N16JR

Substantial
Fatal

Beech A36S/N: E433

Accident Details

Date
Monday, March 13, 2006
NTSB Number
LAX06FA129
Location
Santa Monica, CA
Event ID
20060317X00321
Coordinates
34.003612, -118.493888
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
0
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The failure of an aviation maintenance technician to properly torque and cotter pin the number 2 connecting rod bolts at their attach point to the crankshaft, which resulted in the separation of the connecting rod in flight, and complete power loss.

Aircraft Information

Registration
N16JR
Make
BEECH
Serial Number
E433
Engine Type
Reciprocating
Year Built
1973
Model / ICAO
A36BE36
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
TOMARKEN PETER D
Address
2716 VETERAN AVE
Status
Deregistered
City
LOS ANGELES
State / Zip Code
CA 90064-4240
Country
United States

Analysis

1.1 History of the Flight

On March 13, 2006, at 0943 Pacific standard time, a Beech A36, N16JR, was ditched into the ocean following a loss of engine power after departure from Santa Monica Municipal Airport, Santa Monica, California. The instrument rated private pilot, who was also a registered co-owner of the airplane, was operating it under the provisions of 14 CFR Part 91. The pilot and one passenger sustained fatal injuries; a third occupant listed on the instrument flight plan was not located. The airplane was destroyed. The pilot was destined for Brown Field Municipal Airport, San Diego, California to pick up a passenger and intended to return to Santa Monica later that day. Visual meteorological conditions prevailed and an instrument flight plan was in effect.

The airplane impacted the water off of Santa Monica beach approximately 2.5 statute miles west-southwest of the Santa Monica Airport and about 250 yards off shore. It was submerged in 20 feet of water. The pilot and one occupant were recovered from the airplane. Searches for the third occupant continued but were unsuccessful. Acquaintances of the pilot were unaware of who the third person would have been and at the time of this report, there was no additional information of a third person onboard the airplane.

According to the co-owner of the airplane, he and the pilot normally kept the utility doors locked when there were no aft seat passengers. They also agreed that when ditching the airplane, the cabin door would be unlatched prior to impact with the water. Initial responders reported that the cabin door was unlatched and that the utility doors were locked.

1.1.1 Witness Information

A lifeguard reported that he was 1 mile north of the airplane when he saw it at 400 feet above water level. It appeared to be at lower than normal altitude for airplanes flying in the area and continued a descent toward the ocean. The flight path of the airplane was toward Santa Monica airport from the southwest to the northeast. The lifeguard stated that the pilot appeared to be in control of the airplane and that from the time he first noticed the airplane until its impact with the water, approximately 5 seconds had gone by.

An additional witness was on the beach and took photos of the airplane as it approached the water. The photos show the airplane in a level flight attitude descent, approaching the beach from the west with the landing gear retracted. As the airplane impacted the water, it was in an upright attitude and moving in an easterly direction toward the beach. Upon impact, the airplane turned to a west-southwest heading on the surface of the water, and subsequently sank.

1.1.2 Radar Information and Communications

The pilot was in communications with the Southern California Terminal Radar Approach Control at the time of the power loss, and was then transferred back to Santa Monica Air Traffic Control Tower. In summary, the pilot indicated that he had a power loss and was returning to Santa Monica Airport. He then indicated that he would not be able to make it to the airport, and he was going to attempt to land the airplane on the beach.

Recorded radar information was obtained from the Southern California Terminal Radar Approach Control Facility. The airplane was assigned a discrete transponder code of 4711 and the first target associated with the accident airplane initiated at 0935:55. At 0936:00, the target showed an altitude of 600 feet. The target showed a climb to 3,200 feet on a west-northwest ground track. At 0939:04 the squawk code changed to 7777 and remained there throughout the remainder of the flight. The radar track then showed a descent from 0939:32 and a 180-degree turn to the east-southeast. The last radar hit was at 0942:04 at an elevation of 600 feet.

1.2 Personnel Information

The pilot held a private pilot certificate for single-engine airplanes with an instrument rating. He was issued a third class medical certificate in July of 2005 with the restriction that he must wear corrective lenses during flight.

Copies of the pilot's personal flight logbook were obtained from his family. The logbook was dated from October of 1991 until the last entry date of February 20, 2006. The total flight time logged was 428.4 hours. The pilot obtained his instrument rating on October 15, 2004, in the accident airplane, which equated to his most recent flight review. The pilot logged 70.6 hours in the last 12 months, 15 hours in the last 6 months, and 2.2 hours in the past 30 days.

