# NTSB SEA01LA115: Beech E35, N7362B, Eastsound, WA, June 9, 2001 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 9, 2001, 14:00 local (21:00 UTC) - Place: Eastsound, WA - Coordinates: 48.619953, -122.870361 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.6200&lon=-122.8704&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 3 serious, 1 minor - Status: Completed, report December 18, 2001 - Report: Approved by Office Director - Parties: Federal Aviation Administration - ADs cited in the narratives: [AD 55-26-02](https://openairdocs.org/ad/55-26-02) (OpenAirDocs) - NTSB case key (mKey): 52490 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA01LA115 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/52490/pdf - Page: https://openairdocs.org/ntsb/SEA01LA115 ## Probable cause Failure of the engine driven fuel pump due to a worn snap ring which resulted in a loss of engine power during initial climb. Failure to comply with Service Bulletin inspection instructions, and collision with trees were factors. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - maintenance,service bulletin/letter - not complied with, other maintenance personnel (contributing factor) - fuel system,pump - failure,total (cause) - miscellaneous,bolt/nut/fastener/clamp/spring - worn (cause) - Forced landing, emergency descent/landing - In flight collision with object, emergency descent/landing - object - tree(s) (contributing factor) ## Analysis Shortly after takeoff, at about 150 feet above ground level, the engine suddenly lost power. The pilot was unable to restart the engine and turned the aircraft toward a clearing. The aircraft stalled just before colliding with trees and subsequently the ground. During the engine examination, it was found that the engine driven fuel pump was loose at the base of the pump, and the splined shaft of the pump was not properly engaged in the pump. The drive pin was not properly engaged and the snap ring securing the seal spring retainer and spring from extending beyond the end of the shaft was not secured around the end of the rotor. A section from the end of the rotor was broken off. Metallurgical examination of the fuel pump components revealed that the seal spring retainer snap ring was severely worn and when assembled in place on the rotor, would barely keep the seal spring retainer on the shaft end of the rotor. The rotor fracture was typical of overstress. The mechanic who last inspected the fuel pump reported that during the inspection of the fuel pump drive pin, he did not disassemble the components as indicated in the accomplishment instructions of a service letter by the engine manufacture that he was using nor the Service Bulletin published by the fuel pump manufacturer. The mechanic reported that he did not remove the snap ring to gain access to the drive pin for the drive pin inspection, nor did he replace any of the fuel pump components. The Service Bulletin, in a note under assembly of the pump, states to not reuse the snap ring. ## Factual narrative HISTORY OF FLIGHT On June 9, 2001, at 1400 Pacific daylight time, a Beech E35, N7362B, registered to and operated by the private pilot as a 14 CFR Part 91 personal flight, experienced a loss of engine power shortly after takeoff from Orcas Island airport, Eastsound, Washington, and subsequently collided with trees and the terrain during the forced landing. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was substantially damaged and the private pilot and two of his passengers were seriously injured. The fourth passenger received minor injuries. The flight was departing for Roche Harbor, Washington. Witnesses to the accident reported to the San Juan County Sheriff's Department personnel, who responded to the accident site, that the aircraft took off to the south and attained an altitude between 100 and 150 feet above ground level. After the aircraft cleared the runway and the landing gear was retracted, the engine suddenly lost power, "as if turned off." The aircraft continued to the south, loosing altitude as it approached the Lavender Hollow Apartments. The witnesses reported that the aircraft appeared to turn to the left prior to striking trees. During a telephone interview and subsequent written statement, the pilot reported that the start, taxi, run up and takeoff from runway 16 were normal. The airplane attained an altitude of about 150 feet above ground level when the engine suddenly lost power. The pilot began emergency procedures and adjusted the engine controls (mixture, propeller, throttle) with no engine response. The pilot reported that he did not activate the wobble pump. The stall warning horn sounded, and he lowered the nose of the aircraft to gain airspeed. The pilot noted a clearing to the left and turned toward the clearing. The aircraft subsequently stalled into the trees and collided with the ground. WRECKAGE AND IMPACT INFORMATION Personnel from the Sheriff's Department reported to the National Transportation Safety Board (NTSB), that the aircraft appeared to have struck trees with the right wing, then spun around and came to rest right-side-up and facing to the north. The engine had been displaced to the left side, and the cockpit area was severely damaged. The aircraft was recovered from the accident site and taken to the airport by personnel from Island Aircraft Services, where it was stored until a Federal Aviation Administration Inspector from the Flight Standards District Office arrived on site to inspect the engine. During the inspection, the engine driven fuel pump was found loose at the base of the pump. The pump was removed, and the inspector noted that, "... the splined shaft of the pump was not properly engaged in the pump, and the drive pin which should be installed through the shaft was still located in the pump, but was not attached through the drive shaft." The pump was retained for further inspection and taken to an accessory shop for teardown. During the inspection, it was noted that the seal spring retainer snap ring was loose and not secured in the groove to the rotor (see attached photo). A small piece was found fractured from the shaft end of the rotor. The drive pin was found loose and not secured