Monday, July 13, 2020

Schleicher ASW 27-18, N167TM: Fatal accident occurred July 11, 2020 in Ely, White Pine County, Nevada

Federal Aviation Administration / Flight Standards District Office; Reno, Nevada

Glider crashed under unknown circumstances.


https://registry.faa.gov/N167TM


Date: 11-JUL-20

Time: 22:20:00Z
Regis#: N167TM
Aircraft Make: ALEXANDER SCHLEICHER
Aircraft Model: ASW
Event Type: ACCIDENT
Highest Injury: FATAL
Aircraft Missing: No
Damage: DESTROYED
Activity: PERSONAL
Flight Phase: UNKNOWN (UNK)
Operation: 91
City: ELY
State: NEVADA

Those who may have information that might be relevant to the National Transportation Safety Board investigation may contact them by email eyewitnessreport@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov.

Golden Circle Air T-Bird Tandem TBT-06, N50JH: Fatal accident occurred July 11, 2020 in Grosse Ile, Wayne County, Michigan

Federal Aviation Administration / Flight Standards District Office; East Michigan

Aircraft crashed under unknown circumstances into a tree.

https://registry.faa.gov/N50JH

Date: 11-JUL-20
Time: 21:00:00Z
Regis#: N50JH
Aircraft Make: GOLDEN CIRCLE
Aircraft Model: T-BIRD
Event Type: ACCIDENT
Highest Injury: FATAL
Total Fatal: 1
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: PERSONAL
Flight Phase: UNKNOWN (UNK)
Operation: 91
City: DETROIT
State: MICHIGAN

Those who may have information that might be relevant to the National Transportation Safety Board investigation may contact them by email eyewitnessreport@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov.




A 57-year-old Lincoln Park man involved in a plane crash on Grosse Ile is dead, leaving officials with the task of figuring out if he died from the impact or if he died from a medical condition while flying, causing the crash.

Grosse Ile first responders responded to the 27000 block of Loma Circle at about 5 p.m. Saturday after receiving several reports that an airplane had crashed in the residential neighborhood, located near the south end of the island.

Officials found a ultralight aircraft overturned at the base of a tree in the backyard of a residence, according to a statement released by the Grosse Ile Police Department on Sunday.

The pilot, identified as Jeffrey Dean Oliver, had been ejected from the aircraft and was receiving CPR from a resident when rescue personnel arrived. Oliver was rushed to Henry Ford Wyandotte Hospital, where he was pronounced dead.

An autopsy will be performed by the Wayne County Medical Examiner to determine whether the cause of death was the result of injuries sustained in the crash or a "medical condition that occurred while in flight," according to the statement released by police.

The Federal Aviation Administration and National Transportation Safety Board are investigating the incident.

https://www.thenewsherald.com




GROSSE ILE, Michigan – Police have provided new details following the death of a man after a plane crashed on Grosse Ile Saturday.

Officials say at around 4:47 p.m. an airplane crashed in a residential neighborhood in the 27000 block of Loma Circle. Police and fire personnel discovered a ultralight aircraft overturned at the base of a tree in the backyard of a residence, officials said.

Police say the pilot, 57-year-old Jeffrey Dean Oliver of Lincoln Park, was ejected from the plane. The man was receiving CPR when officials arrived on the scene.

Oliver was then transported to the hospital where he was pronounced dead.

Officials are investigating whether his death was caused by injuries sustained during the crash or a medical condition that may have occurred during the flight. The Wayne County Medical Examiner is scheduled to perform an autopsy.

The FAA and NTSB are investigating.

https://www.clickondetroit.com

Cessna T188C AGhusky, N2690J: Fatal accident occurred July 10, 2020 in Dustin, Hughes County, Oklahoma

Federal Aviation Administration / Flight Standards District Office; Oklahoma City, Oklahoma

Aircraft crashed under unknown circumstances.

