, 3 fatal. (-23) The aircraft appears to have lost power, and was attempting to land on a private airstrip. During the approach while on a modified base leg the aircraft… ## Docket (22 files) The files NTSB released with the investigation on August 11, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54595. 32.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 451 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408782&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Materials Laboratory 15 - Factual Report 03-050 (item 2, .PDF, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40182580&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2003-050-Master.PDF - Passenger Statement (item 3, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408783&FileExtension=.PDF&FileName=Passenger%20Statement-Redacted.PDF - Wreckage Diagram (item 4, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216519&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Seal Met Exam, Cylinder 1, Report and Figures 1-11 (item 5, .PDF, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172905&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Cylinder%201,%20Report%20and%20Figures%201-11-Master.PDF - Seal Met Exam, Cylinder 1, Figures 12-19 (item 6, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172907&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Cylinder%201,%20Figures%2012-19-Master.PDF - Seal Met Exam, Cylinder 1, Figures 20-30 (item 7, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172908&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Cylinder%201,%20Figures%2020-30-Master.PDF - Seal Met Exam, Cylinder 1, Figures 31-40 (item 8, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172909&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Cylinder%201,%20Figures%2031-40-Master.PDF - Seal Met Exam, Cylinder 1, Figures 41-51 (item 9, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172910&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Cylinder%201,%20Figures%2041-51-Master.PDF - Seal Met Exam, Exhaust Valves, Report and Figures 1-9 (item 10, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408784&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Exhaust%20Valves,%20Report%20and%20Figures%201-9-Redacted.PDF - Seal Met Exam, Exhaust Valves, Figures 10-22 (item 11, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172913&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Exhaust%20Valves,%20Figures%2010-22-Master.PDF - Seal Met Exam, Exhaust Valves, Figures 23-32 (item 12, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40172914&FileExtension=.PDF&FileName=Seal%20Met%20Exam,%20Exhaust%20Valves,%20Figures%2023-32-Master.PDF - Oil Analysis Reports (item 13, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216294&FileExtension=.PDF&FileName=Oil%20Analysis%20Reports-Master.PDF - Airframe and Engine Logbook Excerpts (item 14, .PDF, 515 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408785&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Logbook%20Excerpts-Redacted.PDF - Toxicological Reports (item 15, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408786&FileExtension=.PDF&FileName=Toxicological%20Reports-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 16, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408787&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 17, .PDF, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40408788&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1-Accident Site from Landing Strip (item 18, .PDF, 410 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216520&FileExtension=.PDF&FileName=Photo%201-Accident%20Site%20from%20Landing%20Strip-Master.PDF - Photo 2-Right Rear View of Main Wreckage (item 19, .PDF, 647 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216521&FileExtension=.PDF&FileName=Photo%202-Right%20Rear%20View%20of%20Main%20Wreckage-Master.PDF - Photo 3-Aft End of Main Wreckage (item 20, .PDF, 637 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216522&FileExtension=.PDF&FileName=Photo%203-Aft%20End%20of%20Main%20Wreckage-Master.PDF - Photo 4-Empennage Main Wreckage (item 21, .PDF, 674 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216523&FileExtension=.PDF&FileName=Photo%204-Empennage%20Main%20Wreckage-Master.PDF - Photo 5-Cylinder Number 1 Internal View (item 22, .PDF, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40216524&FileExtension=.PDF&FileName=Photo%205-Cylinder%20Number%201%20Internal%20View-Master.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.