Pilot Debrief

Beech A36 near Ruleton, KS — 2012-08-17

Final reportCEN12LA558
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Date
2012-08-17
Location
Ruleton, KS, USA
Aircraft
Beech A36
Registration
N262EA
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Climb

Probable cause

The improper installation of the wastegate controller O-ring, which resulted in a partial loss of engine power.

NTSB narrative

Shortly after leveling off at a cruise altitude of 8,500 feet mean sea level, the pilot noted that the engine rpm increased to above its red line limit (2,700 rpm). The pilot was able to reduce power to 2,500 rpm but was unable to restore thrust and maintain altitude, so he made a forced landing in a nearby wheat field. During postaccident examination, the engine turbocharger controller was found covered with oil. Examination of an elbow fitting on the turbocharger wastegate control revealed that an O-ring was improperly installed and flattened, which allowed oil to seep out. When the O-ring was reseated and the elbow fitting torqued, no seepage was observed.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot did not check oil before departure, leading to engine failure.

NTSB coding

Evidence available

  • Photos
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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