Agra Tech Inc

https://registry.faa.gov/N2690J

Date: 10-JUL-20
Time: 12:53:00Z
Regis#: N2690J
Aircraft Make: CESSNA
Aircraft Model: T188
Event Type: ACCIDENT
Highest Injury: FATAL
Total Fatal: 1 
Aircraft Missing: No
Damage: SUBSTANTIAL
Activity: AERIAL APPLICATION
Flight Phase: UNKNOWN (UNK)
Operation: 137
City: DUSTIN
State: OKLAHOMA

Those who may have information that might be relevant to the National Transportation Safety Board investigation may contact them by email eyewitnessreport@ntsb.gov, and any friends and family who want to contact investigators about the accident should email assistance@ntsb.gov.

Fuel Starvation: Beech A36 Bonanza, N6677D; accident occurred July 25, 2015 near Dutchess County Airport (KPOU), Poughkeepsie, New York


Pilot Keith Kilgallen and his wife, Margaret discuss their experience.




The National Transportation Safety Board did not travel to the scene of this incident.

Additional Participating Entities: 

Federal Aviation Administration / Flight Standards District Office; Teterboro, New Jersey
Continental Motors Inc; Mobile, Alabama

Aviation Accident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

https://registry.faa.gov/N6677D 

Location:  Poughkeepsie, NY

Accident Number: ERA15LA286
Date & Time: 07/25/2015, 1040 EDT
Registration: N6677D
Aircraft: BEECH A36
Aircraft Damage: Substantial
Defining Event: Fuel starvation
Injuries: 1 Minor, 1 None
Flight Conducted Under: Part 91: General Aviation - Personal

On July 25, 2015, about 1040 eastern daylight time, a Beech A36; N6677D, was substantially damaged during an emergency landing, after a partial loss of power during takeoff at Duchess County Airport (POU), Poughkeepsie, New York. The private pilot received minor injuries, and the passenger was uninjured. Visual meteorological conditions prevailed, and an IFR flight plan was filed for the flight, conducted under the provisions of Title 14 Code of Federal Regulations Part 91, destined for Burlington National Airport (BTV), Burlington, Vermont.

According to the pilot, after arriving at POU from Lehigh Valley International Airport (ABE), Allentown, Pennsylvania, he purchased 15 gallons of fuel and then sumped the tanks in preparation for the next leg of the flight to BTV.

After starting the engine he taxied out, did his engine runup, checked the magnetos, and cycled the propeller. Then during the takeoff from runway 24, he noticed a vibration and unusual noise as he rotated. He believed that it may have been from the wheels and applied the brakes to stop the wheels from rotating and retracted the landing gear but, the vibration continued. He was however unable to continue climbing, as the engine suddenly incurred a partial loss of power.

He checked that the propeller, throttle, and mixture, was full forward but the airplane still would not climb. With the airspeed being low, he knew that he could not make it back to the airport without stalling the airplane.

There were "trees everywhere" and a set of power lines directly ahead of him. He then pulled back on the control wheel, was able to clear the power lines, and then "forced the nose down" to prevent the airplane from stalling, and landed gear up about 300 feet from the power lines. 

Pilot Information


Certificate: Private
Age: 67, Male
Airplane Rating(s): Single-engine Land; Single-engine Sea
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed:No 
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/05/2014
Occupational Pilot: No
Last Flight Review or Equivalent: 02/01/2015
Flight Time:  8954 hours (Total, all aircraft), 6311 hours (Total, this make and model), 8896 hours (Pilot In Command, all aircraft), 92 hours (Last 90 days, all aircraft), 34 hours (Last 30 days, all aircraft), 7 hours (Last 24 hours, all aircraft)

According to Federal Aviation Administration (FAA) and pilot records, the pilot held a private pilot certificate with ratings for airplane single-engine land, airplane single engine sea, and instrument airplane. His most recent application for a FAA third-class medical certificate was dated August 5, 2014. The pilot reported that he had accrued approximately 8,954 total hours of flight experience, of which 6,311 hours were in the accident airplane make and model. 

Aircraft and Owner/Operator Information


Aircraft Make: BEECH
Registration: N6677D
Model/Series: A36
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-1581
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 12/17/2014, Annual
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 97 Hours
Engines: 1 Reciprocating
Airframe Total Time: 6796.6 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Installed, activated, did not aid in locating accident
Engine Model/Series: IO-520-BB
Registered Owner: On file
Rated Power: 285 hp
Operator: On file
Operating Certificate(s) Held: None

The accident airplane was a low wing, retractable single engine airplane, of conventional metal construction, equipped with retractable tricycle type landing gear. It was powered by an air cooled, 6-cylinder, horizontally opposed, 285 horsepower Continental IO-520-BB engine driving a McCauley 3-bladed, variable pitch, constant speed propeller.

