# NTSB LAX03FA074: Beech 95, N2733Y, Rancho Cucamong, CA, January 25, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: January 24, 2003, 16:26 local (Jan 25, 2003, 00:26 UTC) - Place: Rancho Cucamong, CA - Coordinates: 34.130279, -117.609443 - Nearby events: https://openairdocs.org/map.md?lat=34.1303&lon=-117.6094&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 14, 2007 - Report: Approved by Office Director - Parties: Raytheon (Beechraft), Federal Aviation Administration, Hartzell Propeller, Inc., Lycoming Engines - Safety recommendations: Yes - NTSB case key (mKey): 56399 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03FA074 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56399/pdf - Page: https://openairdocs.org/ntsb/LAX03FA074 ## Probable cause The fracture and separation of a propeller blade during cruise flight due to fatigue and corrosion pits in the blade pilot bore, and an improper overhaul of the separated propeller by repair station personnel. Factors contributing to the accident were the FAA's inadequate surveillance of the repair station, and the repair station's inadequate procedures. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Propeller failure/malfunction, cruise - procedure inadequate, other maintenance personnel (contributing factor) - inadequate surveillance of operation, faa(organization) (contributing factor) - maintenance,overhaul - improper, other maintenance personnel (cause) - propeller system/accessories,blade - corroded (cause) - propeller system/accessories,blade - fatigue (cause) - propeller system/accessories,blade - separation (cause) - Loss of control - in flight, cruise - engine assembly,mount - buckled - aircraft control - not possible - In flight collision with object, descent - uncontrolled - object - residence ## Analysis While in cruise flight, a portion of a propeller blade separated from the right engine. The resulting vibration partially separated the engine from its airframe mounts, and the uncontrollable airplane rolled inverted and dived into a private residence. The house was severely damaged, the airplane was destroyed. The separated propeller was overhauled about 3 years and 5 operational hours prior to the accident flight. The separated 2.5-foot-long span of the failed blade was found about 1 mile from the main wreckage. The blade was examined by the NTSB's Metallurgical Laboratory, which found that the blade failed as a result of fatigue cracking initiated by corrosion pitting in the pilot tube bore. A fatigue crack had initiated at two corrosion pit sites in the bore, which had been painted over without the corrosion being dressed out during the overhaul. Also, many additional corrosion pits were located circumferentially in line with the origin area. The blade's bore was also contaminated with glass beads. All of these conditions found during the examination were contrary to the procedural steps in the manufacturer's overhaul instructions, and established that the blade was reassembled with an incomplete and improper overhaul. The FAA inspector assigned to oversee the overhaul company said he did not observe any repair station deficiencies during his surveillance inspections. A Safety Board inspection following the accident disclosed that the repair station's personnel were not following prescribed manufacturer overhaul procedures, did not have the required chemicals for blade treatment, and did not possess required procedure manuals. Additional inspections of other propellers overhauled by the company revealed that propellers overhauled as early as 1997, when the company commenced business, showed evidence of corrosion in the pilot bores, and were unairworthy. ## Factual narrative HISTORY OF FLIGHT On January 24, 2003, about 1626 Pacific standard time, a Beech 95, N2733Y, experienced the in-flight separation of one right engine propeller blade, which was followed by the engine dislodging from its firewall mounts. The pilot was unable to maintain controlled flight, and the airplane descended into a private residence in Rancho Cucamonga, California. The sole occupant in the house was not injured. The airplane was destroyed, and its private pilot, the sole occupant in the airplane, was fatally injured. The pilot co-owned and operated the airplane. The personal flight, which was reportedly the first following maintenance, was performed under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from the (uncontrolled) Cable Airport, Upland, California, about 1620. The airplane departed from runway 24 and climbed to about 4,500 feet mean sea level. A pilot who was flying in the area observed the Beech and noticed it suddenly made a steep turn. Subsequently, the airplane descended. Several ground-based witnesses who noted smoke trailing from the airplane observed the descent. One witness reported observing the right engine hanging straight down toward the ground with the propeller stopped. Thereafter, the airplane rolled over until becoming upside down, and it dove straight toward the ground. Several other witnesses also reported observing the airplane in a steep right bank turn and then a nosedive toward the ground. The airplane's descent terminated when it impacted a house in a near vertical nose down attitude. OTHER DAMAGE A single family residence was partially destroyed. PERSONNEL INFORMATION Pilot. The pilot held a private pilot certificate with airplane single and multiengine land ratings. He also held an aircraft repairman certificate, which was issued on January 6, 1998. The repairman certificate was valid for troubleshooting, inspection, and maintenance of aircraft, airframe, and engines while employed by Foothill Aircraft Sales and Service, Inc., Upland. The pilot's previous aircraft repairman certificate was issued on July 24, 1981. The pilot's flight time and currency information was provided by acquaintances of the pilot and by the Federal Aviation Administration (FAA). The pilot's personal flight record logbook was not provided for examination, and his recent flying experience/currency was not confirmed. The pilot's flight hours reported herein are derived from the aforementioned sources and Safety Board investigator estimates. Acquaintances reported they believed the pilot's total flight time was about 3,000 hours; his flying activity during the preceding 90 days was 40 hours, and his experience flying the Beech 95 was 25 hours. According to FAA airmen medical records, on medical certificate applications dated 