NTSB Identification: LAX02FA148.
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Accident occurred Saturday, April 27, 2002 in OAK SHORES, CA
Probable Cause Approval Date: 09/29/2004
Aircraft: Beech C23, registration: N9180S
Injuries: 3 Fatal,1 Serious.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

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.

Full narrative available

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