Mechanical & Engine Failure · NTSB CEN15FA424

BEECH S35 — Pagosa Springs, CO

2 fatal High-time pilot
DateSeptember 25, 2015
LocationPagosa Springs, CO
AircraftBEECH S35
Purpose of flightPersonal
ConditionsDay · Visual Meteorological Cond
Phase / occurrenceEmergency descent Collision with terr/obj (non-CFIT)
Pilot age70
Pilot total time5,640 hrs · High time
Time in typeUnknown
Fatalities2

Probable cause

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.

NTSB findings

  • Aircraft-Aircraft power plant-Engine (reciprocating)-Recip engine power section-Failure - C
  • Personnel issues-Task performance-Maintenance-Installation-Maintenance personnel - C
  • Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Contributed to outcome

What happened

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.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →