Friday, September 25, 2015

Loss of Engine Power (Total): Beech S35 Bonanza, N193Q; fatal accident occurred September 25, 2015 near Stevens Field Airport (KPSO), Pagosa Springs, Archuleta County, Colorado

View of Fuselage and Left Wing – Destroyed by Postaccident Fire


View of Steel Post, Gravel Road, and Debris Path


View of Steel Post with White Paint Transfer


View of Main Wreckage in Field


View of Main Wreckage in Field


View of Engine in Field


View of Separated 3-Blade Propeller Assembly in Field


View of Half Engine Crankcase, Engine Crankshaft, and Engine Camshaft  -Continental Motors


View of No. 4 Main Bearing and Journal -Continental Motors


View of No. 4 Main Bearing and Journal -Continental Motors


View of No. 4 Main Bearing and Journal -Textron 


View of No. 4 Main Bearing Support -Textron


View of No. 6 Connecting Rod Crankshaft Journal -Continental Motors


View of No. 6 Connecting Rod Crankshaft Journal  -Textron


View of No. 6 Damaged Connecting Rod  -Continental Motors




Wreckage Diagram (Textron)




Continental Engine Information


Need For Speed website information.

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Denver, Colorado
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama 

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N193Q


Location: Pagosa Springs, CO
Accident Number: CEN15FA424
Date & Time: 09/25/2015, 1126 MDT
Registration: N193Q
Aircraft: BEECH S35
Aircraft Damage:Destroyed 
Defining Event: Loss of engine power (total)
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal

Analysis

On the day before an air race competition, the accident pilot and another pilot decided to execute a practice circuit of the race course in their airplanes. As the two airplanes entered the course, the accident airplane was behind the other airplane. After they passed the first course waypoint, the accident pilot radioed the other pilot and stated that his airplane’s engine had lost power and that the airplane was going down. No further communications were heard from the accident airplane. Witnesses observed white smoke coming from the underside of the airplane before they lost sight of it. Examination of the accident site indicated that the pilot was attempting to land on a gravel road when the airplane impacted a steel pole adjacent to the road and traveled about 200 yards before coming to rest inverted. Examination of the engine showed that the No. 6 connecting rod failed due to oil starvation. The oil starvation resulted from movement of the No. 4 main crankshaft bearing to a position where it blocked the oil transfer passage to the No. 6 connecting rod. The engine thru-bolts were improperly torqued by unknown maintenance personnel, and this allowed the No. 4 main bearing movement to occur. In addition, disassembly of the engine revealed that unapproved pistons had been installed. However, the unapproved pistons were not related to the engine failure.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
Improper engine assembly by unknown maintenance personnel, which resulted in the failure of the No. 6 connecting rod due to oil starvation from the shifting of the crankshaft's No. 4 main bearing.

Findings

Aircraft
Recip engine power section - Failure (Cause)

Personnel issues
Installation - Maintenance personnel (Cause)

Environmental issues
Fence/fence post - Contributed to outcome

Factual Information

HISTORY OF FLIGHT

On September 25, 2015, about 1126 mountain daylight time, a Beech S35 single-engine airplane, N193Q, impacted terrain following a loss of engine power while maneuvering near Pagosa Springs, Colorado. The private pilot and passenger sustained fatal injuries. The airplane was destroyed by the impact and postaccident fire. The airplane was registered to and operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The airplane departed the Durango-La Plata County Airport (DRO), Durango, Colorado, at an unknown time, and was enroute to the Stevens Field Airport (PSO), Pagosa Springs, Colorado.

The accident airplane departed DRO with another airplane, and the two pilots planned to participate in an air race competition in the Pagosa Springs area on September 26th. Prior to landing at PSO, the pilots in the two airplanes, who were communicating via airplane radio, decided to execute a circuit in the Pagosa Springs air race course. As the airplanes entered the course, the accident airplane was behind the other airplane. After the first course waypoint, the accident pilot radioed the other pilot and stated the engine lost power, and the airplane was going down. No further communications were heard from the accident airplane.

Witnesses, who were located in the Pagosa Springs area, reported observing white smoke coming from the underside of the accident airplane. The airplane turned left, descended below rising terrain, and a smoke plume was then seen shortly thereafter. Witnesses stated the sky was clear and the winds were calm.

PERSONNEL INFORMATION

The pilot, age 70, held a private pilot certificate, with airplane single-engine land, airplane multi-engine land, and rotorcraft - helicopter ratings. In addition, the pilot held an airframe and powerplant mechanic's certificate. The pilot's most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on August 19, 2014, with a limitation of "Must have available glasses for near vision."

According to the pilot's FAA medical certificate application, he reported a total of 5,640 flight hours and 20 hours in the previous six months. The pilot's logbook was not located during the investigation.

AIRCRAFT INFORMATION

The accident airplane was a 1964 Beech S35, serial number D-7708. The airplane was powered by a Continental Motors IO-520-B reciprocating engine and a Hartzell controllable pitch propeller. The airplane was issued a standard airworthiness certificate on December 7, 1964.

The maintenance logbooks were not located during the investigation. The total airframe and engine time could not be determined. According to a family member, the airplane underwent its most recent annual inspection in November 2014. The family member reported that approximately 2 or 3 years prior, the engine cylinders had been chromed. The family member was not aware of any additional maintenance on the airplane.

The following information was noted on the engine oil filter: Date: June 9, 2015; Tach Time: 2037.3.

METEOROLOGICAL INFORMATION

At 1153, the DRO automated surface observing system, located approximately 45 miles west of the accident site, reported the wind calm, visibility 10 miles, sky clear, temperature 21 degrees Celsius, dew point 4 degrees Celsius, and an altimeter setting of 30.44 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed the airplane impacted a 4-inch steel pole adjacent to a gravel road. The steel pole displayed white paint transfer, and paint chips were found near the pole. The airplane then traveled about 200 yards before coming to rest inverted in a field. The main wreckage consisted of the fuselage, both wings, and empennage. The engine separated from the airframe and came to rest within the debris field. The three-blade propeller assembly separated from the engine and came to rest approximately 75 feet from the main wreckage. The fuselage and cockpit were consumed by postaccident fire.

The left wing came to rest inverted and partially attached to the fuselage. The flap was attached and found in the extended position. The aileron remained attached to the wing. The left main landing gear was found retracted and the gear door was closed. During recovery of the airplane, approximately 25 to 30 gallons of fuel was drained from the left wing tank.

The right wing came to rest inverted and partially attached to the fuselage. The flap was attached and found in the extended position. The aileron remained attached to the wing, and the outboard section displayed thermal damage. The right main landing gear was found retracted and displayed thermal damage. The right wing fuel tank was consumed by fire.

The fuselage, cockpit, instrument panel, and cockpit controls were consumed by fire. Three seat frames were located within the fuselage area. One seat belt buckle/tag and shoulder harness bayonet fitting were identified. The seat belt buckle and tag were clasped, and the shoulder harness bayonet was not engaged in the clasped buckle. The main cabin door latch bolt was retracted and the upper latch bolt hook was not extended. The position of the latch bolt and bolt hook were consistent with the door in an unlocked position.

The empennage was partially consumed by fire. The right stabilizer was bent upward, and the elevator remained partially attached to the stabilizer. The elevator was fractured mid-span. The left stabilizer displayed thermal damage, and the elevator remained attached.

Flight control continuity was established from the cockpit to the respective flight control surfaces. The down elevator flight control cable arm was separated from the pitch idler bellcrank in the empennage. The pitch trim actuator was extended 15/16 inches, which corresponded to a trim tab setting of 0 to 5 degrees trailing edge up. The right flap actuator nut was consumed by fire. The left flap actuator was extended 6 1/4 inches, which corresponded to a flaps down (30 degrees) position.

The engine separated from the engine mount. The upper engine cowling was separated from the fuselage and came to rest near the engine. The left interior cowling door and exterior cowling doors were coated with oil. Oil streaking was noted in a forward to aft direction.

