National Transportation Safety Board

Transcription

National Transportation Safety Board - Aircraft Accident/Incident Database
Accident Rpt# WPR14CA205
05/13/2014 1430
Regis# N5281D
Nampa, ID
Acft Mk/Mdl CESSNA 180A
Acft Dmg:
Eng Mk/Mdl CONT MOTOR O-470 SERIES
Fatal
Opr Name:
0
Apt: Nampa Municipal Airport MAN
Rpt Status: Factual Prob Caus: Pending
Ser Inj
Opr dba:
0
Aircraft Fire:
Events
1. Landing-landing roll - Loss of control on ground
Narrative
On May 13, 2014, about 1430 mountain daylight time, a Cessna 180A, N5281D, sustained substantial damage to the left wing during a ground loop at the
Nampa Municipal Airport (MAN), Nampa, Idaho. The private pilot and one passenger were not injured. The airplane was owned and operated by the pilot under
the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight
originated from MAN at about 1415.
The pilot reported that after an uneventful approach to the runway, he landed the tailwheel equipped airplane in a tail low, three-point landing. About 30 feet into
the landing roll the airplane suddenly turned sharply to the right and ground looped. Subsequently, the landing gear collapsed and the left wing impacted the
ground.
Postaccident examination of the tailwheel by a Federal Aviation Administration inspector revealed the tailwheel was heavily worn; however, it castered freely,
and no anomalies were noted.
Printed: April 22, 2015
Page 1
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Prepared From Official Records of the NTSB By:
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Accident Rpt# ERA15CA007
10/04/2014 1810 EDT Regis# N85707
Maryville, TN
Apt: Kagley Field NONE
Acft Mk/Mdl AERONCA 7AC
Acft SN 7AC-4453
Acft Dmg: SUBSTANTIAL
Eng Mk/Mdl CONTIENENTAL MOTORS A&C 65
Acft TT
Fatal
Flt Conducted Under: FAR 091
Opr Name: CHARLES W HALL
Opr dba:
1714
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to the pilot/owner, he had purchased the airplane a few weeks prior to the accident and the flight was to accomplish training in a conventional landing
gear airplane. During the training flight, numerous takeoffs and landings were accomplished at various airports in the area. While on the final leg of the traffic
pattern the flight instructor (CFI) commanded a go-around maneuver and the pilot/owner stated that he "had the landing." The CFI again instructed that the
go-around maneuver be performed and he advanced the throttle to full power. The pilot/owner applied back pressure and maintained the best rate of climb.
According to the CFI, the pilot/owner was informed that the airplane was "high and hot" on final, after repeating that, the throttle was advanced, by the
pilot/owner, and a go-around maneuver began. Neither of the pilots remembered advancing the throttle. The airplane impacted the approximate 60-foot tall trees
at the departure end of the runway and nosed over, coming to rest inverted at the base of the trees, which resulted in substantial damage to the fuselage,
wings, and rudder. The intended runway had a 42 foot incline, residence on the left side, and high tension powerlines on the right side. Both pilots reported that
there were no mechanical malfunctions or abnormalities that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot/owner's failure to
maintain a stabilized approach during the final leg of the traffic pattern. Contributing to the accident was both pilot's lack of aeronautical decision making.
Events
1. Approach-VFR pattern final - Attempted remediation/recovery
2. Approach-VFR go-around - Loss of lift
3. Approach-VFR go-around - Collision with terr/obj (non-CFIT)
Findings - Cause/Factor
1. Personnel issues-Action/decision-Action-(general)-Pilot - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - F
3. Personnel issues-Task performance-Communication (personnel)-Following instructions-Pilot - C
4. Aircraft-Aircraft oper/perf/capability-Aircraft capability-Climb capability-Capability exceeded - F
5. Personnel issues-Task performance-Communication (personnel)-CRM/MRM techniques-Instructor/check pilot - F
Narrative
According to the pilot/owner, he had purchased the airplane a few weeks prior to the accident and the flight was to accomplish training in a conventional landing
gear airplane. During the training flight, numerous takeoffs and landings were accomplished at various airports in the area. While on the final leg of the traffic
pattern the flight instructor (CFI) commanded a go-around maneuver and the pilot/owner stated that he "had the landing." The CFI again instructed that the
go-around maneuver be performed and he advanced the throttle to full power. The pilot/owner applied back pressure and maintained the best rate of climb.
According to the CFI, the pilot/owner was informed that the airplane was "high and hot" on final, after repeating that, the throttle was advanced, by the
pilot/owner, and a go-around maneuver began. Neither of the pilots remembered advancing the throttle. The airplane impacted the approximate 60-foot tall trees
at the departure end of the runway and nosed over, coming to rest inverted at the base of the trees, which resulted in substantial damage to the fuselage,
wings, and rudder. The intended runway had a 42 foot incline, residence on the left side, and high tension powerlines on the right side. Both pilots reported that
there were no mechanical malfunctions or abnormalities that would have precluded normal operation.
