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The aircraft engines performed normally during the run up, taxi and take-off. At approximately 500 feet after take-off, the pilot noticed the right hand engine manifold pressure gauge indication slowly decreasing. Thinking that the throttle friction may have slipped, he advanced the right hand throttle. There was a momentary pause in the decreasing manifold pressure reading. The right hand throttle was gradually advanced to the full power position, however, manifold pressure continued to decay. Following completion of the trouble checks the pilot shut down the right hand engine and feathered the propeller. Because the flight was only a six minute positioning flight, for maintenance purposes and the aircraft was performing to his satisfaction on one engine, the pilot elected to continue to Parafield. He advised air traffic services of the engine failure and of his intention to proceed to Parafield. The aircraft subsequently made an uneventful single engine landing. At the end of the landing roll the pilot who was wearing a headset, heard the fire warning bell. At the same time he noticed for the first time that the right hand engine bay fire warning light was illuminated. A post-flight inspection revealed substantial fire damage within the right hand engine bay forward of the firewall and a large section of the number four cylinder head was found lying in the lower cowling. The cylinder head had failed at the threaded joint of the head and barrel. Metallurgical examination showed that the fatigue failure had developed over a period of approximately 900 start/stop cycles. However, the development of the crack would probably have been visible to external inspection only during the latter 15 start/stop cycles prior to failure. The failure was probably the result of defective cylinder maintenance and assembly techniques and heat treatment used during overhaul. The engine fire had developed in the vicinity of the failed cylinder and spread throughout the engine bay fed by raw fuel through the cracked cylinder head and burnt fuel lines. It is likely that the fire self extinguished when the pilot turned the electric fuel pump off and shut the engine down. The engine bay fire warning system apparently activated and, because it had not been detected by the pilot, remained activated until after the landing. The warning system did not self-cancel after the fire abated. The aural warning system was found to be inaudible at high power settings and due to the ambient light conditions prevailing during the take-off into bright sun and glare, the steady red fire warning light was not noticed by the pilot. Approved check lists did not include a check of the fire warning system as part of the emergency procedures cockpit drill.

Download Final Report
[ Download PDF: 25KB]
General details
Date: 02 October 1989 Investigation status: Completed 
Time: 830  
Location:Adelaide Airport Investigation type: Occurrence Investigation 
State: South Australia  
Release date: 30 October 1990  
Report status: Final Occurrence category: Accident 
 Highest injury level: None 
Aircraft details
Aircraft manufacturer: Beech Aircraft Corp 
Aircraft model: 65 
Aircraft registration: VH-CLG 
Serial number: LC-330 
Type of operation: Charter 
Damage to aircraft: Substantial 
Departure point:Adelaide Airport SA
Departure time:0815
Destination:Parafield Airport SA
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