According to FAA and maintenance records, the airplane was manufactured in 1979. The airplane's most recent annual inspection was completed on December 17, 2014. At the time of the inspection, the airplane had accrued 6,796.6 total hours of operation. 

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: POU, 164 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 1047 EDT
Direction from Accident Site: 235°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.01 inches Hg
Temperature/Dew Point: 25°C / 13°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Poughkeepsie, NY (POU)
Type of Flight Plan Filed: IFR
Destination: BURLINGTON, VT (BTV)
Type of Clearance: IFR
Departure Time: 1042 EDT
Type of Airspace: Class D

The recorded weather at POU, at 1047, about 7 minutes after the accident, included: calm winds, 10 miles visibility, clear skies, temperature 25° C, dew point 13° C, and an altimeter setting of 30.01 inches of mercury.

Airport Information


Airport: Dutchess County Airport (POU)
Runway Surface Type: Asphalt
Airport Elevation: 164 ft
Runway Surface Condition: Dry
Runway Used: 24
IFR Approach: None
Runway Length/Width: 5001 ft / 100 ft
VFR Approach/Landing: Forced Landing; Straight-in 

POU was owned by Dutchess County and was a public use, tower-controlled airport. It was located four miles south of Poughkeepsie, New York. The airport elevation was 165 feet above mean sea level.

There were two runways oriented in an 6/24 and 15/33 configuration.

Runway 24, had a left-hand traffic pattern, was asphalt, grooved, and in excellent condition. The total length was 5,001 feet-long and 100 feet-wide.

It was marked with precision markings in good condition and equipped with high intensity runway edge lights.

Obstructions were present off the departure end of the runway in the form of 18 ft trees, located 380 ft from the runway, 300 ft right of centerline which took a 10:1 slope to clear.

Wreckage and Impact Information


Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: 1 None
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor, 1 None
Latitude, Longitude: 41.626667, -73.884167 (est) 

Examination of the accident site revealed that the airplane had initially touched down on its belly in a grassy area, then traveled over the top of a large rock and came to rest.

Examination of the airplane revealed that it had touched down with the landing gear in the up (stowed) position. All major parts of the airplane were on site, and the airplane had been substantially damaged when it struck and traveled over the rock.

The outboard sections of all three blades of the propeller had been bent backwards, the right side nose wheel door had separated at the hinge line, the aft portion of the lower cowling had been buckled and crushed, the upper cowling had partially opened on impact.

The nose landing gear wheel well had been crushed upward, and both right side engine mounts were fractured. The throttle body had one of the mount lugs fractured and two of the fuel fittings were fractured.

The lower portion of the firewall was buckled, and the fuselage had buckled just aft of the firewall. The wing flaps were in the 15°position, and the inboard portion of the left wing flap was bent. Fuel was observable in both the left, and right, wing tanks. 

Tests And Research


Review of Maintenance Records


Review of maintenance records and the Pilot/Operator Accident/Incident Report submitted by the pilot, indicated that the factory rebuilt engine was installed on the airplane on February 23, 2012, at a recorded tachometer time of 6,103.9 hours.

On June 14, 2013, at 279.1 hours after engine installation, maintenance personnel replaced the airplane's auxiliary fuel pump (fuel boost pump).

On February 6, 2014, (tachometer and engine time not specified), maintenance personnel located in Fort Pierce, Florida, "bled fuel line, checked fuel strainer, cleaned injectors due to rough running engine." The engine was test run and returned to service.

On February 7, 2014, at an unspecified tachometer and engine time, maintenance personnel located in Stuart, Florida, "removed all spark plugs, cleaned, gapped, and rotated upon reinstallation, removed all fuel injectors cleaned inspected and reinstalled, [and performed] aircraft operational and functional check" with no discrepancies noted.

On December 17, 2014, at a recorded tachometer time of 6,796.6 hours, the engine underwent an annual inspection. On December 18, 2014 (same tachometer reading as annual inspection), the spark plugs were removed, cleaned, and reinstalled, and the ignition leads, and magnetos were checked with no anomalies noted.