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Accident Rpt# CEN15CA196
04/11/2015 1034 EDT Regis# N85664
Cambridge, OH
Apt: Cambridge Muni CDI
Acft Mk/Mdl AERONCA 7AC
Acft SN 7AC-4409
Eng Mk/Mdl CONTINENTAL C85-8F
Acft TT
Fatal
Opr Name: DANIEL T. JOHNSTON
Opr dba:
3576
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
Narrative
The pilot reported that he had landed and was beginning to taxi when a gust of wind lifted the left wing. He added engine power and attempted to correct;
however, he was unable to maintain control. The airplane subsequently departed the runway pavement, encountered a ditch, and overturned. The pilot stated
that there were no failures or malfunctions associated with the airplane before the accident. He reported a 50-degree left crosswind at 10 knots about the time
of the accident.
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Accident Rpt# ERA13FA325
07/18/2013 1011 EDT Regis# N2333Z
Laurel, MD
Apt: Suburban Airport W18
Acft Mk/Mdl BEECH 23
Acft SN M-49
Eng Mk/Mdl LYCOMING 0-320-D2B
Acft TT
Fatal
Opr Name: DIXON RONALD H
Opr dba:
4998
0
Ser Inj
1
Aircraft Fire: NONE
Events
2. Initial climb - Loss of engine power (total)
HISTORY OF FLIGHT
On July 18, 2013, about 1011 eastern daylight time, a Beech 23, N2333Z, was substantially damaged after a loss of power when it struck a tree and then
houses shortly after takeoff from Suburban Airport (W18), Laurel, Maryland. The private pilot was seriously injured. Visual meteorological conditions prevailed,
and no flight plan was filed for the personal flight operated under the provisions of Title 14 Code of Federal Regulations Part 91, destined for Gettysburg
Regional Airport (W05), Gettysburg, Pennsylvania.
According to the pilot, on the morning of the accident, he awoke about 0830, and left for the airport. He arrived at W18 at approximately 0910. He then
preflighted the airplane and visually checked the fuel. It was full of fuel as he had topped it off two days before, and "everything was normal". He selected the
left tank before taxi, and prior to departure did an engine runup, checking the engine for about 15 minutes. He did a "mag and mag drop" check and a "carb heat
drop" check during the run-up and "both were normal".
Prior to departure he selected "one notch of flaps", and proceeded to takeoff from runway 03. Everything was normal until the airplane was over the end of the
runway at approximately 250 feet when the engine suddenly lost power. The pilot switched tanks, and turned on the boost pump in an attempt to get the engine
to run without result. He then maneuvered to the left, and then to the right. The last thing he remembered was seeing a gray house.
Review of air traffic control data revealed that the pilot had filed a VFR special flight rules area (SFRA) flight plan. Prior to departure, the pilot had obtained a
beacon code to operate within the Washington SFRA however; he was not able to contact air traffic control prior to the loss of engine power. Radar data
indicated that after takeoff, the airplane reached a peak altitude of 300 feet, but approximately 9 seconds later at 10:10:20, descended below the floor of radar
coverage.
According to a witness, at approximately this time, she observed the airplane flying west to east and noticed the left wing "dropped" and the plane started
heading towards the ground. She then heard a "boom" and observed smoke.
PERSONNEL INFORMATION
According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine land, and instrument
airplane. He also held a repairman experimental aircraft builder certificate. His most recent application for a FAA third-class medical certificate was dated July
19, 2006. The pilot reported that he had accrued 3,571 total hours of flight experience.
AIRCRAFT INFORMATION
The accident aircraft was a four place, low wing monoplane of conventional construction. The all metal semi-monocoque airframe structure was composed of
aluminum, magnesium, and alloy steel. The wings were constructed of bonded aluminum honeycomb. It was equipped with tricycle landing gear, and was
powered by a 160 horsepower, four cylinder, normally aspirated, air cooled engine, driving a two bladed, fixed-pitch, forged aluminum propeller.
According to the pilot, the airplane had been previously damaged prior to the accident, when it had been involved in an off airport landing in Wyoming in 1984
where the right main landing gear, wing box assembly, and right wing lower wing skins were damaged. Then in 1985 the rudder was replaced after it was
damaged, and then most recently, the right wingtip had been hit by a lawnmower.
According to FAA and maintenance records the airplane was manufactured in 1962. The engine had been overhauled on January 1, 1992 at 4,476.44 total
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hours of operation. The airplane's most recent annual inspection was completed on January 5, 1998 at 4719.0 total hours of operation, and at the time of the
accident, the airplane had accrued 4997.56 total hours of operation.
