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NTSB Report

August 21, 2022 · Beech F33A · N4133S

Wilder, ID

Overview

Report Status
Final with probable cause
Event Type
Accident
Date
August 21, 2022
Injury Outcomes
2 injuries (2 minor injuries)
Location
Wilder, ID
Aircraft
Beech F33A (1975)
Tail Number
N4133S
Injuries
Minor
Aircraft Damage
Substantial
NTSB Number
WPR22LA314

The airplane sustained a catastrophic engine failure shortly after takeoff due to a separated crankshaft counterweight. The pilot performed a forced landing, during which the airplane sustained substantial damage. The engine had been overhauled about 14 years and 950 flight hours before the accident. Examination of the remaining counterweights revealed that, during that overhaul, some of their retaining pins had been installed back to front. According to the engine manufacturer, such installation has been known to cause failure of the counterweights and the catastrophic damage observed. The correct installation is documented in the engine maintenance manual and reiterated in a service bulletin that was published 5 years before the engine was overhauled.

NTSB Probable Cause

Catastrophic engine failure during the initial climb due to an incorrectly installed crankshaft counterweight retaining ring.

Full Narrative

On August 20, 2022, about 1800 mountain daylight time, a Beech F33A, N4133S was substantially damaged when it was involved in an accident near Wilder, Idaho. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and a mechanic had been performing maintenance, attempting to resolve a problem where the engine would intermittently shudder during flight. After checking the cylinder compression, replacing a set of spark plugs, cleaning the fuel injectors, and confirming the engine timing, they decided to perform a test flight. The engine runup and takeoff were uneventful, and during the initial climb they monitored the engine instrument gauges, and all indicated nominal values. A short time later, the engine shook violently, and stopped producing power. They performed a forced landing into a field, and the airplane sustained damage to the lower forward fuselage and both wings. The airplane was powered by an IO-520-BA engine manufactured by Continental Motors, and overhauled by T.W. Smith Engine Company in 1998, about 950 flight hours before the accident. During the 14-year period leading up to the accident, routine maintenance was performed on the engine, with no work that would have required opening the crankcase or removing any cylinders. The engine was equipped with two sets of moving counterweights mounted to crankshaft blades adjacent to the journals of cylinder Nos. 1 and 2, and 3 and 4. Each counterweight was attached to their respective crankshaft blade by two pins housed within bushings and held in place at their ends with retaining plates and internal retaining “snap” rings. Examination of the engine revealed a large hole in the upper rear section of the crankcase, next to the Nos. 1 and 2 counterweights. Both counterweights had separated from their respective blades and showed similar damage signatures, with one counterweight mounting hole intact with its bushing in place, and the other split open with its material formed outwards. The Nos. 1 and 2 connecting rod caps had detached, and the rods remained attached to their respective pistons. Remnants of the connecting rod caps and bolts, along with two counterweights, fragments of counterweight bushings, a single counterweight pin, and four retaining rings and plates were found in the oil sump. Examination of the fracture surfaces of the remnants revealed features consistent with ductile overload, including granular and rough separation areas, bolt necking along with smear and bending damage consistent with impact. There was no evidence of scoring or heat distress to the rod journals or rod bearings contact surfaces for cylinder Nos. 1 and 2. The engine was then completely disassembled, and although the two counterweights for cylinder Nos. 3 and 4 were intact and essentially undamaged, one retaining ring, retainer plate, and pin were missing. The Continental Maintenance Manual applicable to the engine gives specific instructions for the installation of the counterweight assembly. It states that the retaining rings, which are stamp-cut, have a sharp side and a beveled side, and should be installed with the sharp side out. The retaining ring ears should be installed towards the crankshaft centerline, and to confirm proper fitment after installation the gap between the ears should be no less than 0.179 inches (Figure 1). Figure 1 – One of the counterweights with its retaining plates and rings, showing the incorrectly installed ring on the right. Examination of the engine revealed that one retaining ring on each of the remaining counterweights was installed incorrectly with the sharp side in, and both had ear-gaps of 0.11 (Figure 1) and 0.14 inches respectively. Continental Service Bulletin (SB) M93-4, issued in February 1993, reiterates the importance of thorough inspection and proper assembly of crankshaft counterweights during engine overhaul, or any time the crankshaft is removed from the engine. It warns that improper installation of the bushings, retaining plates, or retaining rings will cause engine failure. The SB also states that the retaining rings should be fully seated in the bushing bore grooves with the sharp edge facing out.

Flight

Event TypeAccident
Event Time17:00 PDT
Nearest AirportPARMA (5nm SSE)
Runway12/3
Runway Length2700 ft
Runway Width50 ft
Flight Plan FiledNone
Flight Plan ActivatedNo
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBeech F33A
Tail NumberN4133S
Aircraft CategoryAir
DamageSubstantial
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsContinental · IO-520-BA · Reciprocating · 285
Seats5

People & Injuries

Injury Summary2 injuries (2 minor injuries)
Fatal0
Serious0
Minor2
Uninjured0
Total2
Crew 1Age 43 · Second Class · Minor
Crew 2Age 64 · Second Class · Minor

Conditions

ConditionsVMC
LightDaylight
Wind260° @ 6 kt
Visibility10 sm
CeilingNone
Temperature / Dew Point55 F
Altimeter29.85 inHg
Observation Time17:56
Weather SourceWFAC

Appendix: Source Data