# NTSB LAX92LA042: Beech D18S, N4193, Hilo, HI, November 10, 1991 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 10, 1991, 08:50 local (18:50 UTC) - Place: Hilo, HI - Coordinates: 19.68983, -155.079071 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=19.6898&lon=-155.0791&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 11 uninjured - Status: Completed, report March 2, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 27501 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX92LA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27501/pdf - Page: https://openairdocs.org/ntsb/LAX92LA042 ## Probable cause THE AIRCRAFT'S LACK OF SINGLE ENGINE PERFORMANCE TO MAINTAIN ALTITUDE AFTER THE ENGINE LOST POWER. FACTORS RELATED TO THE ACCIDENT WERE: DISPLACEMENT/MECHANICAL INTERFERENCE WITHIN THE ACCESSORY DRIVE GEAR SYSTEM OF THE LEFT ENGINE, FAILURE OF THE LEFT ENGINE ACCESSORY DRIVE GEAR SHAFT, AND THE FAA'S INADEQUATE CERTIFICATION/APPROVAL OF THE OPERATOR, IN ORDER TO ASSURE COMPLIANCE WITH 14 CFR 135 CONCERNING THE ENGINE-OUT CAPABILITY. ## 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, cruise - normal - 1 engine - accessory drive assy,drive gear - binding(mechanical) (contributing factor) - accessory drive assy,drive shaft - failure,total (contributing factor) - fuel system,pump - disengaged - ignition system,magneto - disengaged - Forced landing, descent - emergency - aircraft performance,engine out capability - inadequate (cause) - inadeq certification/approval,operation/operator, faa(organization) (contributing factor) ## Analysis ABT 45 MI FM LNDG, THE L ENG RPM BGN TO FLUCTUATE, THEN AT ABT 15 MI FM LNDO, IT LOST POWER ALTOGETHER. THE PLT SAID THE ACFT WOULD NOT MAINT ALTITUDE. UNABLE TO RCH THE RWY, HE DITCHED THE ACFT IN HILO BAY ABT 1/4 MI FM SHORE & 1.5 MI FM THE ARPT. AFTER RETRIEVAL, THE ACFT & L ENG WERE EXAMINED. THE ACCESSORY GEAR DRIVE SHAFT WAS FND TO HAVE FAILED IN TORSIONAL OVERLOAD. ON THE INSIDE OF THE CASE, AN AREA OF GOUGING & ABRASION WAS FND DRCTLY IN FNT OF THE STARTER GEAR. (THE LEFT MAG, FUEL PUMP & PROP GOVERNOR WERE DRIVEN BY THE ACCESSORY DRIVE GEAR.) DEEP IMPRESSIONS WERE NOTED ON ABT 70% OF THE GEAR TEETH, WITH MTRL DISPLACEMENT & GOUGING EVIDENT. THERE WAS EVIDENCE THAT THE COLLECTOR DRIVE FLOATING GEAR MAY HAVE MOVED FORWARD & HAD CONTACTED THE ENG CASE. ALSO, THERE WAS EVIDENCE OF MECHANICAL INTERFERENCE WITHIN THE ACCESSORY DRIVE GEAR SYS. THE ACFT GROSS WT AT THE TIME OF THE ACDNT WAS ABOUT 9108 LBS. ## Aircraft - Registration: [N4193](https://openairdocs.org/deregistered/N4193-2012-11-20), registration cancelled 2012-11-20, S/N A-980, built 1953 (OpenAirDocs) - Reported make and model: BEECH D18S - Registry model: [Beech D18S](https://openairdocs.org/model/beech-d18s) (registry code 1151004) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985 series](https://openairdocs.org/engine/pratt-whitney-r-985-series) (registry code 52008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: A980 - Airframe hours: 19936 - Engines: P&W R-985-AN14B 450 horsepower reciprocating - Damage: Substantial damage - Flight: Part 135 - Operator: Tomy International, doing business as Scenic Air Tours - Registered owner: Tomy International - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 28, 1991, 35 hours before - Departed: HNL, HONOLULU, HI - Destination: ITO, HILO, HI - Flight plan: VFR - Airport: ITO, Hilo International, runway 8, 9,800 × 150 ft, macadam ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; flight hours: 18,579 total, 323 in this make and model, 10,712 as pilot in command, 180 in the last 90 days, 59 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 10 knots - Visibility: 15 statute miles - Lowest ceiling: 28,000 ft broken - Temperature: 79 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: ITO, 1 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 19911110050039A](https://openairdocs.org/incident/19911110050039A), Nov 10, 1991: Beech D18S, Hilo, HI, Substantial damage. Left mag drive shaft failed stopped left engine on approach. Ditched in bay. Unable sustain flight on good engine. ## Other investigations on N4193 (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 NYC70D0179](https://openairdocs.org/ntsb/NYC70D0179), Oct 2, 1969: Beech D18S (N4193), Karthaus, PA, 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.