On May 11, 2015, at a tachometer time of 6,881 hours, the engine underwent an oil and oil filter change.

According to the pilot, the engine had accumulated 790 hours at the time of the accident.

Engine Test Run


On November 2, 2015, in order to help determine why in the maintenance records the engine had been reported to have been running rough and why the loss of engine power had occurred, an engine test run was performed.

Prior to the test run several airframe related items were removed in preparation for operation in the test cell. The removed items included:

- Both fractured Engine mounts (right front and right rear)
- Fuel fittings (the throttle body outlet and mixture return)
- Cooling Baffles
- Propeller Governor

The following substitute or repaired parts were then installed for engine operation:

- Engine Mount legs
- Fuel fittings

The magneto-to-engine timing which was specified to be 22° before top dead center (BTDC) was then checked, with the following results:

- Left Magneto (21°BTDC)
- Right Magneto (20°BTDC)

The engine was not disassembled prior to the engine run. The crankshaft end-play was measured 0.010" and the run-out was 0.001".

The engine was prepared for operation by installing the appropriate thermocouples, pressure lines and test pads for monitoring purposes. The engine was then moved to a test cell, mounted for operation, and then fitted with a club type propeller for testing.

The engine experienced a normal start on the first attempt without hesitation or stumbling in observed RPM. The engine RPM was advanced in steps for warm-up in preparation for full power operation. The engine throttle was advanced to 1200 RPM and held for five (5) minutes to stabilize. The engine throttle was advanced to 1600 RPM and held for five (5) minutes to stabilize. The engine throttle was advanced to 2450 RPM and held for five (5) minutes to stabilize. The engine throttle was advanced to the fully open position and held for five (5) minutes to stabilize. The engine throttle was rapidly advanced from idle to full throttle five times where it performed normally without any hesitation, stumbling or interruption in power.

Throughout the test phase, the engine accelerated normally without any hesitation, stumbling or interruption in power and demonstrated the ability to produce rated horsepower.

After the test run with the engine still hot, a cylinder leakage test was performed in accordance with the latest revision of CMI Service Bulletin SB03-3 with the following results (master orifice reading – 43 PSI):

- Cylinder No. 1 - 17/80 PSI (rings)
- Cylinder No. 3 - 56/80 PSI (rings)
- Cylinder No. 5 - 60/80 PSI (rings)
- Cylinder No. 2 - 72/80 PSI (rings)
- Cylinder No. 4 - 36/80 PSI (rings)
- Cylinder No. 6 - 60/80 PSI (rings)

(*) – Leakage Source

Airplane Fuel System


Airplane fuel systems are designed to provide an uninterrupted flow of clean fuel from the fuel tanks to the engine. The fuel must be available to the engine under all conditions of engine power, altitude, attitude, and during all approved flight maneuvers. Two common classifications apply to fuel systems: gravity-feed and fuel-pump systems.

Low- and mid-wing single reciprocating engine airplanes cannot utilize gravity-feed fuel systems because the fuel tanks are not located above the engine. Instead, one or more pumps are used to move the fuel from the tanks to the engine.

In a low wing airplane, with a fuel injection system such as the Continental system, fuel pressurized by an engine-driven pump is metered as a function of engine rpm. It is first delivered from the fuel tanks (one for each wing), To a three-way selector valve (LEFT, RIGHT, or OFF). The selector valve also acts simultaneously as a diverter of air that has been separated out of the fuel in the engine-driven fuel pump and returned to the valve. It routes the air to the vent space above the fuel in the selected tank.

An electric auxiliary fuel pump draws fuel through the selector valve. It forces the fuel through the strainer, making it available for the engine-driven fuel pump. The electric auxiliary pump also supplies fuel pressure while starting, is used to prevent vapor lock, and is also used as a backup should the engine-driven pump fail and does not need to be operating to allow the engine-driven fuel pump access to the fuel.

