NTSB CAROL · Event
Event WPR22LA314
Aircraft involved
Probable cause & findings
Catastrophic engine failure during the initial climb due to an incorrectly installed crankshaft counterweight retaining ring.
Factual narrative
On August 20, 2022, about 1800 mountain daylight time, a Beech F33A, N4133S was substantially damaged when it was involved in an accident near Wilder, Idaho. The pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and a mechanic had been performing maintenance, attempting to resolve a problem where the engine would intermittently shudder during flight. After checking the cylinder compression, replacing a set of spark plugs, cleaning the fuel injectors, and confirming the engine timing, they decided to perform a test flight. The engine runup and takeoff were uneventful, and during the initial climb they monitored the engine instrument gauges, and all indicated nominal values. A short time later, the engine shook violently, and stopped producing power. They performed a forced landing into a field, and the airplane sustained damage to the lower forward fuselage and both wings. The airplane was powered by an IO-520-BA engine manufactured by Continental Motors, and overhauled by T.W. Smith Engine Company in 1998, about 950 flight hours before the accident. During the 14-year period leading up to the accident, routine maintenance was performed on the engine, with no work that would have required opening the crankcase or removing any cylinders. The engine was equipped with two sets of moving counterweights mounted to crankshaft blades adjacent to the journals of cylinder Nos. 1 and 2, and 3 and 4. Each counterweight was attached to their respective crankshaft blade by two pins housed within bushings and held in place at their ends with retaining plates and internal retaining “snap” rings. Examination of the engine revealed a large hole in the upper rear section of the crankcase, next to the Nos. 1 and 2 counterweights. Both counterweights had separated from their respective blades and showed similar damage signatures, with one counterweight mounting hole intact with its bushing in place, and the other split open with its material formed outwards. The Nos. 1 and 2 connecting rod caps had detached, and the rods remained attached to their respective pistons. Remnants of the connecting rod caps and bolts, along with two counterweights, fragments of counterweight bushings, a single counterweight pin, and four retaining rings and plates were found in the oil sump. Examination of the fracture surfaces of the remnants revealed features consistent with ductile overload, including granular and rough separation areas, bolt necking along with smear and bending damage consistent with impact. There was no evidence of scoring or heat distress to the rod journals or rod bearings contact surfaces for cylinder Nos. 1 and 2. The engine was then completely disassembled, and although the two counterweights for cylinder Nos. 3 and 4 were intact and essentially undamaged, one retaining ring, retainer plate, and pin were missing. The Continental Maintenance Manual applicable to the engine gives specific instructions for the installation of the counterweight assembly. It states that the retaining rings, which are stamp-cut, have a sharp side and a beveled side, and should be installed with the sharp side out. The retaining ring ears should be installed towards the crankshaft centerline, and to confirm proper fitment after installation the gap between the ears should be no less than 0.179 inches (Figure 1). Figure 1 – One of the counterweights with its retaining plates and rings, showing the incorrectly installed ring on the right. Examination of the engine revealed that one retaining ring on each of the remaining counterweights was installed incorrectly with the sharp side in, and both had ear-gaps of 0.11 (Figure 1) and 0.14 inches respectively. Continental Service Bulletin (SB) M93-4, issued in February 1993, reiterates the importance of thorough inspection and proper assembly of crankshaft counterweights during engine overhaul, or any time the crankshaft is removed from the engine. It warns that improper installation of the bushings, retaining plates, or retaining rings will cause engine failure. The SB also states that the retaining rings should be fully seated in the bushing bore grooves with the sharp edge facing out. The airplane sustained a catastrophic engine failure shortly after takeoff due to a separated crankshaft counterweight. The pilot performed a forced landing, during which the airplane sustained substantial damage. The engine had been overhauled about 14 years and 950 flight hours before the accident. Examination of the remaining counterweights revealed that, during that overhaul, some of their retaining pins had been installed back to front. According to the engine manufacturer, such installation has been known to cause failure of the counterweights and the catastrophic damage observed. The correct installation is documented in the engine maintenance manual and reiterated in a service bulletin that was published 5 years before the engine was overhauled. 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).
- — Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng rear section-Incorrect service/maintenance
- — Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel
Verbatim from NTSB's published report. Source file
NTSB_2022_WPR22LA314.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 (stall, engine failure, 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 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- 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…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- 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.
Browse the full corpus — academia portal ↗