NYC94LA129

NTSB accident investigation · Pitts S-1S · Stevensville, MD · July 15, 1994

Accident · Minor injuriesLimited investigationFinal report
Date
July 15, 1994, 14:45 local (18:45 UTC)
Place
Stevensville, MD
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N515TNPitts S-1S
Weather
Visual (VMC) · Day
Status
Completed · report March 27, 1995
Report
Approved by Office Director
FAA report
19940715018639A
Case key
38792

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

Inadequate maintenance by which undertorquing of the accessory gear retaining bolt resulted in fatigue failure of the bolt and the subsequent loss of engine power.

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.

Loss of engine power(total) - mech failure/malfClimb
Accessory drive assy - undertorqued
Maintenance - inadequateOther maintenance personnel
Accessory drive assy - fatigue
Accessory drive assy - disconnected
Forced landingDescent - emergency
On ground/water collision with objectLanding - roll
Object - tree(s)

Analysis

The airplane's engine lost total power just after takeoff when the pilot reduced the throttle. The pilot re-applied full throttle with no result. During the forced landing in a field, the airplane's wing struck a tree, and the airplane nosed over. Examination of the engine revealed that the crankshaft gear (13S19646) became disconnected from the crankshaft due to a broken bolt. Metallurgical examination of the accessory gear retaining bolt (p/n STD-2213), and dowel pin (p/n STD-1065) revealed that they separated as a result of high cycle fatigue mechanism, most likely caused by insufficient torque of the bolt.

Factual narrative

On July 15, 1994, at 1445 eastern daylight time, a Pitts S-15, N515TN, registered to and piloted by Teresa Nagy, sustained substantial damage when it impacted the terrain at the Kentmore Airport, Stevensville, Maryland. The pilot received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed. The flight was operated under 14 CFR Part 91.

The airplane's engine lost partial power just after takeoff. The pilot was attempting to return to the airport, when the engine lost total power. The pilot made a forced landing in a field, the airplane's wing struck a tree, and the airplane nosed over.

According to the pilot's statement on the NTSB Form 6120.1/2:

I applied power and began climb at 100 IAS...at approximately 500 feet I began to gently reduce power...just prior to the power reduction I thought I heard a "surge" but no vibration or any indication of problem. When I reduced the power the engine stopped, I immediately re applied full throttle-no result....

The engine was removed from the airplane, and retained for further examination. On October 6, 1994, the engine from N515TN, was disassembled under the supervision of NTSB Investigator, Margaret Napolitan, at Lycoming Engine's facilitates, Williamsport, Pennsylvania.

The engine disassembly revealed that engine continuity could not be established as result of the crankshaft gear (13S19646) becoming disconnected from the crankshaft. The accessory gear retaining bolt (STD-2213) was fractured, and a crack was observed in the root of the adjacent thread. According to Lycoming, "...this is consistent with overtorqueing of the bolt." The head of the bolt was worn from coming in contact with the oil pump drive after it was fractured and while it was encapsulated in the crankshaft gear counterbore. The lockplate (LW-18639) was worn, a portion of it was missing, and was not recovered. The dowel (STD-1065), used to position the gear for internal timing, was fractured. The fracture surface of the dowel displayed crack arrest lines (beach marks).

The engine disassembly also revealed that the connecting rods were not torqued to the specified 40 foot pounds. Several bolts used in various locations were not the correct parts, and safety wire was not used were required.

The following parts to include, two pieces of the accessory gear retaining bolt, P/N STS-2213; the separated dowel pin. P/N STD-1065; and lockplate, P/N STD-1065, were sent to the NTSB Materials Laboratory, Washington, DC.

Examination of the accessory gear retaining bolt, revealed that the fracture on the head portion of the bolt and the bolt identification markings were completely obliterated by post separation mechanical damage.

The fracture face on the threaded portion of the bolt, revealed features typical of fatigue cracking over approximately 90 percent of the bolt cross section. A secondary crack was found located in the root of the third tread from the fracture surface.

The examination of the bolt revealed no material defects at the fracture origin. Material of the bolt and its hardness were found to be within the specified requirements.

Examination of the dowel pin revealed that most of the fracture contained well defined crack arrest positions consistent with a fatigue fracture mechanism. The fracture features in the final fracture zone were typical of overstress separations. A band of fretting wear was found in the area adjacent to the fracture surface.

Aircraft

Registration
N515TN
Reported as
Pitts S-1S
Category
Airplane, amateur-built
Serial number
7-0255
Airframe hours
144
Engine
Lycoming O-360-A4G, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Registered owner
Teresa & John Nagy
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · June 10, 1994 · 9 hours before
Departed
3W3
Destination
ESN · Easton, MD
Airport
3W3 · Kentmore Airpark, runway 10, 2,000 × 75 ft, grass/turf

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
46
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Center
Flight hours
640 total · 61 in this make and model · 345 as pilot in command · 17 in the last 90 days · 14 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
90° at 8 knots
Visibility
5 statute miles
Temperature
91 °F, dew point 77 °F

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.