NEW BRAUNFELS, TX, USA
N4014T
Beech B23
The student pilot made several takeoffs and landings prior to departing the traffic pattern. Witnesses reported observing the airplane flying at an altitude of approximately 20 feet above the trees, and they reported that they did not hear the airplane's engine running. A witness stated that the airplane flew by her in a level attitude, and after the airplane cleared some power lines it started to descend. It then appeared that the airplane's left wing impacted some trees before it nosed down into the trees. Continuity was established to all of the 1968-model Beech Musketeer's flight controls. Examination of the engine oil pressure and suction screens revealed the presence of metal particles, shavings and flakes. The oil pressure relief valve plug, spring, and ball were removed. The ball had metal adhering to it, and the ball seat was contaminated with metal, which according to the manufacturer representative, "may have prevented the ball from contacting the seat." A large amount of sludge was found inside of the crankshaft. A teardown examination of the engine revealed evidence of a lack of lubrication. A review of the airplane's maintenance records revealed that the engine's last oil change was on July 2, 1999, at a total airplane and engine time of 1,665.0 hours. There was no record that the oil suction screen or oil pressure screens were cleaned during that oil change. The last documented cleaning of the oil screens was December 1, 1996. At the time of the accident, the airplane had accumulated a total time of 1,680.92 hours and the engine had never undergone an overhaul. The engine's operating manual states that "at each 100 hour inspection remove suction screen. Inspect for metal particles; clean and reinstall. Inspect and clean pressure screen every 25 hours."
HISTORY OF FLIGHT On February 8, 2000, at 1330 central standard time, a Beech B23 (Musketeer) airplane, N4014T, was substantially damaged when it impacted trees and terrain during a forced landing, following a loss of engine power near New Braunfels, Texas. The airplane was owned and operated by the pilot. The student pilot, sole occupant, sustained fatal injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 solo instructional flight. The local flight departed the New Braunfels Municipal Airport, approximately 1230. The airport manager reported that the pilot made several takeoffs and landings prior to departing the traffic pattern. The airport manager further reported that he heard the pilot call "mayday I do have an engine out" over the Unicom radio. The pilot stated that his position was east of the airport, and he had the runway in sight. Witnesses reported observing the airplane north-northwest of the airport flying at an altitude of approximately 20 feet above the trees. They further reported that they did not hear the airplane's engine running. One witness stated that he saw the airplane's right wing come up to vertical and then the airplane nosed down into the trees. Another witness stated that the airplane flew by her in a level attitude, and after the airplane cleared some power lines, it started to descend. It then appeared that the airplane's left wing impacted some trees before it nosed down into the trees. PERSONNEL INFORMATION FAA records indicate the student pilot held a third class medical certificate, which was issued on March 14, 1999. A review of the student pilot's flight logbook revealed that his first instructional flight was on November 19, 1995. Between November 19, 1995, and January 13, 1999, the pilot logged a total of 10.8 hours. The student pilot completed his first supervised solo flight after a preparation flight with a flight instructor on March 17, 1999. On December 3, 1999, he received his last 90-day solo endorsement. The last entry in his logbook was dated December 31, 1999, for a 1.0-hour solo flight. The student pilot had accumulated a total of 49.8 flight hours, of which 41.3 hours were dual and 39.0 hours were in the Beech Musketeer. AIRCRAFT INFORMATION The 1968-model Beech Musketeer, was a low wing, single-engine, four-place airplane, which had fixed tricycle landing gear. It was powered by a Lycoming O-360-A2G engine rated at 180-horsepower, and a Sensenich, two-bladed, fixed pitch propeller. An estimate of the weight of the airplane at the time of the accident placed it within weight and balance limits. A review of the airplane's maintenance records revealed that the engine's last oil change was on July 2, 1999, at a total airplane and engine time of 1,665.0 hours. There was no record that the oil suction screen or oil pressure screens were cleaned during that oil change. The last documented cleaning of the oil screens was December 1, 1996, at a total time of 1,615 hours. The airplane underwent its last annual inspection on October 6, 1999, at a total time of 1,672.54 hours. At the time of the accident, the airplane and engine had accumulated a total time of 1,680.92 hours. The Textron Lycoming Operator's Manual for the O-360 engine states in Section 5, Maintenance Procedures, page 5-6, Lubrication System, Suction and Oil Pressure Screens, "At each 100 hour inspection remove suction screen. Inspect for metal particles; clean and reinstall. Inspect and clean pressure screen every 25 hours." On October 16, 1981, at a total engine time of 1,066.0 hours, the #2 cylinder was replaced. On January 20, 1986, at a total engine time of 1,325.4 hours, the #2 cylinder was replaced. On August 1, 1987, at a total engine time of 1,351.59 hours, the #2 cylinder was overhauled. No entry indicating the engine had received a major overhaul was noted in the maintenance records. According to the engine manufacturer, "the engine did not appear to comply with the provisions of Textron Lycoming Service Instruction 1009 - Recommended Time Between Overhaul Periods - which states in part, all engines that do not accumulate the recommended operating hours before overhaul in twelve (12) year period must be overhauled in the twelfth year." The recommended operating hours before overhaul was 