Pilot Debrief

BEECH C23 near Gonzales, TX — 2023-09-24

Final reportCEN23LA418
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Date
2023-09-24
Location
Gonzales, TX, USA
Airport
T20
Aircraft
BEECH C23
Registration
N18994
Category
Airplane
Highest injury
Minor
Fatalities
0
Phase of flight
Approach

Probable cause

The loss of engine power during go-around due to a failed muffler flame tube, which resulted in an exhaust blockage. Contributing to the accident was maintenance personnel's inadequate inspection of the exhaust system during the most recent maintenance.

Contributing factors

Contributing to the accident was maintenance personnel's inadequate inspection of the exhaust system during the most recent maintenance.

NTSB narrative

According to the pilot, while on final approach to the runway he experienced wind shear and elected to go around. He applied full throttle and began to climb out when the engine sustained a loss of power, so he made a forced landing to a field off the left side of the runway. The airplane collided with a fence and a tree, which separated the right wing near the wing root. Postaccident examination of the exhaust system revealed that a portion of the muffler flame tube had failed and blocked at least 95% of the tailpipe exit path. The piece of flame tube was lodged in the tailpipe. A 3-inch crack was noted on the muffler endcap opposite of the separated flame tube. There were no other mechanical malfunctions or failures that would have precluded normal operation. The muffler had been repaired and reinstalled on the airplane about 23 years before the accident and accumulated 504.84 hours. The most recent 100-hour/annual inspection, which was completed 55.4 hours before the accident, failed to identify the degraded and corroded flame tube.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have opted for a different approach or landing strategy before wind shear.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 11 docket documents
View NTSB final reportView NTSB docket

Docket documents11

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