The engine driven pump supplies a higher-than needed volume of fuel under pressure to the fuel control. Excess fuel is returned to the pump, which pumps it through the selector valve into the appropriate tank. Fuel vapor is also returned to tanks by the pump. The fuel control unit meters the fuel according to engine rpm and mixture control inputs from the cockpit and then supplies it to the fuel manifold and injectors, which spray fuel without any air mixed in directly into the cylinders, to provide a measured, continuous spray and smooth engine operation.

Auxiliary Fuel Pump


The auxiliary fuel pump was controlled by an ON-OFF toggle switch on the control console. It provided pressure for starting and emergency operation. Immediately after starting, the auxiliary fuel pump could be used to purge the system of vapor caused by extremely high ambient temperature or start with the engine hot. The auxiliary fuel pump provided for near maximum engine performance should the engine driven pump fail.

On May 4, 2016, the auxiliary fuel pump was tested.

It was noted that the fuel pump was intact and had not been disassembled from the time of manufacture.

During the testing, it took 5-7 seconds for the pump to self-prime and to start pumping.

Fuel pump requirements were a minimum of 42 gph at 16 psi, with a maximum amperage draw of 3 amps at 28 volts dc.

The pump during testing produced 53 gph at 16 psi, and amperage draw was 2.1 amps at 28 volts dc. indicating that the pump was operating within specifications.

During the testing however, it was discovered that the discharge fitting was leaking. Disassembly of the discharge fitting revealed that it appeared that it had had been installed to the proper torque, but it was observed that there were deep scratches on the O-Ring boss on the pump side of the fitting, and a piece of metal was found imbedded in the O-Ring.

The fittings were then removed, and the pump was then retested with another set of fittings. No leaks were found with the pump and /or the replacement fittings. 

Additional Information


According to the auxiliary pump manufacturer, fittings and O-rings can be a source of leakage. Care should be taken to ensure that fittings are inspected for cracks, scratches and cross threaded threads. New O-Rings should be installed at the time of fuel pump replacement and if the O-Rings have been on the fittings more than 10 years.
















Photo 13 – Image of Auxiliary Fuel Pump – Courtesy of CJ Aviation


Photo 14 – Pump Operating at 16 PSI and 53 GPH – Courtesy of CJ Aviation

Photo 15 – Pump Operating at 28 VDC at 2.1 Amps – Courtesy of CJ Aviation 

Photo 16 – Deep Scratches on O-Ring Boss on Pump Side of Discharge Fitting – Courtesy of CJ Aviation 

Photo 17 – Embedded Metal in O-Ring – Courtesy of CJ Aviation

Sunday, July 12, 2020

Loss of Engine Power (Total): Beechcraft King Air B100, N6756P; accident occurred July 16, 2014 at Meadows Field Airport (KBFL), Bakersfield, Kern County, California




The National Transportation Safety Board did not travel to the scene of this incident.

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; San Diego, California
Honeywell; Phoenix, Arizona 
Federal Aviation Administration/ Aircraft Certification Office; Fort Worth, Texas

Aviation Incident Factual Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Location: Bakersfield, CA
Incident Number: WPR14IA297
Date & Time: 07/16/2014, 2130 PDT
Registration: N6756P
Aircraft: BEECH B100
Aircraft Damage:Minor 
Defining Event: Loss of engine power (total)
Injuries: 1 None
Flight Conducted Under: Part 91: General Aviation - Business 

On July 16, 2014, at 2130 Pacific daylight time, a Beech B100, N6756P, was not damaged after it experienced an uncontained failure of its left engine in flight near Bakersfield, California. The commercial pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot reported to the NTSB investigator-in-charge (IIC) that he was cruising at flight level 190 (19,000 feet mean sea level (msl)), about 30 miles east-northeast of Bakersfield, when the left engine spooled back. The pilot executed the engine failure in-flight procedures and landed uneventfully at Meadows Field Airport. Post flight inspection revealed damage, consistent with an uncontained engine event, to the left nacelle and external damage to the left engine.

