Sunday, September 8, 2019

Loss of Engine Power (Total): Beech A36 Bonanza, N87RY; fatal accident occurred August 28, 2017 in Ellabell, Bryan County, Georgia

Pilot Randy Hunter (bottom right) along with (top right) William Byron Cocke and wife Catherine Cocke died when the Beechcraft A36 Bonanza they were in (left) crashed in Bryan County, Georgia, on August 28th, 2017.


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

Additional Participating Entities:

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

Aviation Accident Factual 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/N87RY 


Catherine and William Byron Cocke

Location: Ellabell, GA
Accident Number: CEN17FA331
Date & Time: 08/28/2017, 0839 EDT
Registration: N87RY
Aircraft: BEECH A36
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (total)
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Business 

On August 28, 2017, at 0839 eastern daylight time, a Beech A36 airplane, N87RY, was destroyed when it collided with trees and terrain near Ellabell, Georgia, during a forced landing following a complete loss of engine power. The pilot and two passengers were fatally injured. The airplane was registered to the pilot who was operating it under the provisions of Title 14 Code of Federal Regulations (CFR)Part 91 as a business flight. Visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan was filed. The flight originated from Savannah/Hilton Head International Airport (SAV), Savannah, Georgia, at 0829 and was destined for Cobb County International Airport – McCollum Field (RYY), Kennesaw, Georgia.

Radar data for the flight showed that the airplane departed SAV at 0829. After takeoff, the airplane made a left turn to a heading of about 300° and reached an altitude of 3,900 ft mean sea level (msl) about 6 minutes later; at that time, the airplane was about 16 miles northwest of SAV. At 0835:46, the pilot declared an emergency and reported that the airplane's engine had failed. At 0837:35, a tower controller at SAV provided the pilot with directional guidance to Cypress Lakes Airport (GA35), Bloomingdale, Georgia, but the controller then expressed concern about whether the airplane would make it to GA35. The final communication that the controller received from the pilot was at 0838:57; the pilot stated that the airplane "would probably make it."

After reaching its peak altitude of 3,900 ft msl about 0835, the airplane began descending and made a left 180° turn. The final radar data point, at 0839:39, showed the airplane at an altitude of 400 ft msl and a heading of about 120°. At that time, the airplane was about 0.1 mile from the accident site, which was about 6 miles from GA35.

Pilot Randy Hunter of Peachtree City, Georgia 
Hunter Aviation and Consultants

PERSONNEL INFORMATION


The 39-year-old pilot held a commercial pilot certificate with single-engine land, multiengine land, and instrument airplane ratings. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on March 20, 2017, without waivers or limitations.

The pilot's logbook was found within the wreckage. The logbook indicated that the pilot had accumulated 1,420 hours of total flight experience, including 786 hours in single-engine land airplanes and 633 hours in multiengine land airplanes.

AIRCRAFT INFORMATION

The Beech A36, serial number E-2917, was manufactured in 1994 as a single-engine airplane with retractable tricycle landing gear and seating for six occupants, including two flight crewmembers. The airplane was constructed primarily of aluminum and was powered by a 300-horsepower Continental Motors IO-550-B29B engine, serial number 675936.

The airplane's maintenance records indicated that the airplane was maintained in accordance with 14 CFR 91.409, Inspections, using a program recommended by the airplane manufacturer. The most recent engine overhaul was performed on December 5, 2007, at which time the engine had accumulated a total of 1,815 hours. A maintenance entry dated May 23, 2016, indicated that all six engine cylinders were replaced on that date; the Hobbs meter reading at the time was 516.6 hours. The most recent maintenance was performed on June 29, 2017, at which time the airframe had accumulated a total of 3,215.2 hours. The recording hour meter reading at the time was 680.6 hours.

The recording hour meter reading during the postaccident examination was 743.2 hours, indicating that the airplane had accumulated 62.6 hours since the most recent maintenance and that the engine had accumulated 226.6 hours since the engine cylinders were replaced.