METEOROLOGICAL INFORMATION
The recorded weather at Tipton Airport (FME), Fort Meade, Maryland, located 3 nautical miles east of the accident site, at 1012, included: winds 360 at 3
knots, 10 miles visibility, sky clear, temperature 31 degrees C, dew point 22 degrees C, and an altimeter setting of 30.12 inches of mercury.
WRECKAGE AND IMPACT INFORMATION
Accident Site Examination
Post accident examination of the accident site revealed that the airplane had come to rest approximately a « mile from the departure end of runway 03. It
initially made contact with a 40 foot tall pine tree, striking the tree approximately 24 feet above the base of the tree and fracturing the upper portion of the tree
into two sections. The airplane then struck the northwest corner of a house separating the right wing from its mounting location. The airplane then continued
forward approximately 70 feet, struck the west side of another house located across the street from the initial impact point with the tree, fracturing the fuselage
just aft of the baggage door. It then came to rest against the southwest side of the residence with the left wing penetrating the front of the house.
Airplane Examination
Examination of the wreckage did not reveal any preimpact malfunctions of the airplane. There was no indication of structural failure and control continuity was
established from the flight controls to the rudder pedals and control wheel. Further examination revealed that the right wingtip and right wing outboard leading
edge displayed damage that had been taped over with duct tape and appeared to have occurred prior to the accident. The rudder was also a different color than
the rest of the airplane.
Both wing tank fuel caps were closed and locked. Both the left and right wing fuel tanks were compromised however; approximately 12 ounces of fuel was
recovered from left wing fuel tank. Examination of the fuel revealed that it was consistent with 100LL aviation gasoline, and a check with water finding paste
revealed no indication of water being present.
Examination of the fuel strainer also revealed the presence of fuel consistent with 100LL aviation gasoline and a check with water finding paste also did not
reveal the presence of water.
Examination of the cockpit revealed that the wing flap lever was in the 15 degree (first notch) position and the stabilator pitch trim was in the takeoff range
(green arc). The fuel selector was in the right wing tank position. The primer was in and locked. The throttle was full open, the mixture was full rich, and the
carburetor heat was off. The fuel boost pump was also off.
Propeller and Engine Examination
Examination of the propeller revealed that the propeller had remained attached to the crankshaft flange. One blade was curved aft about 10 degrees and
exhibited chord-wise abrasions on the forward surface. The other blade was bent aft about 45 degrees at about mid-span. It exhibited chord-wise abrasions and
paint transfer on the forward surface of the blade.
Examination of the engine revealed that it had remained attached to the aircraft firewall by the tubular engine mount. Examination of the engine revealed that
the engine compartment contained the remains of bird nests, and bird excrement. A red colored piece of cloth was also visible inside the right cowling inlet.
Further examination of the cloth revealed that it was the cloth jacketing from a foam filled cowl plug and that the cloth jacketing along with the foam insert were
protruding from, and blocking, the engine combustion air inlet opening.
The drive train was rotated by turning the crankshaft flange and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Suction and
combustion were observed from all four engine cylinders.
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The carburetor remained attached to the engine and no external damage was noted. The carburetor bowl screws were snug and no fuel stains were noted on
the exterior surfaces of the carburetor. The carburetor was partially disassembled. Liquid with an odor consistent with that of aviation gasoline was observed in
the carburetor bowl. A check with water finding paste revealed no indication of water in the bowl. No damage was noted to the carburetor internal components
however, it was discovered that, a mud dauber wasp nest about the size of a golf ball was present in the carburetor throat (venturi) below the main fuel nozzle.
The engine driven fuel pump remained attached to the engine. It was removed and produced air at the outlet port when actuated by hand.
Both magnetos remained attached to the engine and produced spark from all ignition towers, and no damage was observed on the ignition harness. The
electrodes on the No.1, 2, 3, and 4 sparkplugs from the top of the cylinders were undamaged and appeared normal. The No. 1 cylinder bottom spark plug was
obstructed by the exhaust and was not removed. The No. 2, 3, and 4 cylinder bottom sparkplug electrodes, also were undamaged and appeared normal.
The starter had remained attached to the engine and displayed evidence of rotational scoring on the starter nose case. The generator had also remained
attached to the engine and was undamaged.
The exhaust muffler displayed heavy rust deposits and circumferential cracking.
The engine contained about 6« quarts of oil. The oil suction screen appeared clean, the inside of the oil filter appeared clean, the oil hoses to the oil cooler
were secure, and oil cooler integrity was not compromised. According to the information recorded on the oil filter, the filter was last replaced on October 17,
2010 at 4995.26 total hours of operation.
