WPR20FA005

NTSB accident investigation · Bede BD5 · Camarillo, CA · October 8, 2019

Accident · FatalClass 3 · FieldFinal report
Date
October 8, 2019, 12:29 local (19:29 UTC)
Place
Camarillo, CA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N501BDBede BD5
Defining event
Approach-VFR pattern downwind: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20191008014329A
Case key
100392

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The No. 4 connecting rod’s bearing shift and separation of the No. 4 connecting rod, which resulted in a total loss of engine power and subsequent forced landing.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The pilot departed in the experimental, amateur-built airplane and remained in the airport traffic pattern. The tower controller noticed that the airplane was low on the downwind leg and asked the pilot if he could climb. The pilot responded that he was having issues climbing and would need to stay at that altitude. The pilot also stated that he would need to make a full-stop landing. The pilot was cleared to land, and, shortly thereafter, the airplane was observed in a rapid descent. Several witnesses located near the accident site reported that the airplane was low before it descended rapidly toward the ground. One witness stated that the propeller was not moving. The airplane impacted a lettuce field about 3/4 mile south of the airport and immediately nosed over. Postaccident examination of the engine revealed that the connecting rod bearing, and endcap had separated from the crankshaft. Engine disassembly revealed that the engine’s oil galleys and the No. 4 connecting rod journal’s oil galley were not obstructed. The section of the rod end cap with the bearing tang insert had mechanical damage consistent with bearing shift. The bearing shift likely led to the No. 4 rod bearing and endcaps to separate and resulted in a total loss of engine power.

