Pilot Debrief

Beech A36 near Southold, NY — 2019-06-08

Final reportERA19FA189
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Date
2019-06-08
Location
Southold, NY, USA
Aircraft
Beech A36
Registration
N8014T
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Descent

Probable cause

A total loss of engine power due to a main bearing shift and the pilot’s subsequent failure to maintain a proper glide path to the selected forced landing site. Contributing to the accident was the pilot’s decision to operate the airplane with known mechanical deficiencies.

Contributing factors

Contributing to the accident was the pilot’s decision to operate the airplane with known mechanical deficiencies.

NTSB narrative

The pilot departed on a cross-country flight when, shortly after takeoff, he announced to air traffic control that the airplane had experienced an engine failure and that he would perform a forced landing in a field. Radar data showed the airplane descending over an area of open fields, and surveillance video near the accident site captured the airplane at low altitude in a steep left bank before it descended out of view behind trees and impacted the ground. A mechanic stated that, several weeks before the accident, the pilot asked him to look at the airplane due to higher-than-normal engine oil temperature and lower than normal oil pressure. The mechanic subsequently discovered metal debris in the oil filter. He stated that he expressed concern to the pilot about operating the airplane multiple times in the weeks and days before the accident, as he felt the engine was rapidly degrading and was susceptible to a catastrophic loss. Postaccident examination of the engine revealed that the No. 1 main aft bearing had shifted, was separated from the crankshaft, and sustained extensive thermal damage. The rear of the crankshaft was no longer connected to the main bearing and there was extensive internal and thermal damage. It is likely that the bearing shift resulted in the loss of engine power. The pilot’s decision to fly the airplane with known engine deficiencies increased the risk of a loss of engine power in flight. Following the loss of engine power, the pilot failed to maintain a proper glidepath to the forced landing site, which resulted in his low altitude maneuvering and impact with terrain.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot could have replaced the engine after mechanic's warnings about its condition.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • Photos
  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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