1. Is Your Aircraft
Talking to You?
Listen!
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Cathy Gagne, AS-70

2. General Aviation (GA) Safety
• About 1,500 accidents,
475 people killed annually
• GA on NTSB Most Wanted List
• Personal flying sector of GA:
greatest activity, proportion of
accidents
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3. Top Occurrence Categories
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Fatal accidents in GA personal flying sector, 2000-2011

4. Discussion of Accident Cases
• Completed cases: common
causes, factors, and scenarios
• Used as educational tools
• Not intended to admonish accident
pilots
• Intended to help other pilots learn
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5. Scenario 1: Beech 36
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6. Accident Synopsis
• Pilot/owner planned personal
round-trip night IFR flight
• Complete engine power loss on
return leg
• Forced landing, pilot fatal
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7. Pilot
• Sole owner/operator
• About 2,300 total flight hours
• Flight instructor, with multi-engine
and instrument ratings
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8. Airplane History
• Engine:10 hours since overhaul
at time of pilot’s purchase
• Pilot added about 50 hours prior
to accident
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9. Airplane History
• Engine oil pressure problem
several weeks before accident
• Mechanic: Overhaul issue
• 1 week later, pilot said engine
“seemed OK”
• No evidence of corrective actions
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10. Accident Flight
• No outbound leg problem reports
• Midnight taxi out, return to FBO
• Pilot requested mechanic
(unavailable until morning)
• Pilot then opted to depart, IFR
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11. Accident Flight
• Complete loss of power 9 miles
from destination
• Night IMC forced landing
• Engine examination: crankshaft
fracture
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12. Bearing, Crankshaft Damage
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13. Missed Opportunities
• Actively address problem
• Maintenance troubleshooting
• Do not fly until resolved
• Take conservative approach
• Take all indications seriously
• Ground airplane until problem
identified and resolved
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14. What Pilots Can Learn
• Resist external pressures to fly
• Identify, assess all risks
• Maintenance: Don’t talk self into
believing what you want to hear
• Problem indications not always
obvious
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15. What Pilots Can Learn
• Conservative approach can be
inconvenient, costly (but is safer!)
• To avoid inappropriate choices:
• Consider options and outcomes
• Prevent outside factors from
adversely influencing decisions
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16. What Pilots Can Learn

17. Scenario 2 – Vans RV-6
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18. Accident Flight
• Vans RV-6
• Departed 20 minutes before
accident
• Private pilot was fatally injured
• Maintenance test flight
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19. Airplane History
• Oil leak discovered 6 weeks earlier
• Source of leak: propeller governor
high pressure oil line
• Weld “repair” was made
• Pilot departed for test flight, but
chose to conduct cross-country flight
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20. Accident Site
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21. Wreckage Examination
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22. Missed Opportunities
• Stick to maintenance test plan
• Review service bulletins,
airworthiness directive
• Be prepared to execute
emergency procedures
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23. What Pilots Can Learn
• If signs of problem persist, be
prepared to discontinue flight
• Review, practice emergency
procedures
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24. Scenario 3 – Beech G35
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Photo from sales advertisement

25. Scenario 3 – Beech G35
• 1956 Beech Bonanza (G model)
• Recent purchase by two pilots
• Lost engine at destination
• Owner/pilot: 40 hours in BE35
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26. Airplane History
• 3,350 hours total time airframe
• 80 hours since major overhaul on
Continental E-225 powerplant
• Owners: Multiple mechanics
troubleshooting oil leaks
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27. Airplane History
• Mechanics found,
fixed some leaks;
troubleshooting
others
• Owners monitored;
mechanics
rechecked daily
• Oil temperature,
oil pressure normal,
no contamination
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Photo from sales advertisement

28. Flight History
• Owner/pilot (low time BE35) flew
RYY to CHS (235 nm) day VFR
• At CHS: remark about oil leak
• Checked oil level, departed on
return flight to RYY
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29. Flight History
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30. Flight History – Outcome?
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31. Flight History – Outcome
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32. Findings
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• Engine teardown: No evidence of
case fretting or bearing damage
• Wrong type of case thread (not
silk) used at overhaul
• Eventual consequences had it
continued to fly? Depends …

33. What Pilots Can Learn
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• Troubleshooting may take time
• Even trusted sources may
provide conflicting information
• Decisions: not easy, not cheap,
not always obvious what is right

34. In Conclusion
• This issue, others
covered in SAs
• Hot links (or short
urls) to find reports,
dockets, other
resources
• www.ntsb.gov
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35. Thank You!
Questions? Discussion?
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