LAX06FA129

The engine lost power during the takeoff-initial climb and the pilot ditched the airplane in the ocean. Examination showed that the number 2 connecting rod fractured from the crankshaft. Metallurgical examination of the connecting rod, and associated bolts, nuts, and bearings, showed that following the first nut and bolt separation, the overall separation was not instantaneous. After the first nut unthreaded from its respective bolt, subsequent increased loads on the opposite bolt then stripped the threads of the other nut that had partially unthreaded from its bolt. Furthermore, there was no evidence of cotter pin installation. In general, a properly torqued nut and connecting rod bolt will not loosen under normal operational conditions. The engine underwent a field overhaul 735.31 hours prior to the accident. At 233.59 hours prior to the accident, the cylinders were removed for a blow by condition during an annual inspection; however, the aviation maintenance technician who performed this work stated that he did not remove the connecting rods from the crankshaft. Review of the autopsy results and impact damage to the wreckage indicated that the occupants' use of shoulder harnesses would have significantly increased their chances of survival.

1.1 History of the Flight

On March 13, 2006, at 0943 Pacific standard time, a Beech A36, N16JR, was ditched into the ocean following a loss of engine power after departure from Santa Monica Municipal Airport, Santa Monica, California. The instrument rated private pilot, who was also a registered co-owner of the airplane, was operating it under the provisions of 14 CFR Part 91. The pilot and one passenger sustained fatal injuries; a third occupant listed on the instrument flight plan was not located. The airplane was destroyed. The pilot was destined for Brown Field Municipal Airport, San Diego, California to pick up a passenger and intended to return to Santa Monica later that day. Visual meteorological conditions prevailed and an instrument flight plan was in effect.

The airplane impacted the water off of Santa Monica beach approximately 2.5 statute miles west-southwest of the Santa Monica Airport and about 250 yards off shore. It was submerged in 20 feet of water. The pilot and one occupant were recovered from the airplane. Searches for the third occupant continued but were unsuccessful. Acquaintances of the pilot were unaware of who the third person would have been and at the time of this report, there was no additional information of a third person onboard the airplane.

According to the co-owner of the airplane, he and the pilot normally kept the utility doors locked when there were no aft seat passengers. They also agreed that when ditching the airplane, the cabin door would be unlatched prior to impact with the water. Initial responders reported that the cabin door was unlatched and that the utility doors were locked.

1.1.1 Witness Information

A lifeguard reported that he was 1 mile north of the airplane when he saw it at 400 feet above water level. It appeared to be at lower than normal altitude for airplanes flying in the area and continued a descent toward the ocean. The flight path of the airplane was toward Santa Monica airport from the southwest to the northeast. The lifeguard stated that the pilot appeared to be in control of the airplane and that from the time he first noticed the airplane until its impact with the water, approximately 5 seconds had gone by.

An additional witness was on the beach and took photos of the airplane as it approached the water. The photos show the airplane in a level flight attitude descent, approaching the beach from the west with the landing gear retracted. As the airplane impacted the water, it was in an upright attitude and moving in an easterly direction toward the beach. Upon impact, the airplane turned to a west-southwest heading on the surface of the water, and subsequently sank.

1.1.2 Radar Information and Communications

The pilot was in communications with the Southern California Terminal Radar Approach Control at the time of the power loss, and was then transferred back to Santa Monica Air Traffic Control Tower. In summary, the pilot indicated that he had a power loss and was returning to Santa Monica Airport. He then indicated that he would not be able to make it to the airport, and he was going to attempt to land the airplane on the beach.

Recorded radar information was obtained from the Southern California Terminal Radar Approach Control Facility. The airplane was assigned a discrete transponder code of 4711 and the first target associated with the accident airplane initiated at 0935:55. At 0936:00, the target showed an altitude of 600 feet. The target showed a climb to 3,200 feet on a west-northwest ground track. At 0939:04 the squawk code changed to 7777 and remained there throughout the remainder of the flight. The radar track then showed a descent from 0939:32 and a 180-degree turn to the east-southeast. The last radar hit was at 0942:04 at an elevation of 600 feet.

1.2 Personnel Information

The pilot held a private pilot certificate for single-engine airplanes with an instrument rating. He was issued a third class medical certificate in July of 2005 with the restriction that he must wear corrective lenses during flight.

Copies of the pilot's personal flight logbook were obtained from his family. The logbook was dated from October of 1991 until the last entry date of February 20, 2006. The total flight time logged was 428.4 hours. The pilot obtained his instrument rating on October 15, 2004, in the accident airplane, which equated to his most recent flight review. The pilot logged 70.6 hours in the last 12 months, 15 hours in the last 6 months, and 2.2 hours in the past 30 days.

1.2.1 Pilot Information

According to Angel Flight personnel, the pilot had volunteered his time and airplane services to assist in the transport of a medical patient from San Diego to the Los Angeles area. The pilot was on the initial leg of the trip to pickup the patient when the accident occurred. The purpose of Angel Flight is to assist those in need of air transportation due to medical services, national crisis, or specific human need by providing flights at no charge. The pilot received an Angel Flight checkout in August of 2005 and the accident flight was his first mission.

1.3 Aircraft Information

1.3.1 General Aircraft History

The airplane was manufactured in 1973. At the time of the accident, the tachometer indicated 3,555.20 hours. It was powered by a Teledyne Continental IO-520-BA (serial number 551008) six-cylinder piston engine, which had accumulated 735.31 hours since the last field overhaul. The engine was equipped with a McCauley model 3A32C76S-MR propeller.

1.3.2 Maintenance Information

An engine logbook entry showed that the engine was overhauled on December 30, 1977, at a total time of 1,775 hours. On February 3, 1998, the engine was field overhauled; there was no tachometer time noted in the maintenance entry. The connecting rod bearings and bushings, and the associated nuts and bolts, were replaced during this overhaul. Following the overhaul, mineral oil was installed in the engine. The engine was placed into storage.

On February 2, 1999, an engine logbook entry indicated, in part, "Due to the long period of storage, it was disassembled, cleaned, inspected, and reassembled in accordance with the TCM IO-520 Overhaul manual, applicable Service Bulletins, and Airworthiness Directives." The engine was reinstalled on the airplane on May 26, 1999, at a tachometer time of 2,819.89 hours.

On July 31, 2004, an annual inspection was performed on the airplane. The tachometer time for the airplane was 3,321.61, and the time since major overhaul (TSMOH) of the engine was 502.72. The logbook entry indicated that all six cylinders were removed due to a blow by condition.

The aviation maintenance technician (AMT) that performed the annual inspection was interviewed on March 23, 2006. At the time of the annual inspection, the pilot was employed part-time at Corporate Jet Support, Hayward, California, about 5 hours per day. He worked full-time as a Production Supervisor for American Airlines, approximately 8 hours per day. Due to his schedule, he ceased his employment at Corporate Jet Support after about one year of employment.

The AMT performed two annual inspections on the airplane; one on July 10, 2003, and one on July 31, 2004. The July 10, 2003, annual inspection was unremarkable. The AMT noted that during the July 31, 2004, inspection, the engine was removed from the airplane because the cylinders had to be removed. The exhaust and intake tubes were detached and the cylinders were pulled, as well as the pistons. The connecting rods were not removed. The cylinders were removed due to a blow by condition that was causing low compression. After the cylinders were repaired, they were reinstalled and the engine operated normally.

The last annual inspection was performed on August 19, 2005, at a tachometer time of 3,510 hours and 691 hours TSMOH at Santa Monica Aviation, Santa Monica, C