Pilot Debrief

Beech V35 near Katy, TX — 2018-07-17

Final reportCEN18LA276
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Date
2018-07-17
Location
Katy, TX, USA
Airport
IWS
Aircraft
Beech V35
Registration
N228Q
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

Maintenance personnel’s failure to remove a paper towel from the engine during recent maintenance, which resulted in oil starvation, the failure of a connecting rod, and a catastrophic engine failure and subsequent total loss of engine power.

NTSB narrative

The private pilot reported that, as he approached the destination airport, he noted "a sudden and severe noise and vibration" and "a…stream of gray smoke from under the right side of the [engine] cowling," followed by a loss of engine power. The pilot subsequently conducted a forced landing, during which the airplane sustained substantial damage to the fuselage and right wing. Postaccident engine examination revealed two holes in the top of the crankcase near the Nos. 3 and 4 cylinders. A teardown examination of the engine revealed that the No. 4 connecting rod had failed due to oil starvation, which resulted in a catastrophic engine failure. Foreign debris, which was similar to a paper towel, was recovered from the engine oil sump and the oil pickup screen. Most of the screen area was obstructed by the debris, which had interrupted the oil flow from the sump to the engine. The airplane maintenance records noted that the alternator and alternator drive gear were replaced about 8 weeks before the accident. The engine had been operated about 24 hours since the alternator replacement. The starter and starter adapter were replaced the day before the accident flight. The engine had been operated about 15 minutes since the most recent maintenance work was performed. It is likely that maintenance personnel left the paper towel in the engine during the recent maintenance work, which resulted in oil starvation, the failure of the connecting rod, and the catastrophic engine failure and subsequent total loss of engine power.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Maintenance records showed debris in oil system; earlier inspection could have prevented failure.

NTSB coding

Evidence available

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

Docket documents6

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