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ASN Wikibase Occurrence # 169125
Last updated: 2 July 2019
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Date:23-AUG-2014
Time:15:00
Type:Silhouette image of generic BE35 model; specific model in this crash may look slightly different
Beechcraft S35 Bonanza
Owner/operator:Coleman John E Jr
Registration: N334DF
C/n / msn: D-7606
Fatalities:Fatalities: 1 / Occupants: 1
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Laurel Hill, Okaloosa County, FL -   United States of America
Phase: En route
Nature:Private
Departure airport:Crestview, FL (CEW)
Destination airport:Florala, AL (0J4)
Investigating agency: NTSB
Narrative:
A friend of the commercial pilot reported that the purpose of the personal flight was to relocate the airplane to an airport about 19 miles northeast of the departure airport, where it could be stored in a hangar while the pilot was on an extended trip overseas. He added that the pilot attempted to complete the flight the day before the accident but that he was unable to start the airplane because the battery required servicing; the battery was serviced the morning of the accident.
A lineman reported that, before the airplane departed on the day of the accident, he observed the pilot perform an extended engine run-up. He stated that typically the pilot would just ďhop in and go.Ē Radar data showed the airplane just after departure on a northerly heading climbing to about 1,600†ft mean sea level (msl). About 2 minutes after departure, the airplane turned west and descended to about 900 ft msl as it turned 360 degrees near the pilotís home. The airplane then resumed a northeasterly course and climbed to 2,400 ft msl, presumably toward the destination airport. About 9 minutes after departure, the airplane entered a descending right turn. The final radar targets showed the airplane about 1.25 nautical miles southeast of the accident site about 1,400 ft msl and on an approximate magnetic heading of 285†degrees. Postaccident examination of the airframe and flight controls revealed no anomalies.
The propeller displayed signatures consistent with lack of engine power at the time of impact. Initial examination of the engine case revealed that it was breached in two locations, near the Nos. 2 and 4 cylinders, and that the Nos. 2, 3, and 4 connecting rods were fractured. Further examination of the engine revealed signatures consistent with preignition and/or detonation in the No. 6 cylinder, which had eroded the No. 6 cylinder piston face and subsequently allowed combustion gases to pressurize the engine crankcase. This likely caused the expulsion of oil from the engine via the breather tube and resulted in a lack of lubrication throughout the engine, consistent with the extreme thermal discoloration and mechanical damage observed in the engineís internal components. The cause of the preignition and/or detonation could not be determined.
During the approximate 10-minute flight before the engine lost power, the pilot should have received several indications of an engine anomaly, including, but not limited to, a drop in oil pressure, a rise in oil temperature, a rise in cylinder head temperature, and engine roughness. However, the airplaneís flight track after takeoff, including the low-level circling of the pilotís home and its continuation to the destination airport rather than returning to the departure airport, suggests that the pilot either did not observe these signs nor recognize them to be indicative of a serious engine problem or that he thought he would be able to complete the remaining short flight to the destination airport. Although it is uncertain when the anomalous engine indications might have begun, given the pilotís extended engine run-up, it is possible that they were observable as early as before takeoff. The fact that the pilot had attempted to complete the flight the previous day and had been unable to do so would likely have increased the pilotís desire to reach the destination airport and contributed to his unwillingness to cancel the flight, return to the departure airport, or conduct a precautionary off-airport landing before the engine failed.
Although toxicological testing of the pilotís specimens detected pheniramine, diphenhydramine, and zolpidem, all of which can be sedating, the detected drug levels were well below therapeutic levels; therefore, it is unlikely that any of the medications or the combination of the medications impaired the pilotís ability to safely operate the airplane.


Probable Cause: A total loss of engine power due to detonation/preignition damage of the No.†6 cylinder. Contributing to the accident was the pilotís decision to continue flight after receiving an indication of an impending engine failure.

Sources:

NTSB: https://www.ntsb.gov/_layouts/ntsb.aviation/brief.aspx?ev_id=20140823X82338&key=1


Revision history:

Date/timeContributorUpdates
24-Aug-2014 08:21 gerard57 Added
24-Aug-2014 23:54 Aerossurance Updated [Aircraft type, Source]
25-Aug-2014 17:58 harro Updated [Aircraft type, Registration, Cn, Location, Source]
29-Aug-2014 14:41 Aerossurance Updated [Location, Departure airport, Destination airport, Source, Narrative]
21-Dec-2016 19:28 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
30-Nov-2017 19:01 ASN Update Bot Updated [Registration, Cn, Operator, Other fatalities, Departure airport, Destination airport, Source, Narrative]

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