Date & Time: Sep 4, 1998 at 2040 LT
Registration:
N600JB
Flight Type:
Positioning
Survivors:
No
Schedule:
Donegal Springs – Philadelphie
MSN:
60-0001
YOM:
1967
Crew on board:
1
Crew fatalities:
1
Pax on board:
0
Pax fatalities:
0
Other fatalities:
0
Total fatalities:
1
Captain / Total flying hours:
1185
Captain / Total hours on type:
398
Circumstances:
The airplane departed at night after maintenance was performed on the left engine. The pilot attempted to return to the airport and while on base leg struck the ground inverted and nose down. The left engine propeller was found feathered. On the left engine, the # 5 cylinder was off the engine and the # 5 piston with the connecting rod still attached were found nearby. Interviews revealed that during maintenance, the # 1,3,5,and 6 cylinders had been removed and reinstalled; however, the # 5 cylinder had not been tightened. Several people had worked on the airplane at various stages of the work. The maintenance facility did not have a system to pass down what had been accomplished, and the FAA did not require the tracking of work accomplished in other than 14 CFR Part 121, or 14 CFR Part 145 facilities.
Probable cause:
The failure of the pilot to maintain airspeed during a precautionary landing which resulted in a loss of control while operating with one engine shutdown. An additional cause was the improper maintenance procedures that resulted in the #5 cylinder not being tightened down. A factor was the night conditions.
Final Report:
N600JB.pdf105.29 KB