No fatalities

17 Aug 2017: BEECH A36 (N48TZ) — GULF CENTRAL AVIATION LLC — Gonzales, LA

Gonzales, LA, United States

On 17 Aug 2017, a BEECH A36 (registration N48TZ) operated by GULF CENTRAL AVIATION LLC was involved in an aviation accident near Gonzales, LA. No fatalities were reported. Investigators recorded the probable cause as: A partial loss of engine power due to inadequate maintenance, including worn spark plugs and a leaking fuel hose fitting. This summary draws on records from NTSB; 12 related events involving the same aircraft type or operator are linked below.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On August 17, 2017, a Beech A36 (N48TZ) sustained substantial damage during a forced landing after departing the Louisiana Regional Airport, Gonzales, Louisiana. The pilot and flight instructor were not injured. The flight was conducted as an instructional flight under Part 91 in day visual meteorological conditions. Investigation revealed a disconnected ignition harness and unauthorized spark plug replacement.

Accident Summary

On August 17, 2017, at approximately 0927 central daylight time, a Beech A36 airplane, registration N48TZ, was substantially damaged during a forced landing. The accident occurred after the airplane departed from the Louisiana Regional Airport (REG) in Gonzales, Louisiana. The pilot and a flight instructor were on board and were not injured. The airplane was registered to and operated by Gulf Central Aviation LLC under Title 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions prevailed for the local flight, which departed without a flight plan at about 0926.

Pilot Account

According to the pilot, he departed from Runway 17 following a normal engine run-up and takeoff roll. After reaching about 150 feet above ground level, the pilot noticed the airplane was no longer climbing and lowered its nose. Perceiving a partial engine power loss, the pilot checked the throttle and mixture lever positions, both of which were full forward. After maneuvering to avoid trees, the pilot initiated a forced landing into a hay field. During the landing roll, the airplane impacted a small ridge and nosed over, damaging the engine firewall.

Examination

Examination at the recovery location revealed that the ignition harness connecting the magnetos to each of the top spark plugs had been disconnected from the spark plugs. All twelve spark plugs appeared new, with no combustion deposits. Without authorization, a mechanic who normally performed maintenance on the airplane stated he had removed and discarded the spark plugs due to several having a worn-out condition. Not realizing the airplane should not be disturbed during the investigation, the mechanic had also removed the fuel screen.

Examination of the throttle and mixture control cables showed proper attachment to their respective control arms. Borescope inspection of piston domes, cylinder wall surfaces, and intake and exhaust valves revealed normal wear patterns and combustion signatures, except for the No. 5 cylinder exhaust valve, which had a green crescent-shaped discoloration on the bottom of the valve face.

Engine Test Runs

After the fuel screen was returned by the mechanic, an engine test run was performed. The engine rotated and ran on the first attempt but stopped after several seconds. A fuel leak was observed adjacent to the fuel pump, with a flexible fuel hose leaking at a B-nut. The nut was tightened about ¼ turn, which seated the nut onto the fitting. The engine-driven fuel pump and the adjacent oil filter adapter were stained with a blue color.

A second fuel leak was observed at the throttle body/metering unit, with the fuel mixture arm and shaft bent in a manner consistent with impact damage. A second engine test run was conducted, during which power was not increased above 1,100 rpm due to a damaged propeller. The engine was operated at varying speeds, and a magneto check was accomplished with no anomalies. The throttle was reduced to idle power, and the engine ran smoothly.

Other Findings

The oil on the oil dipstick was very dark in color. A logbook review revealed the engine had accumulated 163.7 hours since the last oil and oil filter change. The manufacturer recommends oil change intervals of 50 hours for an engine equipped with external filters installed.

Contributing factors

Incorrect service/maintenanceMaintenance personnelFatigue/wear/corrosionDamaged/degraded