TESTS AND RESEARCH
Additional Documents
Documents discovered in the wreckage revealed that some components on the airplane had either been worked on in the airplane or had been removed and
replaced but had not been entered in to the aircraft logbook or engine logbook. These included the magnetos, attitude indicator, directional gyro, fuel filler caps,
wingtips, and transponder.
Airplane Sale
According to the pilot the purpose of the flight was to deliver the airplane to its new owner who had purchased the airplane from him in September of 2012.
Review of FAA records revealed that the airplane was in a sale pending status but the sale had not been completed, and no aircraft bill of sale (FAA Form
8050-2) was on file.
Review of FAA records also did not reveal evidence of an FAA Special Flight Permit (FAA Form 8130-6) being submitted for the flight though the airplane did
not have a current annual inspection.
Potential Buyer's Statements
According to the potential buyer, he had paid the pilot for the airplane approximately 1 year prior to the accident, and had a mechanic examine the airplane. The
sale of the airplane was contingent on the mechanic's findings. In November of 2012, the mechanic reported back to him that the airplane had mechanical
issues and that the airplane was not airworthy. The potential buyer than tried to get his money back from the pilot, but the pilot refused to return his money. The
potential buyer threatened to sue the pilot. Then, a couple of days before the accident the pilot advised the potential buyer that the airplane was ready to go
and the potential buyer assumed that "it was all legal," and the mechanical issues had been corrected. He was waiting for the airplane to be delivered when the
accident occurred.
Mechanic's Statement
According to the mechanic who had inspected the airplane on behalf of the potential buyer, he inspected the airplane about 2 months prior to the accident. The
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airplane was in "deplorable condition" and did not look like it had flown in years. When he inspected it, there were numerous problems which included; the
airplane having been out of license for years, the right wing fuel tank not being able to hold fuel, the left wing tank fuel sump not draining, sand in all of the
airplanes fuel sumps, bird nests in the engine compartment, the rudder being replaced, the seats needing recovering, electrical wiring falling out from
underneath the instrument panel, the aft fuselage displaying some kind of pinching (deformation) aft of the wings, and the right wingtip being dented in, along
the leading edge of the wing.
Additional Pilot Statement
On August 10, 2013, in a written statement to the NTSB, the pilot advised that he had sold the airplane in September of 2012. The new owner left the airplane
at Suburban Airport and had mechanics working on it at the airport. In October of 2012, the new owner told him that someone had taken one of the cowl plugs.
The new owner then removed the remaining one. The airplane sat unattended for 7 months without any cowl plugs. The new owner moved to Gettysburg,
Pennsylvania and wanted the airplane relocated there. The pilot volunteered to fly it there.
Two days prior to the flight, the pilot began to prepare the airplane. He did a thorough check of the cowling, the engine, and the engine mount area due to the
amount of time that it sat without cowl plugs. He removed two bird nests, straw and other debris. He was able to check the engine mount area through an
access panel. After cleaning, there appeared to be no debris in the engine compartment. On the day before the flight, he fueled the airplane with 50 gallons of
fresh "AVGAS" and ran the engine for 30 minutes. He taxied around for continuity and checked the brakes. "Everything was normal."
On the day of the flight, he performed his normal preflight inspection including a visual inspection inside the cowling. Everything was normal. He checked the
fuel level and oil level. He checked the fuel sumps. He did a control integrity check. He selected the left wing tank before starting the engine, then started the
engine and let it run about 15 minutes while he did the preflight checks and prepared the navigational settings.
The pilot then taxied from the parking space to the run-up ramp for runway 3. He conducted the pre-takeoff checks. The magneto checks were normal. The
carburetor heat was normal. He adjusted the elevator trim to the takeoff position, set one "notch" of flaps, and then took off on runway 3. The engine rpm was
normal, the rotation speed was normal, and the takeoff distance was normal.
The airplane climbed normally for about 250 feet but when he was over the far threshold of the runway, the engine stopped. It went silent but continued to
rotate. At this time his airspeed was about 85 mph. He realized that he could not land in the remaining overrun and could not return to the airport. He then made
a slight left turn to position the airplane over the lowest of the trees near a water treatment plant. While doing this, he switched the fuel selector to the right wing
fuel tank and confirmed that the fuel pump was on.
