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NTSB presents: Is your aircraft talking to you? Listen!
General aviation safety is an ongoing concern, with about 1,500 accidents and 475 fatalities annually. This document discusses three accident case studies to help pilots learn from the mistakes of others. The first case involved a Beechcraft Bonanza that lost engine power due to a crankshaft fracture from an improperly addressed oil pressure issue. The second was a Vans RV-6 that crashed during a test flight after an oil leak repair. The third involved a Beechcraft Bonanza that lost its engine after the wrong type of thread was used during an engine overhaul, despite ongoing troubleshooting of oil leaks. In each case, pilots are encouraged to thoroughly address any maintenance issues, follow test flight plans carefully, and avoid flying if
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NTSB presents: Is your aircraft talking to you? Listen!
- 1. Is Your Aircraft Talkingto You? Listen! 1 Cathy Gagne, AS-70
- 2. General Aviation (GA)Safety • About 1,500 accidents, 475 people killed annually • GA on NTSB Most Wanted List • Personal flying sector of GA: greatest activity, proportion of accidents 2
- 3. Top Occurrence Categories 3 Fatalaccidents in GA personal flying sector, 2000-2011
- 4. Discussion of AccidentCases • Completed cases: common causes, factors, and scenarios • Used as educational tools • Not intended to admonish accident pilots • Intended to help other pilots learn 4
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- 6. Accident Synopsis • Pilot/ownerplanned personal round-trip night IFR flight • Complete engine power loss on return leg • Forced landing, pilot fatal 6
- 7. Pilot • Sole owner/operator •About 2,300 total flight hours • Flight instructor, with multi-engine and instrument ratings 7
- 8. Airplane History • Engine:10hours since overhaul at time of pilot’s purchase • Pilot added about 50 hours prior to accident 8
- 9. Airplane History • Engineoil pressure problem several weeks before accident • Mechanic: Overhaul issue • 1 week later, pilot said engine “seemed OK” • No evidence of corrective actions 9
- 10. Accident Flight • Nooutbound leg problem reports • Midnight taxi out, return to FBO • Pilot requested mechanic (unavailable until morning) • Pilot then opted to depart, IFR 10
- 11. Accident Flight • Completeloss of power 9 miles from destination • Night IMC forced landing • Engine examination: crankshaft fracture 11
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- 13. Missed Opportunities • Activelyaddress problem • Maintenance troubleshooting • Do not fly until resolved • Take conservative approach • Take all indications seriously • Ground airplane until problem identified and resolved 13
- 14. What Pilots CanLearn • Resist external pressures to fly • Identify, assess all risks • Maintenance: Don’t talk self into believing what you want to hear • Problem indications not always obvious 14
- 15. What Pilots CanLearn • Conservative approach can be inconvenient, costly (but is safer!) • To avoid inappropriate choices: • Consider options and outcomes • Prevent outside factors from adversely influencing decisions 15
- 16. What Pilots CanLearn
- 17. Scenario 2 –Vans RV-6 17
- 18. Accident Flight • VansRV-6 • Departed 20 minutes before accident • Private pilot was fatally injured • Maintenance test flight 18
- 19. Airplane History • Oilleak discovered 6 weeks earlier • Source of leak: propeller governor high pressure oil line • Weld “repair” was made • Pilot departed for test flight, but chose to conduct cross-country flight 19
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- 22. Missed Opportunities • Stickto maintenance test plan • Review service bulletins, airworthiness directive • Be prepared to execute emergency procedures 22
- 23. What Pilots CanLearn • If signs of problem persist, be prepared to discontinue flight • Review, practice emergency procedures 23
- 24. Scenario 3 –Beech G35 24 Photo from sales advertisement
- 25. Scenario 3 –Beech G35 • 1956 Beech Bonanza (G model) • Recent purchase by two pilots • Lost engine at destination • Owner/pilot: 40 hours in BE35 25
- 26. Airplane History • 3,350hours total time airframe • 80 hours since major overhaul on Continental E-225 powerplant • Owners: Multiple mechanics troubleshooting oil leaks 26
- 27. Airplane History • Mechanicsfound, fixed some leaks; troubleshooting others • Owners monitored; mechanics rechecked daily • Oil temperature, oil pressure normal, no contamination 27 Photo from sales advertisement
- 28. Flight History • Owner/pilot(low time BE35) flew RYY to CHS (235 nm) day VFR • At CHS: remark about oil leak • Checked oil level, departed on return flight to RYY 28
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- 30. Flight History –Outcome? 30
- 31. Flight History –Outcome 31
- 32. Findings 32 • Engine teardown:No evidence of case fretting or bearing damage • Wrong type of case thread (not silk) used at overhaul • Eventual consequences had it continued to fly? Depends …
- 33. What Pilots CanLearn 33 • Troubleshooting may take time • Even trusted sources may provide conflicting information • Decisions: not easy, not cheap, not always obvious what is right
- 34. In Conclusion • Thisissue, others covered in SAs • Hot links (or short urls) to find reports, dockets, other resources • www.ntsb.gov 34
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