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NTSB Report
March 10, 1991 · Beech 35-C33A · N4828J
Key West, FL
Overview
Report Status
Probable Cause
Event Type
Accident
Date
March 10, 1991
Injury Outcomes
3 injuries (3 fatalities)
Location
Key West, FL
Aircraft
Beech 35-C33A
Tail Number
N4828J
Operator
James W Hardin
Injuries
Fatal
Aircraft Damage
Destroyed
NTSB Number
MIA91FA095
WITNESSES RPTD THEY HEARD PROPELLER OVERSPEED FOLLOWED BY ENGINE PWR BEING REDUCED TO IDLE AS IF PILOT PULLED THROTTLE CLOSED. ACFT THEN BANKED TO LEFT AND ENTERED SPIN TO THE LEFT CRASHING INTO A PARKING LOT. POST CRASH EXAMINATION OF THE ENGINE, ACFT STRUCTURE, AND FLIGHT CONTROLS REVEALED NO EVIDENCE OF PRECRASH FAILURE OR MALFUNCTION. EXAMINATION OF THE PROPELLER REVEALED THE NUMBER TWO BLADE PITCH CHANGE ACTUATING PIN HAD FAILED DUE TO FATIGUE. THE PIN HAD BEEN INSTALLED AT OVERHAUL, 600 FLT HOURS BEFORE THE ACCIDENT, BY FOLLOWING MCCAULEY SERVICE BULLETIN 99 WHICH IS NOT APPLICABLE TO THIS MODEL PROPELLER. THE PIN WAS INSTALLED BY USING A SHORT THREADED PIN, A THIN SPACER, AND A BLIND HOLE IN THE FERRULE. THIS COMBINATION ALLOWED THE PIN TO BOTTOM OUT IN THE HOLE THUS NOT TORQUING PROPERLY AND THUS CRACKING DUE TO APPLIED LOADS.
NTSB Probable Cause
THE PILOT-IN-COMMAND'S FAILURE TO MAINTAIN AIRSPEED, WHILE RETURNING FOR AN EMERGENCY LANDING FOLLOWING PROPELLER FAILURE, RESULTING IN THE AIRCRAFT STALLING AND ENTERING A SPIN.
Full Narrative
WITNESSES RPTD THEY HEARD PROPELLER OVERSPEED FOLLOWED BY ENGINE PWR BEING REDUCED TO IDLE AS IF PILOT PULLED THROTTLE CLOSED. ACFT THEN BANKED TO LEFT AND ENTERED SPIN TO THE LEFT CRASHING INTO A PARKING LOT. POST CRASH EXAMINATION OF THE ENGINE, ACFT STRUCTURE, AND FLIGHT CONTROLS REVEALED NO EVIDENCE OF PRECRASH FAILURE OR MALFUNCTION. EXAMINATION OF THE PROPELLER REVEALED THE NUMBER TWO BLADE PITCH CHANGE ACTUATING PIN HAD FAILED DUE TO FATIGUE. THE PIN HAD BEEN INSTALLED AT OVERHAUL, 600 FLT HOURS BEFORE THE ACCIDENT, BY FOLLOWING MCCAULEY SERVICE BULLETIN 99 WHICH IS NOT APPLICABLE TO THIS MODEL PROPELLER. THE PIN WAS INSTALLED BY USING A SHORT THREADED PIN, A THIN SPACER, AND A BLIND HOLE IN THE FERRULE. THIS COMBINATION ALLOWED THE PIN TO BOTTOM OUT IN THE HOLE THUS NOT TORQUING PROPERLY AND THUS CRACKING DUE TO APPLIED LOADS.
Flight
Event TypeAccident
Event Time19:50 EST
Nearest Airport1nm N
Runway0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo
Aircraft
AircraftBeech 35-C33A
Tail NumberN4828J
Aircraft CategoryAir
DamageDestroyed
OperatorJames W Hardin
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · TSIO-520-D · Reciprocating · 285
Seats4
People & Injuries
Injury Summary3 injuries (3 fatalities)
Fatal3
Serious0
Minor0
Uninjured0
Total3
Crew 1Age 47 · Third Class
Conditions
ConditionsVMC
LightDark Night
Wind350° @ 22 kt, gusting 27 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point68 F
Altimeter29.00 inHg
Observation Time00:51
Weather SourceWFAC