Pilot Debrief

Beech 35 near Mayport, FL — 2018-08-17

Final reportERA18LA227
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Date
2018-08-17
Location
Mayport, FL, USA
Airport
NRB
Aircraft
Beech 35
Registration
N1330Z
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Cruise

Probable cause

The failure of a fuel line due to improper installation of a fuel flow sensor, which resulted in fuel starvation and a subsequent total loss of engine power.

NTSB narrative

The pilot reported that he was in cruise flight when the engine lost total power. The pilot's attempts to restart the engine were unsuccessful. He contacted air traffic control and reported that he was unable to make it to the closest airport and ditched the airplane into the Atlantic Ocean. Postaccident examination of the airplane revealed that both elevators had separated from the horizontal stabilizer during the ditching. Examination of the engine revealed that a fuel line that had been attached to the fuel flow sensor was broken. Detailed examination of the fracture surfaces on the broken fuel line fitting revealed features that were consistent with high-stress, low-cycle fatigue crack propagation. The crack initiated at the outside, progressing through the thickness of the aluminum fuel line and partially along its circumference until final overstress fracture. A review of the installation drawings and instructions revealed that the fuel flow sensor was installed without a mounting bracket per installation instructions. Given this information, it is likely that the fuel line fractured in fatigue due to the improper installation, and lack of support that would have been provided by the required bracket. The failure of the fuel line subsequently resulted in fuel starvation, and the total loss of engine power. While the available maintenance records detailed the installation of an engine monitoring device and accompanying cylinder head temperature probes, there were no records that indicated when the fuel flow sensor was installed.

Analysis

Primary failure mode
Engine power loss
First missed decision gate
Proper installation of the fuel flow sensor could have prevented the engine power loss.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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