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07/05/2014 1325 CDT Regis# N891R
Mt. Vernon, IL
Apt: Mount Vernon MVN
Acft Mk/Mdl BEECH 35 33-NO SERIES
Acft SN CD-15
Eng Mk/Mdl CONT MOTOR I0-470 SERIES
Acft TT
Fatal
Opr Name: DON E ROSENTHAL
Opr dba:
5300
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STU
Summary
The pilot reported he experienced an electrical failure while enroute to his destination. As he approached the airport and lowered the landing gear switch
handle, he heard the landing gear lower and felt the airplane slow down. He received the normal indications the landing gear was down and visually confirmed it
using the mirror on the left wing. The pilot reported he used the manual crank to ensure the gear was in the locked position. As the airplane touched down, the
right landing gear and nose gear collapsed. The airplane sustained substantial damage to the right wing. A FAA inspector's examination of the airplane's
electrical system showed system reliability.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to ensure the
landing gear was extended into the fully locked position.
Events
1. Landing-flare/touchdown - Landing gear collapse
1. Personnel issues-Action/decision-Info processing/decision-Expectation/assumption-Pilot - C
Narrative
The pilot reported he experienced an electrical failure while enroute to his destination. As he approached the airport and lowered the landing gear switch
handle, he heard the landing gear lower and felt the airplane slow down. He received the normal indications the landing gear was down and visually confirmed it
using the mirror on the left wing. The pilot reported he used the manual crank to ensure the gear was in the locked position. As the airplane touched down, the
right landing gear and nose gear collapsed. The airplane sustained substantial damage to the right wing. A FAA inspector's examination of the airplane's
electrical system showed system reliability.
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Accident Rpt# WPR13LA346
07/28/2013 1516 PDT Regis# N82182
Lone Pine, CA
Apt: Lone Pine KO26
Acft Mk/Mdl BEECH 35-B33
Acft SN CD-536
Eng Mk/Mdl CONT MOTOR IO-470-N11B
Acft TT
Fatal
Opr Name: SOHAIL SIMJEE
Opr dba:
6185
0
Ser Inj
0
Aircraft Fire: GRD
Events
1. Initial climb - Loss of engine power (partial)
Narrative
HISTORY OF THE FLIGHT
On July 28, 2013, about 1516 Pacific daylight time, a Beech 35-B33 airplane, N82182, experienced a loss of engine power immediately after departing Lone
Pine Airport, Lone Pine, California. The pilot executed a forced landing into desert terrain. All four occupants egressed the airplane with minor injuries, and a
post-accident fire ensued causing substantial damage. The airplane was registered to Sohail Air Ventures LLC, and operated by the private pilot, under the
provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight, and a visual flight plan had not been filed.
The flight originated at 1515 from Lone Pine Airport, and was destined for Corona, California.
The pilot stated that he diverted to Lone Pine Airport to wait out a weather system that was on their route of flight. About 1.5 hours after landing he decided to
proceed on the planned route. He performed a full preflight and engine run up prior to departure, leaning the engine's fuel mixture for takeoff. The auxiliary (aux)
fuel pump switch was in the OFF position. After takeoff he retracted the landing gear. At 300 feet above ground level (agl) he noticed that the airplane was not
climbing normally, and had entered in a slight descent. The engine started to sputter. The pilot reported that he did not have time to perform the "Engine Failure
After Liftoff" procedures, and elected to execute a gear up forced landing onto the terrain directly ahead. After the airplane stopped, he noticed a fire emanating
from the left wing. The three passengers egressed through the right cabin door, and the pilot followed. The fire spread and soon engulfed most of the airplane's
cabin before firefighters arrived to put out the flames.
The pilot, age 46, held a private pilot certificate for airplane single engine land issued April 16, 2012, and a third-class airman medical certificate issued in
November 21, 2012, with no limitations. The pilot reported in the National Transportation Safety Board (NTSB) Pilot Accident Report form 6120.1, that he had
accrued 296 total flight hours, 100 hours in the accident airplane make and model, and his most recent flight review was performed on September 16, 2012.
The four-seat, low-wing, retractable landing gear airplane, serial number CD-536, was powered by a Continental Motors IO-470-N11B, 260-hp engine, and
equipped with a McCauley constant speed propeller. Review of the maintenance logbooks showed that a 100-hour inspection was performed on June 21, 2013,
at 6,145.5 hours total airframe time. A 100-hour inspection was performed on the engine on the same date at an engine time of 1067.6 hours time since major
over haul (TSMOH).
WRECKAGE & IMPACT INFORMATION
The pilot initiated a forced landed into desert terrain shortly after takeoff. Post-accident fire consumed the cabin and half the left wing. Fire-Rescue arrived
on-scene and extinguished the fire. The wreckage was recovered and moved to a storage facility in Phoenix, Arizona.
