WPR10LA003

NTSB accident investigation · Mateskon Fisher DAK · Bozeman, MT · October 3, 2009

Accident · Minor injuriesLimited investigationFinal report
Date
October 3, 2009, 09:48 local (15:48 UTC)
Place
Bozeman, MT
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N359JMMateskon Fisher DAK
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 19, 2010
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20091003019989A
Case key
74843

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

A loss of engine power due to shearing of the crankshaft gear cluster bolts. Contributing to the accident was the lack of regular overhaul periods as recommended by the engine manufacturer.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · Not serviced/maintainedMateskon John FISHER DAKOTA HAWK: 1 caseAll aircraft: 497 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot was departing on a local flight when the engine lost power; the pilot force-landed the airplane in a field. Post accident examination of the engine showed that the bolts securing the crankshaft gear cluster to the crankshaft were sheared. The crankshaft gear cluster is geared to the camshaft gear and rotates as the engine operates. Examination of the bolts showed that all four bolts had sheared between the crankshaft gear cluster and the attach point to the crankshaft. Two bolt heads, including a portion of the bolts’ lengths, were missing. The other portions of these bolts remained threaded to the crankshaft attach points. The two remaining bolt heads were still safety-wired and in place; however, they had sheared from the crankshaft. The lower threaded portions of all four bolts remained threaded at the crankshaft attach points. No pieces of the missing bolt heads or bolt portions were identified in the accessory case or the oil sump. Examination of the fracture surfaces on the threaded bolt portions showed that the surfaces of the sheared bolts with the missing heads appeared battered. The portions of the bolts still threaded in the crankshaft that belonged to the remaining bolt heads were not battered. The engine had not undergone a complete overhaul of the type that would have exposed the accessory gear section to inspection for over 35 years. According to Teledyne Continental Motors Service Instruction Letter 98-9A, the C-85 engine should be overhauled every 12 years or 1,800 hours.

Factual narrative

HISTORY OF FLIGHT On October 3, 2009, at 0948 mountain daylight time, N359JM, a Mateskon Fisher Dakota Hawk, lost engine power during cruise and the pilot force-landed the airplane in a field approximately 5 miles southwest of Gallatin Field, Bozeman, Montana. During the landing, the right wing clipped a tree. The private pilot, who was also the registered owner of the airplane, operated it under the provisions of 14 Code of Federal Regulations Part 91. The pilot sustained minor injuries and the airplane was substantially damaged. Visual meteorological conditions prevailed and no flight plan was filed for the local area flight. The pilot reported that he had departed Gallatin Field about 10 minutes prior to the power loss. The power loss was sudden. He attempted to restart the engine but was unsuccessful. During his approach to a field, the right wing clipped a tree. AIRPLANE HISTORY The pilot had built the airplane over a period of three years. It had accrued approximately 141.4 hours. The pilot indicated that the engine, a Teledyne Continental Motors C-85-12, had been installed on another airplane in the 1980s. The previous engine owner was going to install it on another airplane but did not do so and the engine had been placed into storage. The pilot then purchased the engine for his airplane. The pilot did note that recently he had the piston rings changed due to a higher than normal oil burn. The pilot did not have any other problems with the engine. Review of the maintenance records for the engine showed that the last engine overhaul was a field overhaul that occurred on December 4, 1973. The engine was removed from another airplane in 1987, at 1085.8 hours since major overhaul, and 4,807.8 hours total time. It was in storage until the pilot/builder of the accident aircraft purchased it. The last top overhaul occurred on June 1, 2006. A typical top overhaul does not involve inspection of the accessory gear section. TESTS AND RESEARCH The engine was examined following the accident. The valve covers were removed and the propeller was rotated. No valve movement was evident. Investigators then removed the magnetos and starter from the accessory case and noted that none of the accessory gears turned when the propeller was rotated. Further examination revealed that the crankshaft gear cluster had separated from the crankshaft. The crankshaft gear cluster is geared to the camshaft gear and rotates as the engine operates. The crankshaft gear cluster is attached to the aft section of the crankshaft by four bolts. Examination of the bolts showed that all four bolts had sheared between the crankshaft gear cluster and the attach point to the crankshaft. Two bolt heads, including a portion of the bolts’ lengths, were missing. The other portions of these bolts remained threaded in the crankshaft attach points. The two remaining bolt heads were still safety wired and in place; however, they had sheared from the crankshaft. The lower threaded portions ofall four bolts remained threaded at the crankshaft attach points. No pieces of the missing bolt heads or bolt portions were identified in the accessory case or the oil sump. Examination of the fracture surfaces on the threaded bolt portions showed that the surfaces of the sheared bolts with the missing heads appeared battered. The portions of the bolts still threaded in the crankshaft that belonged to the remaining bolt heads were not battered. ADDITIONAL INFORMATION According to TCM Service Instruction Letter 98-9A, the C-85 engine should be overhauled every 12 years or 1,800 hours.

Aircraft

Registration
N359JM
Reported as
Mateskon Fisher DAK
Category
Airplane, amateur-built
Serial number
DH38
Airframe hours
141
Engine
Cont Motor C85 SERIES, 85 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · October 23, 2008 · 25 hours before
Departed
BZN · Bozeman, MT
Destination
BZN · Bozeman, MT
Airport
BZN · Gallatin Field

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
57
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Medical
Sport pilot
Last flight review
July 15, 2008
Seat
Left
Flight hours
193 total · 141 in this make and model · 10 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 30 °F
Altimeter
29.90 inHg
Observed at
BZN, 4 nm away

Docket · 8

The files NTSB released with the investigation on February 9, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 MB in all.

FAA reports on this event · 1

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