The propeller assembly separated near the crankshaft propeller flange. The propeller blades remained attached to the propeller hub. One propeller blade was bent aft about mid-span, and two propeller blades were curled aft. Scratches were noted along the length of the propeller blades, and no leading edge damage was found on the blades.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the pilot and passenger by the Rocky Mountain Forensic Services, PLLC, Loma, Colorado. The immediate causes of death were listed as smoke and soot inhalation as a result of an accident.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The pilot's toxicological tests were positive for the following: 25 percent carbon monoxide detected in blood (heart), 0.7 ug/ml cyanide detected in blood (heart), Azacyclonol detected in urine, Fexofenadine detected in urine, and Ibuprofen detected in urine.

Hydrogen cyanide, otherwise known as cyanide, can be produced in high concentrations from the burning of nitrogen containing polymers. Cyanide is a highly toxic poison. Likewise, carbon monoxide is produced by the incomplete burning of various substances. Fexofenadine, commonly known as Allegra, is a non-sedating antihistamine used to relieve the allergy symptoms of seasonal allergic rhinitis (hay fever). Azacyclonol is a metabolite of fexofenadine. Ibuprofen, commonly known as Advil, Motrin, and others, is available as over-the-counter (OTC) or prescription strength. OTC ibuprofen is used to reduce fever and to relieve minor aches and pain from headaches, muscle aches, arthritis, the common cold, etc.

TESTS AND RESEARCH

On January 20, 2016, at the facilities of Continental Motors, Inc., Mobile, Alabama, the engine was examined under the supervision of the NTSB. Visual examination of the engine showed a hole in the engine crankcase above the No. 6 cylinder. The engine was disassembled for further investigation.

Disassembly of the engine revealed the Nos. 5 and 6 connecting rods were fractured and separated from the engine crankshaft. Debris, consistent with connecting rod and bearing material, was located in the engine oil sump. The No. 5 connecting rod crankshaft journal appeared to be undamaged. The No. 6 connecting rod crankshaft journal displayed thermal damage and rolled metal, which covered/blocked the oil transfer passage. The crankcase thru-bolts torque was measured, and the torque was found less than Continental Motors specified torque requirements. The No. 4 main bearing supports showed evidence consistent with fretting. The No. 4 main bearing journal displayed evidence of bearing shift and movement within the journal area consistent with the main bearing partially blocking or blocking the oil transfer passage to the No. 6 connecting rod. The No. 4 main bearing showed signatures of deterioration and delamination.

The engine pistons were removed and examined. The piston castings showed the following "NFS-C 550" casted on the inside of the piston head, and "C-510" etched near the piston pin. An internet search of NFS revealed the pistons were manufactured by Need For Speed (NFS) Pistons. According to the manufacturer website, the pistons are "Not Approved For Certified Aircraft Use", and are for "Experimental Aircraft and Airboat Use Only." According to the NFS company, the pistons were shipped to the pilot on February 2, 2011. 

History of Flight

Maneuvering-low-alt flying
Loss of engine power (total) (Defining event)

Emergency descent
Collision with terr/obj (non-CFIT) 

Pilot Information

Certificate: Private
Age: 70, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Helicopter
Restraint Used:
Instrument Rating(s):None 
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 08/19/2014
Occupational Pilot:No 
Last Flight Review or Equivalent:
Flight Time: (Estimated) 5640 hours (Total, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N193Q
Model/Series: S35
Aircraft Category: Airplane
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: D-7708
Landing Gear Type: Retractable - Tricycle
Seats: 3
Date/Type of Last Inspection: 11/01/2014, Annual
Certified Max Gross Wt.: 3307 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-520-B
Registered Owner: BENNETT ROBERT D
Rated Power: 285 hp
Operator: BENNETT ROBERT D
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: DRO, 6689 ft msl
Distance from Accident Site: 45 Nautical Miles
Observation Time: 1153 MDT
Direction from Accident Site: 270°
Lowest Cloud Condition:Clear 
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.44 inches Hg
Temperature/Dew Point: 21°C / 4°C
Precipitation and Obscuration: No Precipitation
Departure Point: Durango, CO (DRO)
Type of Flight Plan Filed: None
Destination: Pagosa Springs, CO (PSO)
Type of Clearance: None
Departure Time:  MDT
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 37.110000, -106.570000

NTSB Identification: CEN15FA424 
14 CFR Part 91: General Aviation
Accident occurred Friday, September 25, 2015 in Pagosa Springs, CO
Aircraft: BEECH S35, registration: N193Q
Injuries: 2 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. 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.

