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Atlas / NTSB / CEN20LA292

NTSB CAROL · Event

Event CEN20LA292

2020-07-18 Burns Flat, Oklahoma, United States None 1 aircraft Status: Completed

Registry · N3412C

FAA Aircraft Registry record.

Make / Model

BEECH A23-24

Year of manufacture

1969 · 51 years old at event

Engine

LYCOMING I0360 SER (180 hp)

Seats / Engines

4 seats · 1 engine

Last airworthiness date

19690710

ADS-B equipped

Yes — Mode-S A3C3A6

Registrant of record

WILSON STEVE D

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

The mechanic’s improper maintenance when he reinstalled the fuel servo during the last annual inspection, which resulted in a loss of engine power during cruise flight when the throttle control rod-end disconnected from the fuel servo throttle linkage.

Factual narrative

On July 18, 2020, about 2245 central daylight time, a Beech A23-24 airplane, N3412V, was substantially damaged when it was involved in an accident near Burns Flat, Oklahoma. The pilot and his 3 passengers were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while established in cruise flight the airplane had a gradual loss of engine power. He was unable to restore engine power by switching fuel tanks, turning on the fuel boost pump, and advancing the throttle, mixture, and propeller controls full forward. The pilot made a forced landing in a grass field. After touchdown the airplane traversed over 3 large terraces, and the main landing gear collapsed when the pilot tried to swerve the airplane to avoid a tree. The horizontal stabilizer and both wings were substantially damaged during the forced landing. The airplane was examined at the accident site by a Federal Aviation Administration airworthiness inspector. Both wing fuel tanks contained about 25 gallons of 100 low-lead aviation fuel. The throttle control was very loose when moved by hand in the cockpit. A visual examination revealed that the throttle control rod-end was not connected to the fuel servo throttle linkage. (Figure 1) The required retaining bolt, washer, and self-locking nut were not located during the investigation. Figure 1. Throttle control rod-end found disconnected from the fuel servo throttle linkage. The airplane had accumulated 8.72 flight hours since the last annual inspection that was completed on October 22, 2019. The inspection authorized (IA) mechanic who had completed the annual inspection stated that the fuel servo had been removed from the engine and overhauled in conjunction with the annual inspection. The IA mechanic stated that he personally reinstalled the overhauled fuel servo on the engine, while another individual moved the throttle and mixture controls in the cockpit. The IA mechanic stated that it is his standard practice to connect both the throttle and mixture controls to the fuel servo at the same time. The IA mechanic stated that he likely reused the bolt and washer to connect the throttle control rod-end to the fuel servo throttle linkage, and that it is also possible that he reused the self-locking nut. However, he would not have reused the self-locking nut if it had fully engaged the bolt threads by hand. The IA mechanic stated that he used two wrenches to secure the self-locking nut and that he did not use a torque wrench. A review of the Beech A23-24 Maintenance Manual revealed no specific assembly instructions on how to physically connect the throttle control rod-end to the fuel servo throttle linkage. The Beech A23-24 Illustrated Parts Catalog specified that the throttle control rod-end be attached to the fuel servo throttle linkage with a 169-910021 bolt, AN960-10 washer, and MS20365-1032 self-locking nut. The pilot and his 3 passengers were on a personal night flight when the airplane had a gradual loss of engine power. The pilot was unable to restore engine power and a forced landing was completed to a grass field. The airplane’s main landing gear collapsed when the pilot intentionally swerved the airplane to avoid a tree after landing, which resulted in substantial damage to the horizontal stabilizer and both wings. A postaccident examination revealed that the throttle control rod-end was not connected to the fuel servo throttle linkage. Additionally, the required retaining bolt, washer, and self-locking nut were not located during the investigation. The airplane had accumulated 8.72 flight hours since the last annual inspection, during which the fuel servo had been removed from the engine and overhauled. It is likely that the mechanic who reinstalled the fuel servo did not adequately torque the self-locking nut that secured the retaining bolt, which allowed the self-locking nut to back-off the retaining bolt. The airplane had a partial loss of engine power when the throttle control rod-end disconnected from the unsecured retaining bolt. The pilot did not have the ability to control engine power after the throttle control rod-end disconnected from the fuel servo throttle linkage. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).

  • C Aircraft-Aircraft power plant-Engine controls-Power lever-Inoperative - C
  • C Aircraft-Aircraft power plant-Engine controls-Power lever-Incorrect service/maintenance - C
  • C Aircraft-Fluids/misc hardware-Misc hardware-Fasteners-Incorrect service/maintenance - C
  • C Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C

Verbatim from NTSB's published report. Source file NTSB_2020_CEN20LA292.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.

Browse the full corpus — academia portal ↗