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Oil starvation, miscommunication prove fatal

By NTSB · January 15, 2015 ·

The lineman who serviced the Beech Bonanza prior to the flight noticed visible oil leaks on the airplane during refueling. He pointed them out to the pilot. The pilot, accompanied by two passengers, was flying in VFR conditions at an altitude of about 7,500 feet over Palm Coast, Fla., when he reported engine vibrations and an “oil pressure problem” to air traffic control and asked for radar vectors to the nearest airport.

The airports in the vicinity were under IFR conditions. The 1,300-hour pilot did have an instrument certificate.

The controller provided the pilot with radar vectors for an Airport Surveillance Radar approach to a nearby airport that did not have a published ASR procedure. The airplane was about 2.5 miles northwest of that airport at an altitude of about 5,300 feet AGL when the pilot reported the oil pressure dropped to zero. He did not provide any more information to the controller about the engine’s power status nor did the controller ask for more information.

During the next seven minutes, the airplane continued on the assigned heading and past the target airport to a point about 6.5 miles northeast before the controller vectored the airplane to the south and then west to the final approach course. The pilot transmitted that they were low and coming in with smoke, then radar contact was lost.

An ATP pilot who saw the airplane on final approach said it looked slow and was in a nose high attitude  The Bonanza crashed into a home 3/4 miles from the runway and burned, killing the pilot and two passengers.

The post-accident investigation revealed the No. 4 connecting rod had failed and punctured the crank case, resulting in a loss of oil.

The NTSB, after reviewing the air traffic control transcripts and interviewing the controllers, determined that the controller vectored the airplane in such a way that it was unable to reach the airport. The NTSB attributed the accident to the failure of the No. 4 connecting rod due to oil starvation, which resulted in a subsequent forced landing. Contributing to the accident was the pilot’s failure to clearly state that the aircraft had lost all power and the air traffic controllers incomplete understanding of the emergency, which resulted in vectoring the airplane too far from the airport to reach the runway.

NTSB Identification: ERA13FA105

This January 2013 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.

About NTSB

The National Transportation Safety Board is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in the other modes of transportation, including railroad, transit, highway, marine, pipeline, and commercial space. It determines the probable causes of accidents and issues safety recommendations aimed at preventing future occurrences.

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