NTSB CAROL · Event
Event NYC94LA129
Aircraft involved
Probable cause & findings
Inadequate maintenance by which undertorquing of the accessory gear retaining bolt resulted in fatigue failure of the bolt and the subsequent loss of engine power.
Factual narrative
On July 15, 1994, at 1445 eastern daylight time, a Pitts S-15, N515TN, registered to and piloted by Teresa Nagy, sustained substantial damage when it impacted the terrain at the Kentmore Airport, Stevensville, Maryland. The pilot received minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed. The flight was operated under 14 CFR Part 91. The airplane's engine lost partial power just after takeoff. The pilot was attempting to return to the airport, when the engine lost total power. The pilot made a forced landing in a field, the airplane's wing struck a tree, and the airplane nosed over. According to the pilot's statement on the NTSB Form 6120.1/2: I applied power and began climb at 100 IAS...at approximately 500 feet I began to gently reduce power...just prior to the power reduction I thought I heard a "surge" but no vibration or any indication of problem. When I reduced the power the engine stopped, I immediately re applied full throttle-no result.... The engine was removed from the airplane, and retained for further examination. On October 6, 1994, the engine from N515TN, was disassembled under the supervision of NTSB Investigator, Margaret Napolitan, at Lycoming Engine's facilitates, Williamsport, Pennsylvania. The engine disassembly revealed that engine continuity could not be established as result of the crankshaft gear (13S19646) becoming disconnected from the crankshaft. The accessory gear retaining bolt (STD-2213) was fractured, and a crack was observed in the root of the adjacent thread. According to Lycoming, "...this is consistent with overtorqueing of the bolt." The head of the bolt was worn from coming in contact with the oil pump drive after it was fractured and while it was encapsulated in the crankshaft gear counterbore. The lockplate (LW-18639) was worn, a portion of it was missing, and was not recovered. The dowel (STD-1065), used to position the gear for internal timing, was fractured. The fracture surface of the dowel displayed crack arrest lines (beach marks). The engine disassembly also revealed that the connecting rods were not torqued to the specified 40 foot pounds. Several bolts used in various locations were not the correct parts, and safety wire was not used were required. The following parts to include, two pieces of the accessory gear retaining bolt, P/N STS-2213; the separated dowel pin. P/N STD-1065; and lockplate, P/N STD-1065, were sent to the NTSB Materials Laboratory, Washington, DC. Examination of the accessory gear retaining bolt, revealed that the fracture on the head portion of the bolt and the bolt identification markings were completely obliterated by post separation mechanical damage. The fracture face on the threaded portion of the bolt, revealed features typical of fatigue cracking over approximately 90 percent of the bolt cross section. A secondary crack was found located in the root of the third tread from the fracture surface. The examination of the bolt revealed no material defects at the fracture origin. Material of the bolt and its hardness were found to be within the specified requirements. Examination of the dowel pin revealed that most of the fracture contained well defined crack arrest positions consistent with a fatigue fracture mechanism. The fracture features in the final fracture zone were typical of overstress separations. A band of fretting wear was found in the area adjacent to the fracture surface. THE AIRPLANE'S ENGINE LOST TOTAL POWER JUST AFTER TAKEOFF WHEN THE PILOT REDUCED THE THROTTLE. THE PILOT RE-APPLIED FULL THROTTLE WITH NO RESULT. DURING THE FORCED LANDING IN A FIELD, THE AIRPLANE'S WING STRUCK A TREE, AND THE AIRPLANE NOSED OVER. EXAMINATION OF THE ENGINE REVEALED THAT THE CRANKSHAFT GEAR (13S19646) BECAME DISCONNECTED FROM THE CRANKSHAFT DUE TO A BROKEN BOLT. METALLURGICAL EXAMINATION OF THE ACCESSORY GEAR RETAINING BOLT (P/N STD-2213), AND DOWEL PIN (P/N STD-1065) REVEALED THAT THEY SEPARATED AS A RESULT OF HIGH CYCLE FATIGUE MECHANISM, MOST LIKELY CAUSED BY INSUFFICIENT TORQUE OF THE BOLT. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1994_NYC94LA129.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (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.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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