WPR22LA314

NTSB accident investigation · Beech F33A · Wilder, ID · August 21, 2022

Accident · Minor injuriesClass 3 · LimitedFinal report
Date
August 20, 2022, 18:00 local (Aug 21, 2022, 00:00 UTC)
Place
Wilder, ID · Open field
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N4133SBeech F33A
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration FSDO
FAA report
20220820014849A
Case key
105790

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

On this page

Probable cause

Catastrophic engine failure during the initial climb due to an incorrectly installed crankshaft counterweight retaining ring.

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): recip eng rear sectionAircraft › Aircraft power plant · Incorrect service/maintenanceBeech F33A: 1 caseAll aircraft: 42 casesProbable cause
Maintenance: scheduled/routine maintenancePersonnel issues › Task performance · Maintenance personnelBeech F33A: 1 caseAll aircraft: 320 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 airplane sustained a catastrophic engine failure shortly after takeoff due to a separated crankshaft counterweight. The pilot performed a forced landing, during which the airplane sustained substantial damage. The engine had been overhauled about 14 years and 950 flight hours before the accident. Examination of the remaining counterweights revealed that, during that overhaul, some of their retaining pins had been installed back to front. According to the engine manufacturer, such installation has been known to cause failure of the counterweights and the catastrophic damage observed. The correct installation is documented in the engine maintenance manual and reiterated in a service bulletin that was published 5 years before the engine was overhauled.

Factual narrative

On August 20, 2022, about 1800 mountain daylight time, a Beech F33A, N4133S was substantially damaged when it was involved in an accident near Wilder, Idaho. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and a mechanic had been performing maintenance, attempting to resolve a problem where the engine would intermittently shudder during flight. After checking the cylinder compression, replacing a set of spark plugs, cleaning the fuel injectors, and confirming the engine timing, they decided to perform a test flight. The engine runup and takeoff were uneventful, and during the initial climb they monitored the engine instrument gauges, and all indicated nominal values. A short time later, the engine shook violently, and stopped producing power. They performed a forced landing into a field, and the airplane sustained damage to the lower forward fuselage and both wings. The airplane was powered by an IO-520-BA engine manufactured by Continental Motors, and overhauled by T.W. Smith Engine Company in 1998, about 950 flight hours before the accident. During the 14-year period leading up to the accident, routine maintenance was performed on the engine, with no work that would have required opening the crankcase or removing any cylinders. The engine was equipped with two sets of moving counterweights mounted to crankshaft blades adjacent to the journals of cylinder Nos. 1 and 2, and 3 and 4. Each counterweight was attached to their respective crankshaft blade by two pins housed within bushings and held in place at their ends with retaining plates and internal retaining “snap” rings. Examination of the engine revealed a large hole in the upper rear section of the crankcase, next to the Nos. 1 and 2 counterweights. Both counterweights had separated from their respective blades and showed similar damage signatures, with one counterweight mounting hole intact with its bushing in place, and the other split open with its material formed outwards. The Nos. 1 and 2 connecting rod caps had detached, and the rods remained attached to their respective pistons. Remnants of the connecting rod caps and bolts, along with two counterweights, fragments of counterweight bushings, a single counterweight pin, and four retaining rings and plates were found in the oil sump. Examination of the fracture surfaces of the remnants revealed features consistent with ductile overload, including granular and rough separation areas, bolt necking along with smear and bending damage consistent with impact. There was no evidence of scoring or heat distress to the rod journals or rod bearings contact surfaces for cylinder Nos. 1 and 2. The engine was then completely disassembled, and although the two counterweights for cylinder Nos. 3 and 4 were intact and essentially undamaged, one retaining ring, retainer plate, and pin were missing. The Continental Maintenance Manual applicable tothe engine gives specific instructions for the installation of the counterweight assembly. It states that the retaining rings, which are stamp-cut, have a sharp side and a beveled side, and should be installed with the sharp side out. The retaining ring ears should be installed towards the crankshaft centerline, and to confirm proper fitment after installation the gap between the ears should be no less than 0.179 inches (Figure 1). Figure 1 – One of the counterweights with its retaining plates and rings, showing the incorrectly installed ring on the right. Examination of the engine revealed that one retaining ring on each of the remaining counterweights was installed incorrectly with the sharp side in, and both had ear-gaps of 0.11 (Figure 1) and 0.14 inches respectively. Continental Service Bulletin (SB) M93-4, issued in February 1993, reiterates the importance of thorough inspection and proper assembly of crankshaft counterweights during engine overhaul, or any time the crankshaft is removed from the engine. It warns that improper installation of the bushings, retaining plates, or retaining rings will cause engine failure. The SB also states that the retaining rings should be fully seated in the bushing bore grooves with the sharp edge facing out.

Aircraft

Registration
N4133S
Reported as
Beech F33A
Category
Airplane
Serial number
CE-591
Built
1975
Airframe hours
2,460.88
Engine
Continental IO-520-BA, 285 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 21, 2022 · 25 hours before
Departed
50S · Parma, ID
Airport
50S · Parma, runway 12/30, 2,700 × 50 ft, asphalt
Equipment
Stall warning system, ADS-B

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 2, With waivers/limitations
Seat
Left
Flight hours
200 total
Role
Pilot
Age
64
Injuries
Minor
Certificates
Commercial, Flight instructor, Airline transport
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Flight hours
10,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
97 °F, dew point 55 °F
Altimeter
29.85 inHg
Observed at
KEUL, 13 nm away
METAR
KEUL 202356Z AUTO 26006KT 10SM CLR 36/13 A2985 RMK AO2 SLP081 T03560133 10361 20289 56014

Docket · 8

The files NTSB released with the investigation on April 25, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.0 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.

Other investigations on N4133S · 1

Matched to the same aircraft by N-number and date.