Accident Beechcraft M35 Bonanza N9820R,
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ASN Wikibase Occurrence # 45935
 
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Date:Saturday 19 May 2001
Time:10:32
Type:Silhouette image of generic BE35 model; specific model in this crash may look slightly different    
Beechcraft M35 Bonanza
Owner/operator:Private
Registration: N9820R
MSN: D-6364
Year of manufacture:1960
Total airframe hrs:4294 hours
Engine model:Continental IO-470-C
Fatalities:Fatalities: 1 / Occupants: 1
Aircraft damage: Substantial
Category:Accident
Location:NORTH LAS VEGAS, NV -   United States of America
Phase: Landing
Nature:Private
Departure airport:North Las Vegas, NV (VGT)
Destination airport:North Las Vegas, NV
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The airplane collided with obstructions during a forced landing precipitated by a loss of engine power. In a radio exchange with the control tower, the pilot reported a total loss of oil pressure. The airplane had accrued about 1 hour of flight time since a owner-assisted annual inspection was accomplished during which the owner changed the oil and filter element. Post accident examination of the underside of the forward fuselage/engine compartment area revealed an oil filter element hanging free from the oil filter base by the installation safety wire and fresh oil on the underside of the fuselage. The airplane had a STC'd remote mounted oil filter base that used a screw on filter element. The installation location was in the aft engine compartment on the forward side of the firewall, requiring a blind insertion of the element by feel only onto the threaded shaft. The only way to see the element pad and threaded shaft is by mirror or by looking up through the right cowl flap with a light. Examination of the filter base revealed evidence of thread damage to the first complete thread in the bore. The first 5 or 6 threads of the shaft were damaged, also with a cross the thread appearance to the first 2 or 3 threads. Other threads were damaged and had the appearance of attempted file repair. Both ends of the shaft revealed internal damage to the bore of the shaft. During manufacture, the shaft is permanently factory installed to a depth about 5 threads with red Locktite and torqued into the base. No evidence of Locktite was noted on the shaft or in the base bore. According to the Aircraft Maintenance Technician and IA who approved the annual inspection, the pilot/owner had recently commented to him that other filter elements could be used besides the one specified for the system. The pilot reportedly told the mechanic that you could either unscrew the 3/4-16 shaft from the other elements or the ones without a shaft could be screwed onto the shaft in the base unit.

Probable Cause: The pilot/owner's failure to correctly install the oil filter, which resulted in oil exhaustion and a loss of engine power. Also causal was his attempt to modify the design of the oil filter element adapter by breaking the bond between the base and the threaded shaft, which resulted in a loss of torque during filter element installation.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: LAX01FA186
Status: Investigation completed
Duration:
Download report: Final report

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20010523X01010&key=1

Location

Revision history:

Date/timeContributorUpdates
28-Oct-2008 00:45 ASN archive Added
21-Dec-2016 19:24 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
10-Dec-2017 11:20 ASN Update Bot Updated [Departure airport, Destination airport, Source, Narrative]

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