On September 25, 2015, about 1126 mountain daylight time, a Beech S35 single-engine airplane, N193Q, impacted terrain following a loss of engine power while maneuvering near Pagosa Springs, Colorado. The private pilot and passenger sustained fatal injuries. The airplane was destroyed by impact and postaccident fire. The airplane was registered to and operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. The airplane departed the Durango-La Plata County Airport (DRO), Durango, Colorado, at an unknown time.

The airplane departed DRO with another airplane enroute to Stevens Field Airport (PSO), Pagosa Springs, and the two pilots planned to participate in an air race competition in the Pagosa Springs area on September 26th. Prior to landing at PSO, the pilots in the two airplanes decided to execute a circuit in the Pagosa Springs air race course. As the airplanes entered the course, the accident airplane was behind the other airplane. After the first course waypoint, the accident pilot radioed the other pilot and stated the engine lost power, and the airplane was going down. No further communications were heard from the accident airplane. 

Witnesses, who were located in the Pagosa Springs area, reported observing white smoke coming from the underside of the accident airplane. The airplane turned left, descended below rising terrain, and a smoke plume was then seen shortly thereafter. Witnesses stated the sky was clear and the winds were calm.

Examination of the accident site revealed the airplane impacted a steel pole adjacent to a gravel road. The airplane then traveled about 200 yards before coming to rest inverted in a field. The main wreckage consisted of the fuselage, both wings, and empennage. The engine separated from the airframe and came to rest within the debris field. The three-blade propeller assembly separated from the engine and came to rest approximately 75 feet from the main wreckage. The fuselage and cockpit were consumed by postaccident fire. Preliminary examination of the engine revealed the crankcase contained a hole above the number 6 cylinder. The engine was retained for further examination.


Robert Dean ("Bobby") Bennett was born to Delia Belle Smith and Robert Lee Bennett on April 1, 1945, in Gorman, Texas. He died unexpectedly September 25, 2015 at the age of 70, in Pagosa Springs, CO in a small aircraft accident. Bobby was preceded in death by his mother, Delia, brother Phillip Bennett, and stepdaughter, Sarah Hopkins. Bobby was survived by his father, Robert, sisters Carolyn Bennett-Norwood, Paula Bennett-Baugess and Pam Bennett-Conditt, daughters Lorie Houston and husband William, Deanna Doss and husband Justin, sons Robert Cast and wife Angela, John Bennett and wife B'Randa, James Bennett and wife Jaime; step daughter Lauren McGee and husband Anthony, grandchildren Skylar, Carra, and Torie Davis, Rhett and Ashlyn Cast, Cloie Summers, Jeremy Bennett, Logan and Peyton Young, Braden Bay, Cordell and Brooklynn Moore, Dalton and Harleigh Doss, great granddaughter, Braisey, his partner in flight and life the last 18 years, AnnElise Bennett, many loved nieces, nephews and a legion of friends. Bobby served active duty in the Vietnam War with the 1st Calvary Division of the US Army where he was a helicopter mechanic receiving the Republic of Vietnam Campaign Medal, National Defense Service Medal, Air Medal with 4 Oak Leaf Clusters, Vietnam Service Medal with 2 Bronze Service Stars, Purple Heart and Army Commendation Medal. Robert Dean Bennett was born to fly. Even when his feet were on the ground, his mind was on the sky. He was a rare man that lived his passion for aviation 24/7 as a Lead Mechanic for 28 years at Southwest Airlines and in his off-duty time as a professional skydiver, pilot and airplane mechanic. Over his lifetime he mentored and influenced numerous people to become aviators, infecting them with his passion. Bobby was beloved by many for his can-do attitude, and a spontaneous zest for life and adventure. He was a man that never knew a stranger, loved people and their stories. He loved to travel and see the world. He was happiest when flying, noticing from bird's eye perspective the landscape paintings done with God's hand. His childlike enthusiasm showed through his smile when he flew. He had been air racing for many years but he cherished the people he met and the friendships he made more than the many trophies on his shelves. He loved his family and friends more than flying, they were his reason for living. He was a hero in war and in life. He was a survivor. He was a good man and has left a void that can never be filled. In keeping with his larger than life personality a memorial service of historic proportions will be held at 4 pm Sunday, October 18, 2015 at 9600 Prairie Chapel Road, Crandall, Tx, 75114. The dress code is boots, jeans, and your favorite cowboy hat (casual). The family will be receiving guests before and after the ceremony. In lieu of flowers, memorial donations may be made in his name to OperationOnceInALifetime.com

The Archuleta County Sheriff’s Office has released additional information concerning the fatal plane crash that occurred late Friday morning.