Examination of the engine by a Safety Board powerplants specialist and the engine manufacturer identified failure of the second stage turbine wheel. The 2nd stage turbine wheel assembly is a repairable assembly of two parts: the 2nd stage turbine wheel and the 2nd stage rotating labyrinth curvic seal (referred to as the 'knife edge seal ring' for the remainder of this report) and they are assembled using a tight interference fit. The knife edge seal ring was fractured and was separated from the 2nd stage turbine wheel hub. The knife edge seal ring was severely scored rotationally on the inner minor assembly faying diameter. Approximately 1/3 of the forward edge was heat eroded, resulting in a wedge shape eroded edge. The knife edge seal ring features 2 castellations, used for assembly ease. One castellation was completely hot gas eroded. A small crack was found on each of the inner corners of the remaining castellation. Only the hub portion of the 2nd stage turbine wheel was found with the web, platform and blades missing. A fractured surface through 360o remained. The forward outer curvic shaft diameter was severely rotationally scored, consistent with contact against the fractured knife edge seal ring. The curvic teeth of the forward and aft coupling were undamaged.

A materials laboratory evaluation of the thermally degraded 1st stage stator vanes revealed that weld repairs had been done to the part. Additionally, a microstructure analysis indicated that the metal had sustained operational temperatures in excess of 1650°F in 1840°F for a long period of time at the outboard leading edges and trailing edge regions respectively.

The 2nd stage stator assembly is an assembled part consisting of a main nozzle casting, onto which an outer support baffle with outer flange is brazed. The outer support baffle, when brazed onto the main nozzle casting, defines an inner cavity with the main nozzle casting that acts as a passage for compressor discharge air which cools the aft face of the 1st stage turbine wheel and the knife edge seal ring and honeycomb seal. Additionally, it is also a structural component since it is along the load path between the outer mounting flange/forward ring/baffle assembly to the nozzle casting. The braze thickness is a tightly controlled dimension during the fabrication of the part. Due to the close proximity of any weld repair of the leading edge of the vane to the forward braze joint presents a risk of oxidation and porosity of the braze material due to the high temperature induced in the braze joint as part of the welding repair.

The cooling airflow that is directed to the back face of the 1st stage turbine wheel and the knife edge seal ring comes from the compressor discharge air through the second stage stator outer housing, through the internal passages of the stator vanes and into the cavity. If areas of the braze joint became separated at any location around the circumference of the nozzle during service prior to the uncontained event, these areas would account for the loss of secondary cooling to the nozzle cavity. Instead of the cooling air being directed to the knife edge seal ring cavity, some of the air would escape the outer support cavity and be drawn to the lower pressure areas near the internal turbine temperature (ITT) probes and into the gas flow path. The loss of cooling flow will result in increased gas flow path ingress into the seal cavity and a corresponding rise in temperature. To further exacerbate the situation, the secondary cooling air passing by the ITT probes will cause a lower ITT indication than the true operating temperature of the engine, causing the pilot to be unaware of the increased engine operating temperature and the resulting insufficient cooling of the knife edge seal ring.

The 2nd stage turbine wheel outboard of the curvic hub exhibited wear/rub that reduced the web thickness by over 0.4 inches at the separation location. The wear/rub was consistent with contact against the fractured and expanded knife edge seal ring. The fracture surface exhibited indications of overload separation in the area of the reduced web thickness.

According to the Honeywell laboratory report, metal temperatures of the knife edge seal ring at the forward and aft ends were estimated to be 1446 °F and 1263 °F respectively. Intergranular fractures were initiated after exposure to these high temperatures. The nominal cavity temperature should be 1060°F.

Repair History

A review of the Authorized Release Certificate Federal Aviation Administration (FAA) Form 8130-3, Airworthiness Approval Tag reveals that the 2nd stage stator assembly, P/N 894528-15, S/N 0-01345-3454, was repaired by Texoma Turbines, in Durant, Oklahoma in accordance with process 72-IR-10 #9 and repair process specification (RPS) SP003 Rev. 2 on February 17, 2009.

At the time this part was repaired, the RPS applicability was for repairing only 2nd stage turbine stator assemblies part numbers 894528 -1, -2, -3, -5, -6, -10, and -11. It was not applicable to the -15 & -16 parts, making the event part, repaired by Texoma Turbines, unapproved.

According to Honeywell's Instructions for Continuing Airworthiness (ICA), there are no instructions or authorizations for vane weld repairs on the 2nd stage stator. When this component fails its respective service limit criteria, Honeywell guidance states that it should be removed from service.

The entire powerplants group chairman's factual report is contained in the official docket of this investigation.