Factual narrative

The factual narrative1,245 words

The low-wing airplane was powered by an experimental Honda EB3 engine. The engine was equipped with a Warp Drive fixed pitch propeller in a pusher configuration. The airframe and engine logbooks were not located. On October 8, 2019, about 1229 Pacific daylight time, an experimental, amateur-built Bede BD-5, airplane, N501BD, was substantially damaged when it was involved in an accident near Camarillo, California. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to air traffic control transcripts, the pilot was cleared to taxi to runway 26, where he completed an engine run-up, and was subsequently cleared for takeoff. The pilot was instructed by the tower controller to extend his upwind for 1/2 mile and was then instructed to turn crosswind. The pilot confirmed turning crosswind. The pilot was then cleared for the option on runway 26. While the pilot was flying the downwind leg of the traffic pattern, the controller advised him that the airplane was a little low and asked if he could increase his altitude. The airplane’s altitude was about 500 ft above ground level (agl), while the traffic pattern altitude was about 800 ft agl. The pilot responded that he was having issues climbing and would need to stay at his current altitude. He further responded that he would need to make a full stop landing. The pilot was cleared to land on runway 26, and shortly thereafter, the airplane was observed in a rapid descent. Several witnesses located near the accident site reported that the airplane was low, then maneuvered, and was rapidly descending toward the ground. One witness stated that the propeller was not moving. The airplane impacted a lettuce field about 3/4 mile south of the airport. The airplane nosed over just after touchdown and came to rest inverted. A postimpact fire ensued. The Ventura County Medical Examiner Office, Ventura, California, conducted an autopsy on the pilot. The medical examiner attributed the cause of death to smoke inhalation and thermal injuries. The FAA's Forensic Sciences Laboratory performed toxicological testing on the pilot. The results were negative for carbon monoxide and cyanide. Testing results were positive for Fluoxetine, Norfluoxetine, Rosuvastatin, Tamsulosin, and Amlodipine. Fluoxetine is a prescription medication used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks. Fluoxetine is in a class of medications called selective serotonin reuptake inhibitors. Norfluoxetine is a metabolite of fluoxetine. It was an unreported and disqualifying antidepressant. Although for some individuals this medication could impair mental and/or physical ability required for performance of potentially hazardous tasks such as flying, the FAA has determined that some airmen may be considered for a special issuance medical certificate for this medication, provided that several stringentcriteria are met. However, there is no record that the pilot ever made such a request. Tamsulosin is a prescription medication used to treat the symptoms of an enlarged prostate. Tamsulosin is in a class of medications called alpha blockers. This medication is generally acceptable for use by airmen. Present also were previous reported medications by the pilot, of amlodipine and atorvastatin. At 1155, the recorded weather conditions at CMA included wind from 190° at 4 knots, 10 statute miles visibility, clear sky, temperature 23°C, dew point 14°C, and an altimeter setting of 29.87 inches of mercury. The pilot held an airline transport pilot certificate with a rating for airplane multiengine land and commercial privileges for airplane single-engine land. He was issued a Federal Aviation Administration (FAA) third-class airman medical certificate on December 15, 2017, with a limitation for corrective lenses. On the application for that medical certificate, the pilot reported 13,700 total hours of flight experience, with 23 hours in the previous 6 months. The airplane impacted level terrain in a field of lettuce at an elevation of about 60 ft mean sea level (msl). A large ground disturbance was observed about 60 ft from the wreckage that measured about 10 ft by 30 ft and extended on a 120° magnetic heading to the main wreckage. An irrigation pipe displayed markings consistent with airplane impact. The airplane came to rest inverted on about a 125º magnetic heading. All major components of the airplane were located at the site. Most of the wreckage debris comprised small fragments of the canopy and the landing gear, which had separated during impact. First responders had cut off the forward section of the airplane to the rear area of the cockpit. There was a postimpact fire that thermally damaged the cockpit area and the fuselage. The left wing was attached and sustained damage to the leading edge about the outboard third. Chordwise scratching was observed on the underside of the wing. The left flap and aileron were attached their respective attachment points. The flap appeared to be near the neutral position. The scratches on the flap were consistent with the flap near the neutral position. The left tank fuel cap was observed secured. The left main wheel assembly had separated and were located near the main wreckage. The left main gear appeared to be extended. The wing tip was separated. The right wing was attached and chordwise scratches were observed on the inboard portion of the underside of the wing. The right flap and aileron were attached at their respective attachment points. The flap appeared to be near the neutral position. The right wingtip was bent downward. The fuel cap was secured. Fuel was observed leaking out of the wing root during recovery. The right main wheel assembly had separated and was located near the wreckage. The right main landing gear appeared to be extended. The empennage remained attached to the fuselage and wasrelatively intact. The vertical stabilizer and rudder were attached to their respective attachment points. The rudder trim tab was near the neutral position. The left and right horizontal stabilators were attached and relatively intact. Flight control continuity was established to the ailerons and rudder. Flight control continuity to the stabilator could not to be established due to the orientation of the wreckage. The instrument control panel and cabin area were thermally damaged. Chordwise scratches were observed on the bottom inboard half of the fuselage. The tail skid was intact. No oil was observed leaking at the accident site. The intake appeared to be free of obstructions. The exhaust tube was attached and appeared to be intact. No bird remains or feathers were present in any of the windshield fragments, in the cabin area, or the main wreckage. The propeller was attached to the crankshaft. Both blades appeared to be intact. The engine was rotated by hand at the propeller assembly and driveshaft and accessory drive continuity was established; however, the No. 4 piston would not move during crankshaft rotation. The oil was drained from the sump and two sections of the No. 4 connecting rod end cap and bolt sections and bearing debris were found in the oil. Engine disassembly revealed that the engine’s oil galleys and the No. 4 connecting rod journal’s oil galley were not obstructed. The No. 4 connecting rod cap sections displayed thermal discoloration and mechanical damage. The section of the rod end cap with the bearing tang insert exhibited mechanical damage consistent with bearing shift. The No. 4 connecting rod bolts were bent, and the fracture surfaces were consistent with overload. Postaccident examination of the airframe and engine revealed no additional preimpact mechanical anomalies or malfunctions that would have prevented normal operation.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N501BD
Reported as
Bede BD5 (B)
Category
Airplane, amateur-built
Serial number
1039
Built
1998
Engine
Amateur/Experimental Unknown, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
CMA · Camarillo, CA
Destination
CMA · Camarillo, CA
Airport
CMA · Camarillo, runway 26, 6,013 × 150 ft, grass/turf

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
82
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Front
Toxicology
Performed
Flight hours
13,700 total

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
73 °F, dew point 57 °F
Altimeter
29.87 inHg
Observed at
KCMA, 1 nm away

Docket · 8

The files NTSB released with the investigation on December 7, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N501BD · 1

Matched to the same aircraft by N-number and date.