MIA91FA095

NTSB accident investigation · Beech 35-C33A · Key West, FL · March 10, 1991

Accident · FatalField investigationFinal report
Date
March 9, 1991, 19:50 local (Mar 10, 1991, 00:50 UTC)
Place
Key West, FL
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N4828JBeech 35-C33A
Weather
Visual (VMC) · Night/dark
Status
Completed · report February 8, 1993
Report
Approved by Office Director
FAA report
19910309004799A
Case key
32747

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot-in-command's failure to maintain airspeed, while returning for an emergency landing following propeller failure, resulting in the aircraft stalling and entering a spin.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Airframe/component/system failure/malfunctionTakeoff - initial climb
Propeller system/accessories,pitch change mech - fatigueFactor
Maintenance,overhaul - improperOther maintenance personnelFactor
Propeller system/accessories,pitch change mech - failure,partialFactor
Engine assembly - vibrationFactor
Loss of control - in flightManeuvering - turn to landing area (emergency)
Airspeed(vs) - not maintainedPilot in commandCause
Stall/spin - inadvertentPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Witnesses rptd they heard propeller overspeed followed by engine pwr being reduced to idle as if pilot pulled throttle closed. Acft then banked to left and entered spin to the left crashing into a parking lot. Post crash examination of the engine, acft structure, and flight controls revealed no evidence of precrash failure or malfunction. Examination of the propeller revealed the number two blade pitch change actuating pin had failed due to fatigue. The pin had been installed at overhaul, 600 flt hours before the accident, by following mccauley service bulletin 99 which is not applicable to this model propeller. The pin was installed by using a short threaded pin, a thin spacer, and a blind hole in the ferrule. This combination allowed the pin to bottom out in the hole thus not torquing properly and thus cracking due to applied loads.

Aircraft

Registration
N4828J
Reported as
Beech 35-C33A
Category
Airplane
Serial number
CE-115
Airframe hours
4,050
Engine
Continental TSIO-520-D, 285 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
James W. Hardin
Registered owner
James W. Hardin
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · August 1, 1990 · 103 hours before
Destination
PBI · West Palm Beach, FL
Flight plan
IFR

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
47
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,200 total · 600 in this make and model · 35 in the last 90 days · 10 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
350° at 22 knots, gusting 27
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 68 °F
Altimeter
29.00 inHg
Observed at
EYW, 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.