METEOROLOGICAL INFORMATION

At 0853, the weather reporting station at SAV recorded wind from 030° at 12 knots, 10 miles visibility, few clouds at 4,000 ft above ground level (agl), broken clouds at 7,000 ft agl, broken clouds at 25,000 ft agl, a temperature of 23°C, a dew point of 18°C, and an altimeter setting of 30.12 inches of mercury.

AIRPORT INFORMATION

Radar data and voice communications revealed the airplane was traveling on a heading of about 300° when the pilot reported the engine power loss. At that time, GA35 was about 6.5 nautical miles (nm) away on a heading of 174°, which required a 126° left turn to divert to GA35. Radar plots showed that the airplane was able to glide about 6.3 nm after the pilot declared the emergency and made the left turn.

FAA published charts for the area showed that Briggs Field Airport (GA43), Guyton, Georgia, was about 3.4 miles away on a heading of 345° when the pilot reported the engine power loss, which would have required a 45° right turn toward GA43. GA43 was a private airstrip with a 2,300-ft long turf runway. Although GA35 was depicted on the air traffic controller's emergency obstruction video map (EOVM) that was used in handling the accident flight, GA43 was not depicted. The figure shows the positions of the airports relative to the airplane's track.


Figure - Google Earth plot of the airplane's flight path (in white) along with the nearest alternate airports. 


FAA Order JO 7210.3Z, Facility Operations and Administration, which was in effect at the time of the accident, provided guidance regarding items depicted on the EOVM. Paragraph 3-8-4d, EOVM Design, stated that the basic design of the EOVM must incorporate, among other items, satellite airports and other airports that could serve in an emergency. This paragraph of the order contained a note stating "to avoid clutter and facilitate maintenance, information depicted on the EOVM should be restricted to only that which is absolutely essential." No guidance was found regarding the determination of airports essential for depiction on the EOVM.

After the accident, GA43, along with several other small airports in the Savannah area, were added to the EOVM at the SAV ATCT.

WRECKAGE AND IMPACT INFORMATION


The airplane impacted trees and terrain near Ellabell, GA. The airplane was found in a wooded swamp area at a GPS elevation of 59 ft. The airplane was upright and facing 323°. An impact crater was centered about 10 ft directly in front of the nose of the airplane. Beyond the impact crater were trees with broken limbs and trunks that indicated a descent angle of about 45°.

The engine was partially separated from the fuselage. The fuselage was buckled in the cabin section with the aft section bent upward. The tail surfaces remained attached to the aft fuselage. The elevator was attached to the horizontal stabilizer, and the rudder was attached to the vertical stabilizer. The windshield and window posts had been cut by first responders to facilitate extrication of the occupants. The forward fuselage was crushed rearward. Both wings exhibited rearward crushing with the right wing crushing more pronounced than that on the left wing. The crush angles indicated a ground impact that was about 25° from vertical. Both wings remained attached to the fuselage, and the flaps and ailerons remained attached to the wings.

The location of the airplane and the terrain precluded a comprehensive on-scene examination. The airplane was recovered from the accident site and transported to a facility for a more comprehensive examination. Subsequent examination of the airframe revealed:
  • The aft fuselage had been cut off to facilitate removal from the scene.
  • The left horizontal stabilizer and elevator had been cut to facilitate removal from the scene
  • The right wing tip had been cut to facilitate removal from the scene.
  • The engine had been removed to facilitate removal from the scene.
Flight control system continuity was verified. The flaps were found in the up position (0°). The landing gear was retracted. No preimpact defects were noted on the airframe.

Examination of the engine revealed a hole that was about 2 inches in diameter in the top right rear of the engine case. The crankshaft was visible through the hole, and no connecting rod was attached to the rod journal. A subsequent teardown examination of the engine revealed that the No. 1 connecting rod was separated from the crankshaft and the piston. Fragments of the No. 1 connecting rod were found within the crankcase. Further examination revealed that four of the eight nuts that retained the No. 1 cylinder and one nut that retained the No. 2 cylinder were loose during disassembly, and no breakout torque reading could be measured. Two of the loose nuts on the No. 1 cylinder were on the studs that provided clamping force on the No. 1 main crankshaft bearing (through-studs). Disassembly of the crankcase revealed that the No. 1 main bearing had shifted to the rear of the crankcase, which obstructed the oil flow to the No. 1 main bearing and the No. 1 connecting rod bearing. All other connecting rods exhibited normal operating signatures with some mechanical damage from the internal components of the engine. No other preimpact anomalies were detected.

