Pilot Debrief

BEECH B36TC near Los Banos, CA — 2021-10-09

Final reportWPR22LA005
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Date
2021-10-09
Location
Los Banos, CA, USA
Airport
LSN
Aircraft
BEECH B36TC
Registration
N7220B
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Descent

Probable cause

The total loss of engine power due to the improper installation of the No. 4 connecting rod bolt nut during a recent overhaul.

NTSB narrative

The pilot reported that he was on the return leg of a cross country flight, about 10,000 ft mean sea level, when the engine lost oil pressure and the manifold pressure dropped. He immediately diverted to the nearest airport. While in the descent to his divert location, the engine was initially producing partial power, but then exhibited serious vibrations and subsequently lost all power. During this time, the cockpit filled with smoke, and fire and sparks were observed exiting from the engine cowling. Due to the fire, the pilot elected to make a forced landing on a road near the approach end of runway. The airplane struck an object during the landing roll which resulted in substantial damage to the wings. A postaccident examination of the engine revealed that the No. 4 connecting rod bolt nut was missing. Prominent thermal distress was observed in the area where the No. 4 connecting rod connected to the crankshaft and was consistent with oil starvation. In June of 2020, the engine was disassembled for a propeller strike inspection. The inspection was about 27.3 hours before the accident. As part of the inspection, the connecting rods were overhauled and then reinstalled on the crankshaft using new bearings, rod bolts, and nuts. Given the recency of the work, it is likely that insufficient torque was applied during installation of the No. 4 connecting rod bolt nut, which subsequently became loose and separated.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have opted for an earlier diversion to LSN before engine failure escalated.

NTSB coding

Evidence available

  • 5 docket documents
View NTSB final reportView NTSB docket

Docket documents5

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