On September 19, 2013, the airframe fuel system and engine were examined by the NTSB investigator-in-charge (IIC) and a technical representative from
Continental Motors, Incorporated. The right wing fuel tank, fuel tank outlet finger screen, and fuel line to the fuel selector valve was uncompromised. The right
fuel line had been separated from the fuel selector valve. The left wing fuel tank was destroyed by fire, and the fuel tank outlet finger screen was present. The
fuel selector valve had been removed from the wreckage by a Federal Aviation Administration (FAA) inspector while on-scene and was shipped to the
wreckage storage facility separately. The fuel selector was examined and disassembled by the NTSB IIC, and was determined to be positioned on the left tank.
The fuel sump screen was clear of debris.
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The engine was discolored gray and black from exposure to the post-accident fire. The crankshaft was rotated by hand and mechanical continuity was
established. The ignition system sustained significant thermal damage that destroyed the left magneto housing and left the other ignition system components
functionally damaged. The left and right magneto remained in place and secured to their respective mounting pads. The fuel pump housing was thermally
destroyed. The fuel pump remained secured to its mounting pad. The pump was removed from the backside of the engine. The drive gear, drive coupling and
drive shaft remained in place and intact. The fuel pump was disassembled and the fuel pump vanes were in place and intact. The throttle body/fuel control unit
remained attached to the oil sump. The mixture and throttle control cables remained attached to their respective control levers and the levers remained secured
to their respective control shafts. The control levers and shafts were marked with white paint and the levers were moved throughout their full range of motion.
The levers moved from stop-to-stop without binding. There was no sign of slippage between the levers and their shafts. The fuel inlet screen plug was
safety-wired. Removal of the fuel inlet screen revealed it was clean and free from debris.
The post-accident examination of the airframe fuel system and engine revealed no evidence of mechanical malfunctions or failures that would have precluded
normal operation of the engine.
ADDITIONAL INFORMATION
According to the Beechcraft Debonair A33 & B33 Pilot Operating Handbook in Section III, Emergency Procedures, it states the following for engine failure after
liftoff and in flight.
"Landing straight ahead is usually advisable. If sufficient altitude is available for maneuvering, accomplish the following:
1. Fuel Selector Valve - SELECT OTHER MAIN TANK (Check to feel detent)
2. Auxiliary Fuel Pump - ON
3. Mixture - FULL RICH, then LEAN as required
4. Magnetos - CHECK LEFT AND RIGHT then BOTH."
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Accident Rpt# GAA15LA022
03/17/2015 1105 EDT Regis# N900TM
New Market, IN
Apt: Crawfordsville Muni CFJ
Acft Mk/Mdl BEECH A36-UNDESIGNAT
Acft SN E-1302
Eng Mk/Mdl CONTINENTAL IO-550
Acft TT
Fatal
Opr Name: RED TOP AVIATION INC
Opr dba:
7389
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Enroute - Fuel exhaustion
2. Enroute - Fuel exhaustion
Narrative
On March 17, 2015 about 1105 eastern daylight time, a Beechcraft BE36A, N900TM, lost engine power due to fuel exhaustion during cruise flight and landed
on an open field two miles southwest of New Market, Indiana. The pilot and sole passenger were not injured, and the airplane sustained substantial damage.
The airplane was registered to Red Top Aviation, Incorporated, Martinsville, Indiana, and operated by the pilot as a day, visual flight rules ferry flight under 14
Code of Federal Regulations Part 91. The airplane was being ferried for repair of its fuel system. Visual meteorological conditions prevailed at the time of the
accident and no flight plan was filed. The flight originated from the Columbus Municipal Airport (BAK), Columbus, Indiana and was destined for Crawfordsville
Municipal Airport (CFJ), Crawfordsville, Indiana.
According to the pilot, after departing BAK, he observed that the right tip tank seemed very slow to transfer fuel. About 15 minutes into the flight, the pilot
reported that the right main tank was intentionally emptied to facilitate maintenance at CFJ. The airplane lost engine power due to fuel exhaustion en-route and
he maneuvered the airplane for landing in an open field. The airplane sustained substantial damage to the right rear wing spar. Upon subsequent investigation
by Federal Aviation Administration airworthiness inspectors, it was determined that the airplane's fuel system had been modified through the supplemental type
certificate process, and that the fuel quantity indications were incorrectly placarded.
The pilot stated he knew about the issue with the tip tank transfer rate, and the inconsistent fuel system quantity placards prior to the flight.