MEDICAL AND PATHOLOGICAL INFORMATION

The Division of Forensic Sciences, Georgia Bureau of Investigation, Savannah, Georgia, performed an autopsy on the pilot. The cause of death was multiple injuries.

Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for all substances in the screening profile. 

Pilot Information

Certificate: Commercial; Private
Age: 39, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 03/20/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 07/01/2016
Flight Time:  1420 hours (Total, all aircraft), 873 hours (Pilot In Command, all aircraft) 

Aircraft and Owner/Operator Information

Aircraft Make: BEECH
Registration: N87RY
Model/Series: A36 UNDESIGNATED
Aircraft Category: Airplane
Year of Manufacture: 1994
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: E-2917
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 06/29/2017, AAIP
Certified Max Gross Wt.: 3651 lbs
Time Since Last Inspection: 63 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3278 Hours at time of accident
Engine Manufacturer: Continental Motors
ELT: C91A installed
Engine Model/Series: IO-550-B29B
Registered Owner: On file
Rated Power: 300 hp
Operator: On file
Operating Certificate(s) Held: None

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: SAV, 50 ft msl
Distance from Accident Site: 13 Nautical Miles
Observation Time: 1253 UTC
Direction from Accident Site: 120°
Lowest Cloud Condition: Few / 4000 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 7000 ft agl
Visibility (RVR):
Wind Speed/Gusts: 12 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 30°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.89 inches Hg
Temperature/Dew Point: 23°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: SAVANNAH, GA (SAV)
Type of Flight Plan Filed: IFR
Destination: ATLANTA, GA (RYY)
Type of Clearance: IFR
Departure Time: 0829 EDT
Type of Airspace: Class G

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude:  32.239444, -81.439167

15 comments:

Anonymous said...

I read about a lot of Bonanza catastrophic engine failures involving Continental engines on this site compared to similar sized Lycoming engines. I wonder why that is?

Anonymous said...

correct, continental engines are known for not being as reliable as lycoming. Personally, I have heard from folks that they are much more likely to have crankshaft issues then lycoming. continental engines are not built as robust as lycoming. there have been many lawsuits against continental for this reason. seems like every week I read about a new continental engine involved crash. you are 100% correct.yes sir

Anonymous said...

It doesn't help when cylinders are replaced and the cylinder bolts and thru bolts are not torqued properly.

RIP to those lost and prayers that those family members affected find peace and closure.

C7

Anonymous said...

Stop with the Lycoming is better than continental argument not the cause here. The engine tear down makes it clear that the main bearing spun due to the cylinder replacement. Truly scary that mechanics will still replace all the cylinders on an engine and not think twice about the fact they just removed all the closure torque from the crankcase through bolts. Probably didn’t wet torque the bolts when they replaced the cylinders either which gave the case more space to shift after heating up. Amazing the engine lasted as long as it did. Sad that 3 nm ahead was an open strip that would have probably saved lives and maybe the plane.

Anonymous said...

So it's more of a lack of following overhaul procedures specified in the manual than an engine more prone to catastrophic failure? This is why you should choose a repair shop as though your life depends on it. RIP

Anonymous said...

Repair shops are a scam. A single solitary IA/AP will supervise 20+ car mechanics or worst and casually check their work from their little office while mostly doing paperwork.

Part 141 shops are the worst. I've seen them botch jets, put the wrong bolts, mess up avionics.

If you're a pilot for quite some time don't be scared by the "eating the elephant" requirements to become an A&P. Doing it through experience is common and one needs to show "30 months of work" which doesn't imply full time work. In fact the FAA did that "month" based requirements for their own inspectors who in order to stay current can show only a few hrs of work as A&P per month.

A&P schools are trying to scare us all with their talk of 2000+ hrs of "training" which is mostly classroom time whereas one can find a few good mechanics willing to sign your mechanic logbook and testify you are good to go for the exams 2-3 years down the road.

