Aircraft Accident/Incident Report

West Palm Beach, Florida 33414
Monday, January 9, 1995 17:50 EST

NTSB Narrative Summary Released at Completion of Accident

The airplane was seen flying erratically, in a rapid descent, with smoke coming from the engine compartment and flames coming from the airplane's right side. Subsequently, the airplane crashed/landed and burned. An investigation revealed that the #1 cylinder had separated from the engine. Examination of the #1 cylinder revealed the upper crankcase thru-bolt at the 10 o'clock position had failed in fatigue below the cylinder deck surface. The lower thru-bolt at the cylinder pad's 8 o'clock position was intact; however, the nut was missing and the threads were battered and polished. The cylinder had 6 deck studs in addition to the thru-bolts. The studs at the 11 and 1 o'clock positions were missing; the studs at the 5 and 7 o'clock positions failed in fatigue; and the studs at the 2 and 4 o'clock positions were fractured with the fractured ends battered. Also, a silicon sealant (RTV) had been used on the thru-bolt threads, though not recommended by the manufacturer. The remaining thru-bolts were examined for tightness using a torque wrench; all were found undertorqued. During a top overhaul of the engine, about 85 flight hours before the accident, all of the cylinders had been removed and reinstalled.

NTSB Probable Cause Narrative

Improper top overhaul by maintenance personnel, and improperly torqued crackcase thru-bolts and cylinder deck studs at the number one cylinder, which led to fatigue failure of four of the bolts, failure and/or separation of the number one cylinder, and a subsequent fire.

Event Information

Type of Event Accident
Event Date 1/9/1995
Event Day of the Week Monday
Time of Event 1750
Event Time Zone Eastern Standard Time
Event City WEST PALM BEACH
Event State FLORIDA
Event Country --
Zipcode of the event site 33414
Event Date Year 1995
Event Date Month 1
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1756 Eastern Standard Time
Direction of event from weather observation facility (degrees) 90
Weather Observation Facility ID PBI
Elevation of weather observation facility 19
Distance of event from weather observation facility (units?) 20
Time Zone of the weather observation EST
Lighting Conditions Dusk
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 21
Dew Point at event time (in degress fahrenheit) 9
Wind Direction (degrees magnetic) 340
Variable Wind Indicator Unknown
Wind Speed (knots) 5
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 1790
NTSB Notification Source --
NTSB Notification Date Jan 9 1995 12:00AM
NTSB Notification Time 1930
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 7 2000 4:00PM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N32TS
NTSB Number NYC95FA049
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? --
Damage Destroyed
Aircraft Fire In-flight
Aircraft Explosion None
Aircraft Manufacturer's Full Name BEECH
Aircraft Model G35
Aircraft Series Identifier G35
Aircraft Serial Number D4643
Certified Max Gross Weight 2775
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Annual
Date of Last Inspection May 31 1994 12:00AM
Airframe hours since last inspection 78
Airframe Hours 4116
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name JOSE PINEDA
Aircraft Owner Street Address 2500 GREENBRIAR BLVD.
Aircraft Owner City W PALM BEACH
Aircraft Owner State FL
Aircraft Owner Country
Aircraft Owner Zipcode 33414
Operator is an individual? --
Operator Name
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address
Operator City
Operator State
Operator Country
Operator Zip code
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code PHK
Departure City PAHOKEE
Departure State FL
Departure Country
Departure Time 0
Departure Time Zone
Destination Same as Local Flt --
Destination Airport Code
Destination City WELLINGTON
Destination State FL
Destination Country
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --