Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Oak Shores, California 93446
Saturday, April 27, 2002 17:45 PDT
NTSB Narrative Summary Released at Completion of Accident
The airplane collided with trees following a loss of engine power. A passenger heard a "roar" through the four-way intercom. The certified flight instructor (CFI) and the student pilot checked the oil pressure and fuel pressure; both were "good." The CFI pointed to the left and directed the student toward a private strip. During or immediately following the left turn, the CFI said, "I've got it." The student looked back at the two passengers, and motioned with his right hand that they were going to land at the strip. The last thing that the passenger remembered was contact with the trees and coming to rest. The airplane cleared a ridge top, but collided with trees about 1/4 mile from the landing strip. The spark plug for cylinder no. 1 sustained mechanical damage and contained metallic debris. The head of the cylinder no. 1 exhaust valve was missing, and the top of the piston exhibited mechanical damage across its entire surface. Metallurgists examined the valve and cylinder. The valve stem was broken and remained in the valve guide. The stem fractured and there were numerous secondary cracks below the fracture surface. The areas around the valve seats were severely damaged. The fracture surface condition was such that the fracture mechanism could not be determined. The secondary cracks were only in a local area where the material was severely battered and deformed. Many of the cracks were slightly curved and/or did not appear to be perpendicular to the outer or inner surface. These types of cracks are most likely to occur where surfaces have overlapped, or are the result of the excessive local strains in the area. There were no material or dimensional abnormalities that would suggest fatigue. The manufacturer issued maintenance instructions describing methods for determining exhaust valve and guide condition. This maintenance function was optional for the operator, and maintenance records indicated that this had not been done. Although the diameter of the exhaust valve stem was slightly below the specified diameter, this would have a small affect on overall stresses. However, a small change in diameter of the valve stem significantly changes the amount of clearance between the exhaust valve stem and the exhaust valve guide. Excessive clearance can lead to exhaust valve sticking, which can lead to overstress fracture. The engine total time was 2,079 hours, and it had not been overhauled since it was new in 1975. The manufacturer recommended overhaul at 2,000 hours or after 12 years of service life. Given the high hours on this engine and the number of years since overhaul, it was likely that the failure was due to exhaust valve sticking.
NTSB Probable Cause Narrative
the number 1 cylinder exhaust valve fractured and separated resulting in a loss of engine power and an off airport forced landing. A finding in the accident was the owner's failure to maintain the engine in accordance with the manufacturer's recommendations.
Event Information
| Type of Event | Accident |
| Event Date | 4/27/2002 |
| Event Day of the Week | Saturday |
| Time of Event | 1745 |
| Event Time Zone | Pacific Daylight Time |
| Event City | OAK SHORES |
| Event State | CALIFORNIA |
| Event Country | -- |
| Zipcode of the event site | 93446 |
| Event Date Year | 2002 |
| Event Date Month | 4 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 354727N |
| Event Location Longitude | 1205937W |
| 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 | Not pertinent |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1753 Pacific Daylight Time |
| Direction of event from weather observation facility (degrees) | 95 |
| Weather Observation Facility ID | PRB |
| Elevation of weather observation facility | 836 |
| Distance of event from weather observation facility (units?) | 21 |
| Time Zone of the weather observation | PDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 12 |
| Dew Point at event time (in degress fahrenheit) | 4 |
| Wind Direction (degrees magnetic) | -- |
| Variable Wind Indicator | Variable |
| Wind Speed (knots) | 4 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.01 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 3 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | 1 |
| Injury Total All | 4 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 16304 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Apr 28 2002 12:00AM |
| NTSB Notification Time | 720 |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Sep 29 2004 1:02PM |
| User who most recently changed record | NTSB\MONR |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | WP-SJC-FSDO |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N9180S |
| NTSB Number | LAX02FA148 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | No |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | Beech |
| Aircraft Model | C23 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | M-1801 |
| Certified Max Gross Weight | 2450 |
| 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 | Fixed |
| Aircraft, Type of Last Inspection | Annual |
| Date of Last Inspection | Apr 6 2001 12:00AM |
| Airframe hours since last inspection | 118 |
| Airframe Hours | 2097 |
| ELT Installed | Yes |
| ELT Activated | Yes |
| ELT Aided Location of Event Site | Yes |
| ELT Type | -- |
| Aircraft Owner Name | Stephen W. Meester |
| Aircraft Owner Street Address | On File |
| Aircraft Owner City | Oakdale |
| Aircraft Owner State | CA |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 95364 |
| Operator is an individual? | No |
| 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? | -- |
| Certified for Part 133 or 137 Operation | -- |
| 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) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | No |
| Departure Airport Code | L52 |
| Departure City | SAN LUIS OBISPO |
| Departure State | CA |
| Departure Country | USA |
| Departure Time | 1630 |
| Departure Time Zone | PDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | 3O8 |
| Destination City | HARRIS RANCH |
| Destination State | CA |
| Destination Country | USA |
| Specific Phase of Flight | Maneuvering - turn to landing area (emergency) |
| Report sent to ICAO? | No |
| Evacuation occurred | No |
| Date of most recent change to record | Aug 11 2004 6:18PM |
| User who most recently changed record | COOS |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | NA |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |