# NTSB MIA91FA095: Beech 35-C33A, N4828J, Key West, FL, March 10, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: March 9, 1991, 19:50 local (Mar 10, 1991, 00:50 UTC)
- Place: Key West, FL
- Coordinates: 24.549694, -81.780654 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=24.5497&lon=-81.7807&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 3 fatal
- Status: Completed, report February 8, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 32747
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA91FA095
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32747/pdf
- Page: https://openairdocs.org/ntsb/MIA91FA095

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Airframe/component/system failure/malfunction, takeoff - initial climb
  - propeller system/accessories,pitch change mech - fatigue (contributing factor)
  - maintenance,overhaul - improper, other maintenance personnel (contributing factor)
  - propeller system/accessories,pitch change mech - failure,partial (contributing factor)
  - engine assembly - vibration (contributing factor)
- Loss of control - in flight, maneuvering - turn to landing area (emergency)
  - airspeed(vs) - not maintained, pilot in command (cause)
  - stall/spin - inadvertent, pilot in command (cause)
- In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N4828J-1991-07-11), registration cancelled 1991-07-11, S/N CE115 (OpenAirDocs)
- Reported make and model: BEECH 35-C33A
- Registry model: [Beech 35-C33A](https://openairdocs.org/model/beech-35-c33a) (registry code 1151410) (OpenAirDocs)
- Category: Airplane
- Serial number: CE-115
- Airframe hours: 4050
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 47; 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 (OpenAirDocs).

- [Accident 19910309004799A](https://openairdocs.org/incident/19910309004799A), Mar 9, 1991: Beech 35C33A, Key West, FL, Destroyed, 3 fatal. Engine overspeed on climbout. Throttled back. Began turn back,stalled. Spun in. Actuating blade pins installed wrong

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.

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