1.2.1 Pilot Information

According to Angel Flight personnel, the pilot had volunteered his time and airplane services to assist in the transport of a medical patient from San Diego to the Los Angeles area. The pilot was on the initial leg of the trip to pickup the patient when the accident occurred. The purpose of Angel Flight is to assist those in need of air transportation due to medical services, national crisis, or specific human need by providing flights at no charge. The pilot received an Angel Flight checkout in August of 2005 and the accident flight was his first mission.

1.3 Aircraft Information

1.3.1 General Aircraft History

The airplane was manufactured in 1973. At the time of the accident, the tachometer indicated 3,555.20 hours. It was powered by a Teledyne Continental IO-520-BA (serial number 551008) six-cylinder piston engine, which had accumulated 735.31 hours since the last field overhaul. The engine was equipped with a McCauley model 3A32C76S-MR propeller.

1.3.2 Maintenance Information

An engine logbook entry showed that the engine was overhauled on December 30, 1977, at a total time of 1,775 hours. On February 3, 1998, the engine was field overhauled; there was no tachometer time noted in the maintenance entry. The connecting rod bearings and bushings, and the associated nuts and bolts, were replaced during this overhaul. Following the overhaul, mineral oil was installed in the engine. The engine was placed into storage.

On February 2, 1999, an engine logbook entry indicated, in part, "Due to the long period of storage, it was disassembled, cleaned, inspected, and reassembled in accordance with the TCM IO-520 Overhaul manual, applicable Service Bulletins, and Airworthiness Directives." The engine was reinstalled on the airplane on May 26, 1999, at a tachometer time of 2,819.89 hours.

On July 31, 2004, an annual inspection was performed on the airplane. The tachometer time for the airplane was 3,321.61, and the time since major overhaul (TSMOH) of the engine was 502.72. The logbook entry indicated that all six cylinders were removed due to a blow by condition.

The aviation maintenance technician (AMT) that performed the annual inspection was interviewed on March 23, 2006. At the time of the annual inspection, the pilot was employed part-time at Corporate Jet Support, Hayward, California, about 5 hours per day. He worked full-time as a Production Supervisor for American Airlines, approximately 8 hours per day. Due to his schedule, he ceased his employment at Corporate Jet Support after about one year of employment.

The AMT performed two annual inspections on the airplane; one on July 10, 2003, and one on July 31, 2004. The July 10, 2003, annual inspection was unremarkable. The AMT noted that during the July 31, 2004, inspection, the engine was removed from the airplane because the cylinders had to be removed. The exhaust and intake tubes were detached and the cylinders were pulled, as well as the pistons. The connecting rods were not removed. The cylinders were removed due to a blow by condition that was causing low compression. After the cylinders were repaired, they were reinstalled and the engine operated normally.

The last annual inspection was performed on August 19, 2005, at a tachometer time of 3,510 hours and 691 hours TSMOH at Santa Monica Aviation, Santa Monica, California. The engine logbook showed that 233.59 hours had accumulated since the cylinders had been removed and reinstalled during the July 2004 annual inspection.

On August 11, 2004, September 29, 2004, January 24, 2005, and February 21, 2006, the oil was changed on the engine and an oil analysis was taken. The analyses were completed at Aviation Oil Analysis, Phoenix, Arizona. The analysis results taken in August and January were identical. Each showed that the aluminum appeared slightly high, silicon appeared slightly high, and to resample to check for dirt/wear. On the September sample, the analysis report also suggested a resample to check for dirt/wear in addition to checking the air induction system for the source of dirt entry due to the high silicon levels. The most recent analysis indicated that the wear metals were high due to possible piston wear, and to resample at the next oil change to check wear trend.

1.3.3 Fueling

The airplane was fueled on March 5, 2006, at Mercury Air in Santa Barbara, California with the addition of 9.6 gallons of 100 low lead. The co-owner of the airplane said that he topped-off the fuel tanks in Santa Barbara and returned to Santa Monica. He estimated that the return trip from Santa Barbara was 40 minutes in duration.

1.4 Meteorological Information

The County of Los Angeles Fire Department Underwater Operations personnel reported the following weather conditions at the time of the accident: 1 to 2-foot waves; swell out of the south; wind, from the west at 5; surface, rippled; water temperature, 54 degrees Fahrenheit.

At 0951, an aviation routine weather report (METAR) at Santa Monica was reporting the following weather conditions: wind, variable at 4 knots; surface visibility, 10 statute miles; sky conditions, clear; temperature, 55 degrees Fahrenheit; dew point, 35 degrees Fahrenheit; altimeter, 30.27 inches of Mercury.

1.5 Wreckage and Impact Information

The airplane impacted offshore of the Santa Monica beach. Divers assisted in the recovery of the airpl...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# LAX06FA129