Pilot Debrief

BEECH A36 near Shullsburg, WI — 2018-05-05

Final reportCEN18LA159
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Date
2018-05-05
Location
Shullsburg, WI, USA
Aircraft
BEECH A36
Registration
N36LP
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

A catastrophic engine failure due to improper torque on the engine through-bolt nuts, which resulted in relative movement between the crankcase halves, damage to a main journal bearing, and a loss of oil lubrication.

NTSB narrative

The commercial pilot reported that he heard an unusual noise from the engine during cruise flight and shortly afterward, the engine experienced a total loss of power. The pilot performed a forced landing to an open field. Visual examination of the engine revealed a hole in the crankcase. A teardown examination revealed fretting on the crankcase mating surfaces, shifting of the No. 2 main bearing within the journal support, thermal damage consistent with a loss of oil lubrication, and separation of the crankshaft. The observed fretting damage was consistent with relative movement of the crankcase halves during operation due to a lack of through-bolt torque. The main journal bearing damage, the separation of the crankshaft, and the crankcase damage were secondary and a result of the loss of lubrication. An engine overhaul was completed in about 11 years 5 months before the accident; about 849 flight hours had accumulated since the overhaul. Two cylinders were replaced 6 years before the accident, and one cylinder was replaced during the most recent annual inspection about 9 months before the accident. It is likely that improper torque of the through-bolt nuts was applied during one of the cylinder replacement events, though it could not be determined which event.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Pilot could have conducted a precautionary landing after hearing unusual engine noise.

NTSB coding

Evidence available

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

Docket documents4

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