Record Retention Requirements

The owner of the repair station stated that he had destroyed the documentation of the repaired part after the FAA prescribed 2-year retention limit. The component was repaired February 17, 2009.

CFR Part 145.219 is applicable for the 2-year retention of records for Repair Station repaired parts/articles.

Sec. 145.219 Record keeping.


(a) A certificated repair station must retain records in English that demonstrate compliance with the requirements of Part 43. The records must be retained in a format acceptable to the FAA.
(b) A certificated repair station must provide a copy of the maintenance release to the owner or operator of the article on which the maintenance, preventive maintenance, or alteration was performed.
(c) A certificated repair station must retain the records required by this section for at least 2 years from the date the article was approved for return to service.
(d) A certificated repair station must make all required records available for inspection by the FAA and the National Transportation Safety Board.
(Amdt. 145-27, Eff. 1/31/2004)

The regulatory requirement allows for the disposal of these records and the true history, which could have helped to understand the problem, is no longer available.

FAA Designated Engineering Representative (DER) Process and Procedures

The original technical documents used to substantiate the repair processes in the RPS could not be located, therefore a review of it could not be done. An FAA technical staff member interviewed from the Fort Worth ACO Branch, believed that there was no technical substantiation data written for this repair and that only the process steps were written by the original DER because the technical substantiation data was not included in the DER's approval. It is not known if the DER considered (1) the braze joint oxidation and porosity sensitivity to welding and heat-treatment heat or (2) of the impact of loss of cooling air of this part on any adjacent or downstream components of the engine.

The technical substantiation data should have been retained by the original DER and the original Repair Station; however, he was no longer a DER and not in the DER directory. Guidance for the retention of technical substantiation documents is defined in FAA Order 1350.15C, Records Management, Chapter 11, Flight Safety, Item 8113 Designated Engineering Representative states that original document destruction is not authorized. There is no guidance for the transfer of documents when a DER quits or dies. 

Pilot Information

Certificate: Commercial
Age: 29, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed:No 
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 05/28/2014
Occupational Pilot: Yes
Last Flight Review or Equivalent: 10/01/2013
Flight Time:  5000 hours (Total, all aircraft), 1000 hours (Total, this make and model), 50 hours (Last 90 days, all aircraft), 15 hours (Last 30 days, all aircraft), 3 hours (Last 24 hours, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N6756P
Model/Series: B100 NO SERIES
Aircraft Category: Airplane
Year of Manufacture:1980 
Amateur Built:No 
Airworthiness Certificate: Normal
Serial Number: BE-92
Landing Gear Type: Retractable - Tricycle
Seats: 10
Date/Type of Last Inspection: 05/05/2014, Continuous Airworthiness
Certified Max Gross Wt.: 11800 lbs
Time Since Last Inspection:
Engines: 2 Turbo Prop
Airframe Total Time: 7807 Hours as of last inspection
Engine Manufacturer: Garret
ELT: Installed, not activated
Engine Model/Series: TPE331-6
Registered Owner: On file
Rated Power: 715 hp
Operator:On file 
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Night
Observation Facility, Elevation: KBFL, 510 ft msl
Distance from Accident Site: 0 Nautical Miles
Observation Time: 2054 PDT
Direction from Accident Site:
Lowest Cloud Condition: Clear
Visibility: 5 Miles
Lowest Ceiling:None 
Visibility (RVR):
Wind Speed/Gusts: 11 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 300°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 29.86 inches Hg
Temperature/Dew Point: 29°C / 13°C
Precipitation and Obscuration: Haze; No Precipitation
Departure Point: S. Lake Tahoe, CA (KTVL)
Type of Flight Plan Filed: None
Destination: Carlsbad, CA (KCRQ)
Type of Clearance: VFR Flight Following
Departure Time: 2030 PDT
Type of Airspace: Class A

Airport Information

Airport: Meadows Field Airport (KBFL)
Runway Surface Type:
Airport Elevation: 510 ft
Runway Surface Condition: Dry
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Unknown

Wreckage and Impact Information

Crew Injuries: 1 None
Aircraft Damage: Minor
Passenger Injuries:N/A 
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 None
Latitude, Longitude: 35.433889, -119.057778 (est)