in the rotor holes. The fuel pump was sent to the National Transportation Safety Board Materials Laboratory in Washington DC for further examination. TESTS AND RESEARCH The NTSB Senior Metallurgist reported that the shaft end of the rotor, with two sets of holes spaced equally around the circumference of the shaft, fractured such that it intersected two of the four holes. The fracture extended through approximately 30 percent of the shaft circumference. The holes were measured in the circumferential and axial directions as indicated in Service Bulletin ESD 182D, dated April 1981 (See attachment Service Bulletin ESD 182D). One set of holes was not worn and measured within specifications. The other set of holes exhibited severe wear and was elongated in the circumferential direction. This set of holes exceeded the wear limits as specified in the Service Bulletin. The fracture intersected one worn and one unworn hole. The metallurgist reported that the fracture revealed features typical of overstress separation. No evidence of fatigue cracking or corrosion degradation was found on the fractured end. The groove around the shaft where the retainer snap ring is installed to keep the seal spring retainer and spring from extending beyond the end of the shaft was examined. The metallurgist reported that the groove exhibited minor wear. The snap ring itself exhibited severe wear damage, both on the internal and external surface. The ends of the snap ring were worn from both edges on both the inside and outside. The seal spring retainer exhibited severe wear in the area that corresponds to the installed position of the snap ring. The metallurgist reassembled the rotor, drive pin, snap ring, and seal spring retainer. The metallurgist noted that the wear to the snap ring was severe enough that it just barely kept the seal spring retainer on the shaft end of the rotor. Additional wear marks and evidence of wear damage to include a narrow gouge mark that extended all around the bore of the pump body was noted. The location of the gouge mark lines up with the rotational axis of an assembled drive pin. Both ends of the pin contained deformation at the edge of the pin. A half moon indent, consistent with the size of the pin was noted at one point along the gouge line around the bore of the pump body. ADDITIONAL INFORMATION The maintenance logbooks were made available to the NTSB for review. It was noted that on June 13, 1956, the logbook page listing Airworthiness Directive (AD) compliance, indicated that AD 55-26-02 was accomplished. The method of compliance was listed as "converted Thompson fuel pump to Model TF 1900." This AD directed the removal of TF-1100 fuel pump and replace with Thompson TF-1900 pump having a larger diameter drive pin. TF-1100 pumps may be converted to TF-1900 pumps when modified in accordance with Thompson Service Bulleting ESD-182A and amendment ESD-182B (See attachment Engine Logbook Excerpts and AD 55-26-02). The logbook entries indicated that the engine, to include the fuel pump, was overhauled on January 7, 1978. Additional entries for maintenance up to March 1, 1999, do not indicate if the fuel pump was inspected or overhauled during this time. On March 1, 1999, at an engine tach time of 717.9 hours and 817.9 hours since overhaul, the airframe and engine were signed off for an annual inspection. The logbook entry sign-off does not indicate if the fuel pump was inspected, however, the section for AD compliance indicated an entry on "3-1-99, Thompson fuel pump pin, 55-26-02, 717.9" Neither the engine nor the airframe logbook indicate that an annual inspection was performed on or before March 2000. Airframe logbook entries recording oil changes on April 10, 2000, tach time 852 hours, and July 29, 2000, tach time 898 hours indicate that the aircraft continued to operate in 2000. The next entry in the engine logbook dated January 14, 2001, at tach time 890 hours, indicated that the engine was removed due to oil leaks. The entry further stated that "CW (Complied with) AD 55-26-02." The engine was reinstalled and test run. On May 1, 2001, at tach time of 950.9 and 1,050 hours since overhaul, the aircraft and engine were signed off for an annual inspection. The aircraft accumulated a total of approximately 24 hours since the last annual inspection at the time of the accident. The mechanic who accomplished the annual inspections in March 1999, and May 2001, and accomplished the engine removal and replacement in January 2001, was interviewed. The mechanic reported that he was aware of the 300 hour drive pin inspection for this fuel pump. The mechanic later prod ## Aircraft - Registration: [N7362B](https://openairdocs.org/deregistered/N7362B-2004-11-22), registration cancelled 2004-11-22, S/N D-3825, built 1954 (OpenAirDocs) - Reported make and model: Beech E35 - Registry model: [Beech E35](https://openairdocs.org/model/beech-e35) (registry code 1151512) (OpenAirDocs) - Registry engine: [Continental E225 series](https://openairdocs.org/engine/continental-e225-series) (registry code 17015, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: D-3825 - Airframe hours: 6904 - Engines: Continental E-225-8 225 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: John C. Laursen - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2001, 24 hours before - Departed: Eastsound, WA - Destination: Roche Harbor, WA - Airport: ORS, Orcas Island ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 47; injuries: serious; private; airplane ratings: single-engine land; medical: class 3; last flight review November 26, 1999; seat: left; flight hours: 561 total, 364 in this make and model, 459 as pilot in command, 39 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 4,500 ft overcast - Temperature: 57 °F, dew point 45 °F - Altimeter: 30.10 inHg - Observed at: FHR, 10 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 20010609015089A](https://openairdocs.org/incident/20010609015089A), Jun 9, 2001: Beech E35, Eastsound, WA, No damage. (-23) Aircraft departed Eastsound, Washington from runway 16. At approximately 150' AGL the engine suddenly quit. A forced landing was made into a small… 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.