9/19/2002, 7/3/2000, and 4/14/1998, the pilot reported that his total flight times were 3,000, 1,200, and 1,800 hours, respectively. On these dates, the pilot also reported that his flying activity during the preceding 6 months was 80, 15, and 10 hours, respectively. AIRCRAFT INFORMATION The Beech 95 (Travelair), serial number TD-72, was manufactured in 1958, and was issued a standard FAA airworthiness certificate. The airplane's two 180 hp Lycoming O-360-AIA engines are equipped with 2-bladed, single acting, hydraulically operated, constant speed, full feathering Hartzell propellers, model HC-92ZK-2. The propellers are manufactured with 8447-12(A,R) blades (Z-shank). This designation identifies them as steel hub, single shoulder blades with internal bronze bushings. Z-shank blades are manufactured from a one-piece aluminum forging. The hub and blade clamps are steel. Oil pressure from the propeller governor is used to move the blades to the low pitch (blade angle) direction. Blade mounted counterweights and feathering springs actuate the blades towards the high pitch/feather direction in the absence of governor oil pressure. Propeller rotation is clockwise as viewed from the rear. Propeller Installation. The National Transportation Safety Board investigator reviewed the airplane, engine, and propeller logbooks provided by the airplane owner's attorney and by the owner of T & W Propellers. In pertinent part, airplane logbook No. 1 indicates that, in 1988, the left engine was equipped with propeller hub serial number (S/N) 279F. The right engine's propeller hub was S/N 282F. The left engine's propeller blade S/Ns were 113573 and 114546. The right engine's propeller blade S/Ns were 114565 and 114356. Subsequently, the left engine's hub was changed, and the two propeller blades on each of the hubs were also changed. According to the airplane's maintenance records, on the accident date the airplane was configured as follows: Left Engine, per Foothill Invoice number 5708: S/N RL-1280-36 Total Time on the Factory Remanufactured Engine: 6,668 hours Hartzell Propeller HC-92ZK-2A; Blade Design 8447-12A Hub: S/N 481F Blades Marked: S/N A49334 and S/N A49352 Right Engine, per Foothill Invoice number 5708: S/N L-501-36 Total Time on Engine: 2,383 Hartzell Propeller HC-92ZK-2B; Blade Design 8447-12R Hub: S/N 282F Blades Marked: S/N C36230 and S/N C36547 NOTE: During the wreckage examination the above listed hub/propeller assemblies were found attached to the opposite engines. The right engine's propeller hub bore S/N 481F. The butt end of the blade shank fragment that remained clamped in the hub (from the separated blade) was found stamped with S/N A49334. (In this report, this failed blade is referred to as blade "R1.") These reversed positions were not documented in the airplane logbook. No explanation was provided by maintenance personnel regarding this discrepancy. According to the Hartzell participant, Beech 95 series aircraft are approved with either 8447-12A or 8447-12R blade designs. The only difference is the blade tip shape; the -12R blade has a round tip with a relatively large tip radius. The propeller positioned on the left engine was found to have -12R blades, and the propeller positioned on the right engine had -12A blades, with a less circular tip shape. Propeller Maintenance History. On December 3, 1996, the airplane received maintenance. As indicated on Foothill Aircraft Sales & Service, Inc., invoice number 1148, at a tachometer time of 1,035 hours, the propellers were removed from the airplane and sent to Southern California Propeller Service (SCPS), which operated an FAA repair station under certificate No. VXSR617L. On Foothill's invoice number 1597, at a tachometer time of 1,435 hours, a notation appears indicating that per SCPS's invoice number 4639, the propellers had been disassembled and inspected. A notation was made that the blade shank inspection and compression roll was required every 500 hours. On December 6, 1996, SCPS, made an entry in the airplane's propeller logbook. The entry indicated that the left engine's hub S/N 481F with blades S/N A49334 and A49352, and the right engine's hub S/N 282F with blades S/N C36230 and C36547, had been "COMPLETELY REPAIRED." The maintenance was also recorded with the same date on the "Overhaul Record" page in the logbook. Also, on the "AIRWORTHINESS DIRECTIVE AND SERVICE BULLETIN/LETTER COMPLIANCE RECORD" page, the following airworthiness directives were listed as having been complied with: 95-11-08 and 85-14-10R2. According to an entry in the airplane's logbook, on December 6, 1996, the airplane received an annual inspection. Its total airplane time was listed as 9,221 hours. The next consecutive logbook entries were dated February 26, 1997; March 28, 1997; and May 23, 1997. These entries indicated performance of annual inspections. On June 10, 1997, the airplane received a 50-hour inspect ## Aircraft - Registration: [N2733Y](https://openairdocs.org/deregistered/N2733Y-2004-09-08), registration cancelled 2004-09-08, S/N TD-72, built 1958 (OpenAirDocs) - Reported make and model: Beech 95 - Registry model: [Beech 95](https://openairdocs.org/model/beech-95) (registry code 1153402) (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: TD-72 - Airframe hours: 9679 - Engines: Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Robert Y. Cable - Registered owner: Marilyn R. & Robert Y. Cable Co. Trustee, - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2003, 5 hours before - Departed: CCB, Upland, CA - Destination: CCB ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3, without waivers/limitations; seat: left; toxicology performed; flight hours: 1,500 total, 25 in this make and model, 40 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 20,000 ft broken - Temperature: 75 °F, dew point 43 °F - Altimeter: 30.04 inHg - Observed at: ONT, 5 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 20030124001099A](https://openairdocs.org/incident/20030124001099A), Jan 24, 2003: Beech 95, Ranchocucamong, CA, Destroyed, 1 fatal. (.19) On January 24, 2003, about 1626 pacific standard time, a Beech 95, N2733Y, experienced the loss of a propeller blade and the subsequent separation of the… ## Other investigations on N2733Y (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 CHI66F0180](https://openairdocs.org/ntsb/CHI66F0180), Aug 14, 1965: Beechcraft 95 (N2733Y), Quincy, IL, substantial damage 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.