ERA13FA105

A total loss of engine power after 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 the controllers vectoring the airplane too far from the airport to reach the runway.

The airplane departed under visual flight rules and was at an altitude of about 7,500 feet when the pilot reported vibrations and an "oil pressure problem." Airports in the area were under instrument meteorological conditions with cloud ceilings of 900 to 1,000 feet above ground level (agl). An air traffic controller provided the pilot with radar vectors for an airport surveillance radar (ASR) approach to a nearby airport that did not have a published ASR procedure. The airplane was about 2.5 miles northwest of the airport, at an altitude of about 5,300 feet agl, when the pilot reported that the engine oil pressure was "zero" with "cool cylinders." The controller did not obtain nor did the pilot provide any additional information about the engine's power status. During the next approximately 7 minutes, the airplane continued past the 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 airplane subsequently struck trees and a residence about 3/4 mile from the approach end of the runway. A postcrash fire destroyed the airframe and engine. Postaccident examination of the airplane revealed that the engine sustained a fractured No. 4 connecting rod due to oil starvation. The connecting rod punctured the crankcase, which resulted in a total loss of engine power. The crankshaft oil transfer passage at the No. 4 journal sustained mechanical damage during the accident sequence and contained displaced journal material. All other oil passages were unrestricted. The airplane's maintenance logbooks were destroyed during the accident. Maintenance performed on the airplane about 1 month before the accident included the replacement of the Nos. 1 and 4 cylinders; however, it could not be determined if this maintenance played a role in the accident. The reason for the oil starvation could not be determined. Review of the air traffic control transcripts and interviews with the controllers revealed that they vectored the airplane such that it was unable to reach the airport. This was likely due to the weather conditions and the controllers' incomplete understanding of the airplane's mechanical condition (complete loss of power), which the pilot did not provide. At the time of the accident, the pilot was using medication for hypertension and had well-controlled diabetes. It was unlikely that either condition significantly affected the pilot's performance at the time of the accident.