Or become an LSRM and 30 months after most FSDO have a "shall issue" order to permit you applying to become an A&P and passing the 3 knowledge and practical exam.

There is absolutely 0 reason why a pilot wouldn't gradually become a certified mechanic besides doing the 31 magic items an owner/operator can perform on his airplane without an A&P signing it off, given the investment of time and skills becoming a pilot requires anyways.

And I know how good a job I am doing on my airplane, including the engine overhaul I just completed under the supervision of an A&P I trust.

LSRM-A, 10 months to go to apply to become an A&P

Anonymous said...

Looking at the Mx log the owner/pilot/mechanic was well on the way to getting the plane into great shape ... Unfortunate that he didn't go behind the shop and check the torques.

Looking at the pilots logbook .... Errrrrr ..... A lot of warming the right seat. Have flown with a few like that and it showed.

Anyway ... RIP to all lost.

7C

T Ibach said...

and the crap about ycomings more robust blah blah...remember all the foks who had to open up their Lycomings and replace crankshafts because they were breaking??...and the fancy cylinders whose heads popped off??

T Ibach said...

and one more comment, from the accident site observations, it appears they were on the verge of landing in a large field more than large enough to accommodate the airplane when they just came up short

Anonymous said...

"from the accident site observations, it appears they were on the verge of landing in a large field more than large enough to accommodate the airplane when they just came up short"

I noticed the same thing when zooming in on Google Earth there. None of us have any idea what he was going through of course and it's easy from our chairs to say he could have tried for the two-lane highway running north-south to the west of that empty field. The only clue is that he said he would "probably" make GA35. But the impact angle of 45-65 degrees based on tree damage and impact damage gives strong evidence to stall with little forward velocity.

Anonymous said...

"and one more comment, from the accident site observations, it appears they were on the verge of landing in a large field more than large enough to accommodate the airplane when they just came up short"

Actually I think they came up long. They overflew several fields that would've worked out well, or at least a lot better than a stand of trees.

He was probably dealing with a lot of oil on the windshield and perhaps even smoke billowing from the engine. "Throwing a rod" is about as catastrophic as engine failure gets. They had suitable places to land but probably had a very difficult time seeing out of the airplane.

T Ibach said...

"Actually I think they came up long."
They overflew several fields that would've worked out well, or at least a lot better than a stand of trees".

well they went in at a fairly steep angle as opposed to rolling along then entering the trees

T Ibach said...

This "alternate field" they mention the FAA didn't have available to the controller is a dirt/grass minimally long airSTRIP with trees all around it, I would be hesitant to try a deadstick landing there unless directly overhead and could assess the landing clearly...as to the comment about engines failing... it's a common error to not properly torque the through bolts, and this is found to be the most common reason for engine mechanical catastrophic failures...and this happens because the threads aren't properly cleaned when re-assembling the engine, some of the thin metal protectant on the threads clogs them causing the wrench to "feel tight"when in fact it's not...the maintenance procedures are to properly clean the threads, use a specific lubricant, and use NEW NUTS any time a cylinder is replaced..this will preclude torquing errors...but I have personally witnessed shops having none of this, which is why the "el cheapo" shop can wind up costing a lot more than a good one

Anonymous said...

I have the NiC3 cylinders on my IO-550-N and they are phenomenal. I love the corrosion resistance, every oil analysis comes back perfect even when I don't get to fly often. I also use CamGuard for protecting the other internals during periods of inactivity.

Maening said...

Pilot had an airfield within easy glide distance, almost straight ahead from the emergency, but apparently didn’t know that. Tried to stretch the glide after doing the 180. Impact shows stall and fall. No oil on fuselage, but investigators may find it on windows.

FlyQ iOS app has a neat augmented reality function that would have been useful to the crashing pilot. The app shows all the nearby airports and landing strips superimposed over what you see out of the window, which you see using the camera. It’s the actual view of what’s there, not a depiction. It would have shown the strip available right off the nose and pilot could have made it no problem. I have this app on my phone and iPad. RIP all these young people who didn’t need to die. The maintenance is a whole other issue, don’t get me started on lousy A&Ps. Use only the best. Too many lazy, careless, and incompetent out there.