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Accident Rpt# WPR13FA284
06/23/2013 1443 PDT Regis# N434M
Acft Mk/Mdl BEECH A45
Acft SN G-756
Eng Mk/Mdl CONT MOTOR IO-550-B23B
Opr Name: JET TEST AND TRANSPORT LLC
Boulder City, NV
Apt: Boulder City BVU
Fatal
2
Ser Inj
0
Opr dba:
Aircraft Fire: NONE
Summary
The pilot, who was also the mechanic for the airplane, had replaced all six cylinders on the engine during the airplane's annual inspection; he reported that, 3
days before the accident, the engine was operated and ran well. On the day of the accident, he was returning the airplane to its home base following a
maintenance inspection on the wings. The pilot was near the end of the flight when he contacted approach control and requested priority handling because an
engine chip light had illuminated. Shortly thereafter, the pilot stated that the engine had lost power on a cylinder, and he declared an emergency. When the
airplane was at 9,500 ft mean sea level, the pilot said that he was going to attempt to land at a nearby airport (elevation 2,201 ft). Before switching to the
airport's common traffic advisory frequency (CTAF), the pilot reported to the approach controller that the airplane was at 3,800 ft with the landing gear down and
that the situation was under control. The pilot did not contact approach control again and did not broadcast over the CTAF. The airplane collided with terrain in
a nose- low attitude about 1 mile west of the airport. Postaccident examination of the airframe revealed no evidence of mechanical anomalies that would have
precluded normal operation.Postaccident examination of the engine revealed that the No. 6 cylinder had separated, and no nuts were located on its through
bolts. Magnified examinations of the bolt threads found the thread profiles intact and only locally distorted, consistent with the nuts not being present during the
No. 6 cylinder separation, which appeared to be the result of the incorrect assembly of the cylinder at the last cylinder change. Fretting damage on the
mounting pad was observed, which indicates looseness and movement between the cylinder and the case that resulted from inadequate preload in the
fasteners either through insufficient initial torque or loss of torque during operation. Considering the short time since cylinder installation, it is likely that the
cylinder fasteners, or at least some of them, were not correctly torqued at installation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot/mechanic's loss of
control during an emergency descent following a loss of engine power while in cruise flight. Contributing to the accident was the pilot/mechanic's incorrect
assembly of the No. 6 cylinder at the last cylinder change, which resulted in a separation of the cylinder and the loss of engine power.
Events
1. Enroute-cruise - Powerplant sys/comp malf/fail
2. Enroute-cruise - Loss of engine power (partial)
3. Enroute-descent - Loss of control in flight
4. Uncontrolled descent - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
3. Aircraft-Aircraft power plant-Engine (reciprocating)-Recip eng cyl section-Incorrect service/maintenance - F
4. Personnel issues-Task performance-Maintenance-Replacement-Maintenance personnel - F
Narrative
HISTORY OF FLIGHT
On June 23, 2013, about 1443 Pacific daylight time, a Beech A45, N434M, collided with terrain during a forced landing near Boulder City, Nevada. Jet Test and
Transport LLC was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and one passenger
sustained fatal injuries; the airplane sustained substantial damage to the wings and fuselage from impact forces. The cross-country personal flight departed
Chandler, Arizona, at an undetermined time with a planned destination of North Las Vegas Airport (VGT), Las Vegas, Nevada. Visual meteorological (VMC)
conditions prevailed, and no flight plan had been filed.
Information from the Federal Aviation Administration (FAA) indicated that the pilot contacted Las Vegas Terminal Radar Approach Control (LAS TRACON). The
airplane was at 9,500 feet mean sea level (msl); the pilot requested priority handling because an engine chip light had illuminated. Shortly thereafter, the pilot
stated that he had lost a cylinder, and declared an emergency. He said that he was going to attempt to land at Boulder City Municipal Airport (BVU), and the
controller approved him to switch to the BVU common traffic advisory frequency (CTAF).
Prior to switching frequencies, the pilot reported that the airplane was at 3,800 feet with the landing gear down, and the situation was under control. There was
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no other contact from the pilot with TRACON or on the CTAF.
The airplane collided with terrain about 1 mile west of the airport.
A review of Federal Aviation Administration (FAA) airman records revealed that the 41-year-old pilot held a commercial pilot certificate with ratings for airplane
single-engine land, rotorcraft-helicopter, lighter-than-air balloon, and instrument airplane. The pilot had a certified flight instructor (CFI) certificate with ratings for
airplane single-engine land and ground instructor-advanced. He additionally held an Airframe and Powerplant (A&P) certificate with Inspection Authorization
(IA).
The pilot was issued a second-class medical certificate on November 22, 2011, with no limitations.
No personal flight records were located for the pilot. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) obtained the aeronautical
experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City.
The pilot reported on his medical application that he had a total time of 945 hours with 250 hours logged in the previous 6 months.
The airplane was a Beech A45, serial number G-756. A review of the airplane's logbook revealed that the original logbooks were lost; the current logbook was
started on July 3, 1993, at a total time of 5,335.4 hours and a tachometer time of 581.4 hours. The tachometer read 691.5 at the last annual inspection on
March 1, 2012.