The following information, which contains excerpts of recorded communications, was obtained by an NTSB air traffic control specialist through interviews and review of communications and radar information obtained from the FAA: At 1349:34, the pilot contacted Daytona Beach approach control and reported that he was at 4,500 feet. Eight minutes later, the pilot requested a climb to 6,500 feet. The approach controller informed the pilot that they had received a pilot report (PIREP) reporting that the cloud tops were at 7,000 feet. The controller advised the pilot to maintain at or above 7,000 feet, and remain in VFR conditions. The pilot complied and climbed to 7,500 feet. At 1407:01, the pilot reported, "…we got a vibration in the prop, I need some help here." The approach controller informed the pilot that the closest airport was at his 12 to 1 o'clock position and 5 miles, and asked him if he was instrument flight rules (IFR) capable and equipped. The pilot stated, "I'm IFR, we're just getting a little vibration. We've got an oil pressure problem; we're going to have to drop quickly here." When asked to clarify the nature of the problem, the pilot stated, "…we got a propeller or something going, I'm backing it up here to see." According to the approach controller, Ormond Beach Airport, which was located approximately 6 miles to the southeast of the airplane's position, was considered briefly, however, because runway 8/26 was closed for construction and there had been a strong tailwind for runway 17, that airport was not an option. The approach controller subsequently cleared the flight to XFL, instructed the pilot to descend and maintain 2,000 feet. About 1408, the approach controller instructed the pilot to continue his present heading, and informed him that he would get him as close as he could to the Flagler airport for a runway 29 approach. He advised the pilot that the weather ceiling at XFL was 900 feet, and that an instrument approach was necessary. The controller subsequently asked the pilot if he could accept an airport surveillance approach (ASR) into XFL and the pilot replied that he was "…lovely with that" (An ASR approach was a type of instrument approach wherein the air traffic controller issued instructions, for pilot compliance, based on an aircraft's position in relation to the final approach course, and the distance from the end of the runway as displayed on the controller's radar scope). Flagler County Airport did not have a published ASR approach. The controllers determined that to best handle the emergency it was necessary to offer the pilot an unpublished ASR approach to runway 29 at XFL using area navigation (RNAV) approach minimums. This determination was based on the information obtained from the pilot, and the need for the pilot to conduct an instrument approach into the airport due to the IFR weather conditions. At 1409, the pilot checked in with the arrival controller and reported he was at 7,000 feet descending to 2,000 feet. The arrival controller instructed the pilot to descend and maintain 3,000 feet, and to turn right to a heading of 060 degrees. According to the arrival controller, he assigned the airplane 3,000 feet because he wanted to ensure the airplane was high enough to remain clear of an antenna that was located northwest of XFL. About 1410, the controller advised the pilot to expect an ASR approach to runway 29 at XFL. At 1411:06, the pilot reported, "…we got zero oil pressure, but we've got cool cylinder head temperature." The controller acknowledged the pilot's transmission and instructed the pilot to turn right to a heading of 090 degrees and to descend and maintain 2,000 feet. At 1411:47, the controller informed the pilot that he would provide guidance along the RNAV runway 29 approach and that the straight in minimum descent altitude (MDA) was 560 feet. At 1413:46, the controller instructed the pilot to turn right to a heading of 180 degrees and advised that the airplane was about 6 miles east-northeast of XFL on " a base leg for about a four and one-half to five mile final." The pilot acknowledged the turn and said "…we're starting to see some ground here." At 1414:27, the controller instructed the pilot to descend to 1,600 feet and to turn right, to a heading of 200 degrees. At 1415:01, the controller informed the pilot that the airplane 5 miles southeast of XFL. About 35 seconds later, the controller provided the pilot turns to intercept the final approach course and informed the pilot that he was 4 miles straight in for runway 29, which the pilot acknowledged. About 1416, the controller informed the pilot that the airplane was three miles from the runway, asked him to advise when he had the airport in sight, and cleared the airplane to land on runway 29. At 1417:25, the controller told the pilot that the airplane was below radar coverage, instructed him to contact the XFL tower, and provided missed approach instructions, "if you don't have the airport in sight, climb straight ahead to 2,000 [feet]." At 1417:59, the pilot transmitted, "…do you read me?" The controller immediately responded that he had him loud and clear and asked the pilot if he had the airport in sight at his 12 o'clock and a mile. The pilot did not respond. At 1418:27, the pilot transmitted, "…we need help; we're coming in with smoke." The arrival controller informed the pilot that Flagler Tower was waiting for him, and that he was cleared to land. At 1418:55, the XFL tower controller called the arrival controller and informed him that the airplane did not make it to the airport. Federal Aviation Administration order 7110.65, "Air Traffic Control," provides guidance and instruction to air traffic controllers when an emergency situation exist or is imminent. Paragraphs 10-1-1, 10-1-2, and 10-2-5 stated in part: 10-1-1: Emergency Determinations...Because of the infinite variety of possible emergency situations, specific procedures cannot be prescribed. However, when you believe an emergency exists or is imminent, select and pursue a course of action which appears to be most appropriate under the circumstances and which most nearly conforms to the instructions in this manual. 10-1-2: Obtaining Information…Obtain enough information to handle the emergency intelligently. Base your decision as to what type of assistance is needed on information and requests received from the pilot because he/she is authorized by 14 CFR Part 91 to determine a course of action. 10-2-5: Emergency Situations…Consider that an aircraft emergency exists…when any of the following exist: a. An emergency is declared by either: 1. The pilot. 2. Facility personnel. 3. Officials responsible for the operation of the aircraft. [For additional information, please see the NTSB Air Traffic Control Group Factual Report located in the Public Docket.] An autopsy was performed on the pilot by the Office of the Medical Examiner, District 23, St. Augustine, Florida. The autopsy report noted the cause of death as "multiple blunt force injures." Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, was positive for the following: "Atenolol detected in Liver Atenolol detected in Blood (Heart) 1949 (mg/dl) Glucose detected in Urine 149 (mg/dl) Glucose detected in Vitreous 7 (%) Hemoglobin A1C detected in Blood" Review of the pilot's most recent FAA medical examination application (dated December 31, 2012) revealed "No" was selected to the question "Do you currently use any medication (Prescription or Nonprescription)." The weather reported at XFL at 1350 was: wind 360 degrees at 7 knots, visibility 3 statute miles, ceiling 900 feet broken, 1,400 feet overcast, temperature 15 degrees Celsius (C), dew point 13 degrees C, and altimeter 30.22 in/hg. The four-