Pilot Debrief

BEECH A45 near Boulder City, NV — 2013-06-23

Final reportWPR13FA284
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Date
2013-06-23
Location
Boulder City, NV, USA
Airport
BVU
Aircraft
BEECH A45
Registration
N434M
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Descent

Probable cause

The pilot/mechanic's loss of control during an emergency descent following a loss of engine power while in cruise flight. Contributing to the accident was the pilot/mechanic's incorrect assembly of the No. 6 cylinder at the last cylinder change, which resulted in a separation of the cylinder and the loss of engine power.

Contributing factors

Contributing to the accident was the pilot/mechanic's incorrect assembly of the No.

NTSB narrative

The pilot, who was also the mechanic for the airplane, had replaced all six cylinders on the engine during the airplane's annual inspection; he reported that, 3 days before the accident, the engine was operated and ran well. On the day of the accident, he was returning the airplane to its home base following a maintenance inspection on the wings. The pilot was near the end of the flight when he contacted approach control and requested priority handling because an engine chip light had illuminated. Shortly thereafter, the pilot stated that the engine had lost power on a cylinder, and he declared an emergency. When the airplane was at 9,500 ft mean sea level, the pilot said that he was going to attempt to land at a nearby airport (elevation 2,201 ft). Before switching to the airport's common traffic advisory frequency (CTAF), the pilot reported to the approach controller that the airplane was at 3,800 ft with the landing gear down and that the situation was under control. The pilot did not contact approach control again and did not broadcast over the CTAF. The airplane collided with terrain in a nose- low attitude about 1 mile west of the airport. Postaccident examination of the airframe revealed no evidence of mechanical anomalies that would have precluded normal operation. Postaccident examination of the engine revealed that the No. 6 cylinder had separated, and no nuts were located on its through bolts. Magnified examinations of the bolt threads found the thread profiles intact and only locally distorted, consistent with the nuts not being present during the No. 6 cylinder separation, which appeared to be the result of the incorrect assembly of the cylinder at the last cylinder change. Fretting damage on the mounting pad was observed, which indicates looseness and movement between the cylinder and the case that resulted from inadequate preload in the fasteners either through insufficient initial torque or loss of torque during operation. Considering the short time since cylinder installation, it is likely that the cylinder fasteners, or at least some of them, were not correctly torqued at installation.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have aborted the flight after engine issues were detected.

NTSB coding

Evidence available

  • FDR / data
  • ADS-B / radar
  • Photos
  • 16 docket documents
View NTSB final reportView NTSB docket

Docket documents16

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