1,800 hours. According to the airport manager, the airplane was fueled with 29.1 gallons of 100LL aviation gasoline prior to departing on the accident flight. WRECKAGE IMPACT INFORMATION The accident site was located using a global positioning satellite (GPS) receiver at 29 degrees 48.686 minutes north latitude and 98 degrees 06.855 minutes west longitude. The accident site was about 7.5 nautical miles north-northwest of the New Braunfels Municipal Airport. An examination of the accident site revealed that the aircraft impacted trees on a heading of 312 degrees magnetic. The aircraft came to rest on its nose, within the trees, on a magnetic heading of 182 degrees. The left wing was partially separated at approximately mid-flap, and was displaced forward, almost parallel with the fuselage. The aileron remained attached to its hinges, and the flap was separated from the wing. The right wing sustained a chordwise tear from the leading edge to the spar just inboard of the aileron. The aileron was separated at both hinge points, but remained attached to the wing by its push rod. The flap remained attached to the wing. Flight control continuity was confirmed from all flight control surfaces through the fuselage to under the instrument panel. The cabin top was buckled aft of the entrance door, and the empennage was buckled aft of the cabin. The propeller was separated from the engine crankshaft with the crankshaft propeller flange still attached to the propeller hub. One blade was bent aft and had a gouge on its leading edge. The spinner was crushed aft and was formed around the propeller mounting area. The engine remained attached to the airframe, and it was displaced aft against the firewall. The crankshaft could not be rotated. There were no external indications of an engine failure; however, an examination of the oil pressure and suction screens revealed the presence of metal particles, shavings and flakes. The engine was removed from the airframe and transported to the New Braunfels Municipal Airport where it was examined and dissembled at the Engine Components, Inc., facility. (See the Tests and Research section of this report.) MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Chief Medical Examiner of Travis County conducted an autopsy of the pilot. There was no evidence found of any preexisting disease that could have contributed to the accident. Toxicological testing was performed by the FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research Center at Oklahoma City, Oklahoma. A level of 0.374 (mg/dl, mg/hg) paroxetine was detected in blood and 1.04 (mg/dl, mg/hg) paroxetine was detected in urine. Alprazolam was detected in urine. Paroxetine is a prescription antidepressant (trade name Paxil) that is also used to treat obsessive-compulsive disorder and panic attacks. Alprazolam is a prescription tranquilizer, often known by the trade name Xanax. It is used for anxiety disorder, anxiety associated with depression, and panic disorder. Alpha-hydroxyalprazolam is the major active metabolite of alprazolam. The FAA's 1999 Guide for Aviation Medical Examiners notes that "the use of a psychotropic drug is considered disqualifying. This includes all sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs (including SSRI's), analeptics, anxiolytics, and hallucinogens." A review of the pilot's past medical certificate applications revealed no record that the pilot had reported his use of this medication to the FAA. TESTS AND RESEARCH The teardown examination of the engine revealed that the left magneto inside mounting flange ring was partially destroyed, and there were metal particles, shavings, and flakes near the impulse coupling stop pins. Both the left and right magnetos produced spark at all four terminals when rotated by hand. The accessory housing assembly was removed, and the oil pump was disassembled. The oil pump parting surface and body had rotational scoring, and the teeth on the impellers were scored. The oil sump assembly was removed. The oil sump assembly contained metal and portions of connecting rod bearings. The oil pressure relief valve plug, spring, and ball were removed. The ball had metal adhering to it, and the ball seat was contaminated with metal, which according to the manufacturer representative "may have prevented the ball from contacting the seat." All four cylinders were removed, and the pistons were removed from the connecting rods. Examination of the cylinders revealed that the #4 cylinder (part number LW12427, piston part number 75089), had one piston pin plug destroyed with a small amount of melted piston pin plug remaining. The #4 piston was damaged and melted in this piston pin area with the damage to the hole extending into the bottom oil regulating piston ring groove. A portion of the bottom piston ring (oil control ring) was missing. There was also corresponding scoring on the cylinder wall. The crankcase assembly was parted. The crankshaft was removed and the connecting rods were removed from the crankshaft. The connecting rods, connecting rod bolts, and connecting rod nuts exhibited blue discoloration indicative of overheating. The crankshaft main journals also displayed blue discoloration. There was a blockage of the oil passage from the #2 main bearing to the #2 and #3 rod end bearings. The #2 and #3 connecting rod journals showed evidence of bearing wiping and displacement of bearing material on the bearing surface. The camshaft was removed and it exhibited some blue discoloration, and the lobes were worn and rough. The #3 and #4 intake tappet body faces were spalled. A large amount of sludge was found inside of the crankshaft. ADDITIONAL DATA The aircraft wreckage was released to the owner's representative on February 10, 2000.
the seizure of the engine while maneuvering due to the oil pressure relief valve plug ball seat becoming contaminated with metal. Contributing factors were the inadequate engine maintenance, and the lack of suitable terrain for the forced landing.
Source: NTSB Aviation Accident Database
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