Aviation Accident Summaries

Aviation Accident Summary FTW95LA119

SANTA ROSA, NM, USA

Aircraft #1

N100BL

BEECH 60

Analysis

WHILE THE AIRPLANE WAS CLIMBING THROUGH FL230 IN DARK NIGHT VMC CONDITIONS, THE RIGHT ENGINE LOST POWER. SECONDS AFTER THE PILOT INITIATED AN EMERGENCY DESCENT, THE LEFT ENGINE LOST POWER. HE THEN ATTEMPTED SEVERAL UNSUCCESSFUL RESTARTS ON BOTH ENGINES UNTIL REACHING 15,000 MSL, AT WHICH TIME HE FEATHERED THE RIGHT ENGINE PROPELLER. CONTINUED ATTEMPTS TO RESTART THE LEFT ENGINE USING VARIOUS COMBINATIONS OF CROSS-FEED, MIXTURE, AND THROTTLE WERE NOT SUCCESSFUL. THE PILOT THEN EXECUTED A FORCED LANDING TO ROUGH TERRAIN WITH THE AIRPLANE COMING TO REST 1/3 MILES WEST OF AN AIRPORT. THE AIRPLANE WAS STRUCTURALLY DAMAGED DURING THE EMERGENCY LANDING. EXAMINATION OF THE RIGHT ENGINE REVEALED THAT THE #5 CONNECTING ROD FAILED DUE TO OIL STARVATION, AND PENETRATED THE CRANKCASE. ADDITIONALLY, THE TURBOCHARGER TURBINE WHEEL WAS FOUND SEPARATED FROM ITS SHAFT. EXAMINATION OF THE LEFT ENGINE ALSO REVEALED A FAILED TURBOCHARGER TURBINE WHEEL SHAFT. TEARDOWN OF BOTH TURBOCHARGER ASSEMBLIES REVEALED EVIDENCE OF EXCESSIVELY HIGH TURBINE INLET TEMPERATURES AND BOTH TURBOCHARGERS HAD UNAPPROVED PARTS INSTALLED.

Factual Information

On February 22, 1995, approximately 2030 mountain standard time, a Beech BE-60, N100BL, was substantially damaged during a forced landing after losing power on both engines, near Santa Rosa, New Mexico. The airline transport rated pilot and two passengers sustained minor injuries. The airplane, owned by Agamemnon Operating Inc., was being operated under 14 CFR Part 91 when the accident occurred. The business flight originated at Santa Fe, New Mexico at 2000 and was en route to Dallas, Texas. An instrument flight rules (IFR) plan was filed and dark night visual meteorological conditions prevailed for the personal cross country flight. The pilot reported that after refueling at Santa Fe Municipal Airport, the airplane departed on an IFR clearance to FL250, en route to Dallas, Tx. Approximately 20 minutes into the flight, and climbing through FL220, the right engine lost power. After initiating an emergency descent, the pilot reported that the left engine lost power. After several unsuccessful restart attempts on both engines, the pilot feathered the right engine propeller. He continued attempts to restart the left engine using various combinations of cross-feed, mixture, and throttle, but was not successful. The pilot then executed a forced landing to rough terrain and came to rest 1/3 miles west of Santa Rosa Airport, New Mexico. The airplane was structurally damaged during the landing. Fuel samples extracted form the airplane were analyzed by Petroleum Specialist Lab, Floresville, Texas. According to their tests, the fuel samples conformed to standard specifications for aviation gasolines. Examination of the right engine revealed that the #5 connecting rod penetrated the crankcase and the turbocharger turbine wheel was found separated from it's shaft and found lodged in the exhaust pipe. Examination of the left engine's turbocharger also revealed a separated turbine wheel from it's shaft. Teardown of both right and left turbocharger assemblies revealed evidence of excessively high turbine inlet temperatures (TIT). The TIT probes from both turbochargers displayed excessive heat erosion and according to the manufacturer, "not installed properly." The manufacturer reported that the eroded TIT probes in conjunction with their improper installation, could have allowed the turbine components to operate at temperature above specification. During an examination of both turbochargers, it was noted that the manufacturer's markings were missing from the journal bearings. The manufacturer documented that the bearings were not an approved part. Additionally, the center housings from both turbochargers had solid anti-rotation pins for the thrust bearings installed. According to the manufacturer, solid pins are used in automotive applications only, and their presence indicates that either an unapproved repair was performed, unapproved parts were used during the repair, or an automotive center housing was installed at one time. (See enclosed turbocharger teardown report).

Probable Cause and Findings

THE FAILURE OF THE RIGHT ENGINE'S TURBOCHARGER RESULTING IN OIL STARVATION AND SUBSEQUENT FAILURE OF THE #5 CONNECTING ROD WHICH PENETRATED THE CRANKCASE, AND THE FAILURE OF THE LEFT ENGINE'S TURBOCHARGER RESULTING IN THE LOSS OF POWER ON BOTH ENGINES. FACTORS WERE THE LACK OF SUITABLE TERRAIN FOR THE FORCED LANDING, DARK NIGHT LIGHT CONDITIONS, AND UNAPPROVED TURBOCHARGER PARTS.

 

Source: NTSB Aviation Accident Database

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