Two died when the plane, a Bonanza Beechcraft, crashed south of Pagosa Springs shortly before 11:30 a.m. on Friday, Sept. 25.

The ACSO confirmed that there were two occupants in the aircraft, with both being from out of state. A female occupant has been positively identified, but her identity will not be released until the identification of a male occupant is confirmed at an autopsy scheduled for Tuesday.

According to an ACSO statement released Sunday afternoon, “It is believed that the pilot was having mechanical problems, which he radioed to a fellow pilot who was flying in his own plane about eight to nine miles south (in front) of the deceased.”

The statement further notes that witnesses on the ground reported that there was white smoke coming from the airplane just prior to the crash and that the pilot was banking hard to the left to turn around, possibly in an attempt to land on a nearby gravel road.

The initial investigation was completed by the ACSO, and the department transferred the case to the National Transportation Safety Board (NTSB) for further investigation on Sept. 26. The wreckage was removed from the site and transported to a facility for further review and investigation.

At approximately 3:30 p.m. on Sunday, Sept. 27, the NTSB and Federal Aviation Administration (FAA) released the scene of the accident back to local law enforcement. The public is reminded that the crash site is on private property and should not be visited.

The ACSO, Pagosa Fire Protection District, Emergency Medical Services and the coroner responded and provided assistance on scene immediately following the crash.

Two people died when a small plane crashed Friday morning in Archuleta County, according to a statement from the Archuleta County Sheriff’s Department. 

It went down around 11:30 a.m. near U.S. Highway 84 south of Pagosa Springs.

“We received the report almost immediately,” said Undersheriff Tonya M. Hamilton.

The two people in the plane were preparing for an airplane race by flying the course, she said.

She did not know the make and model of the airplane.

The Archuleta County Sheriff’s Department, Pagosa Fire Protection District, emergency services and the Archuleta County coroner all responded to the crash scene, and sheriff’s deputies performed an initial investigation, the statement said.

The National Transportation Safety Board was to take over the investigation Friday evening, Hamilton said.

Both people in the plane were from out of state. Their names have not been released, she said. 

Source: http://www.durangoherald.com

PAGOSA SPRINGS, CO (KRQE) – On Friday, September 25, 2015, at approximately 11:26 am, local officials were notified of a small plane that had crashed at an undisclosed area within Archuleta County.  It was confirmed that there were two occupants of the small aircraft, both from out of state, and both had perished in the crash. Names are being withheld at this time pending further notification of family. An initial investigation was performed by the Archuleta County Sheriff’s Department and the scene has been cordoned off until the National Transportation Safety Board arrives, at which time the investigation will be handed over to them.

PAGOSA SPRINGS, Colo. (AP) — A small plane with two people on board has crashed in a field near Pagosa Springs. Both were killed in the crash.  FAA spokesman Allen Kenitzer says a Beech 35 Bonanza crashed under unknown circumstances about 7 miles south of Pagosa Springs on Friday.  Authorities say the aircraft tried to land on a gravel road and crashed into a field. The Federal Aviation Administration and the National Transportation Safety Board are investigating.

Source:  http://denver.cbslocal.com


While the investigation remains open, the Archuleta County Sheriff’s Office has released additional information concerning the fatal plane crash that occurred Sept. 25 — including the identities of the two victims.   According to Undersheriff Tonya Hamilton, the pilot has been identified as Robert “Bobby” Bennet, 70, of Midlothian, Texas. The passenger was identified as Svetlana Solodovnyk, 53, of Ukraine. The couple died when Bennet’s plane, a 1964 Beechcraft S35 Bonanza single-engine plane, crashed south of Pagosa Springs shortly before 11:30 a.m. on Sept. 25. The crash was reported at 11:26 a.m., an ACSO statement reported.

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