The engine was a Continental Motors, Inc. (CMI), IO-550-B23B, serial number 296827-R. It was a factory remanufactured 0-time engine, and was installed on
the airplane on June 21, 1996. A new hour meter was installed on May 5, 1997, that read 32.0 hours; this was to match the hour meter with the engine total
time of 32.0 hours.
The pilot was performing maintenance on the airplane under his mechanic authorization. An annual inspection was in progress, and work completed included
replacement of all six cylinders with new cylinders. He had flown the airplane to Chandler for a required maintenance inspection of the wings the day before the
accident, and was returning to North Las Vegas.
Written communication between the pilot/mechanic and the owner of the airplane indicated that, 3 days prior to the accident, the engine had been operated. It
ran well, and the airplane was nearly ready for flight.
An email to the owner the evening before the accident stated that the inspection in Chandler had been difficult, because the pilot/mechanic had spent a lot of
time looking for tools and parts. The email stated that the plan was to return the airplane to North Las Vegas the following day. It noted that the airplane was
flying great, and the cylinder head temperatures were coming down and equalizing. The pilot/mechanic said that the plan (for the day after the accident) was to
complete all paperwork and billing for the work performed, and return the airplane to service.
METEOROLOGICAL CONDITIONS
An aviation routine weather report (METAR) for BVU, (elevation 2,201 feet) was issued at 1435. It stated: wind from 140 degrees at 25 knots gusting to 30
knots; visibility 10 miles; sky clear; temperature 36/97 degrees Celsius/Fahrenheit; dew point -3/27 degrees Celsius/Fahrenheit; altimeter 29.67 inches of
mercury; and 8 percent relative humidity.
The IIC and inspectors from the FAA examined the wreckage at the accident scene. Detailed on site notes are in the public docket.
The first identified point of contact (FIPC) was a circular ground scar with a narrow ground scar to the right that was perpendicular to the debris path and about
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21 feet long. The orientation of the fuselage was opposite the direction of the debris path. The debris field was about 80 feet long by 80 feet wide.
The separated propeller hub with the spinner and all three blades attached was in the FIPC. A few feet away was the separated and deformed connecting rod
for cylinder number six. Six feet into the debris field was cylinder number six, which had separated. The main wreckage was 34 feet past the FIPC, and
consisted of the engine and airframe. A few small parts separated, and were scattered throughout the debris field. The rear canopy was one of the most distant
parts at 76 feet past the FIPC along the debris path centerline.
The front of the airplane sustained severe upward crush damage. The forward fuselage and wings were crushed up about 45 degrees.
The nose landing gear separated, and was in the first part of the debris field. Both main landing gear remained attached, and were extended.
Both flaps were in an extended position, and sustained upward crush damage to their trailing edges.
The left horizontal stabilizer, elevator, and the trim tab all sustained crush damage. There were chevrons from the outboard leading edge toward the center
inboard trailing edge. The inboard forward portion of the left side was coated with a black viscous substance. The right horizontal stabilizer and rudder appeared
to be undamaged.
MEDICAL AND PATHOLOGICAL INFORMATION
The Clark County Coroner completed an autopsy on the pilot, and determined that the cause of death was blunt force trauma. The FAA Forensic Toxicology
Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot.
Analysis of the specimens contained no findings for carbon monoxide, volatiles, or tested drugs. They did not perform a test for cyanide.
TESTS AND RESEARCH
Follow Up Examination
Investigators from the NTSB and CMI examined the wreckage at Air Transport, Phoenix, Arizona, on June 26, 2013.
A full report is contained within the public docket for this accident.
Airframe
Flight control continuity was established from the control surfaces to the deformed cockpit area. All identified push-pull tubes that connected the front and
cockpit flight controls were bent or buckled, and many had fractured and separated along jagged and angular planes.
Engine
Numerous metal chunks were in the oil sump. Metal flakes contaminated the oil filter element, and metallic debris was on the chip detector.
The airplane was equipped with a warning light annunciator panel that included two chip lights. The panel was sent to the NTSB Office of Research and
Engineering for examination. The filaments in both chip light bulbs exhibited stretching. Filaments for all of the other lights were intact and unstretched.
A JPI EDM-700 engine monitoring unit was installed in the airplane. This unit did not have recording capability, and no accident data was available.
NTSB Materials Laboratory Examination
The NTSB Materials Laboratory examined the number six cylinder and other engine components. A complete report is in the public docket.
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As part of the engine design, the number six cylinder was attached to the crankcase by six case studs and two through bolts that passed through the base
flange of the cylinder. The cylinder was designed to be further clamped to the case by a deck plate on a 7th stud located between the number six and number
four cylinders. The two through bolts passed through the forward flange of the number six cylinder and through the number four main bearing. The follow up
examination determined that the nuts were missing from the through bolts on the number six side of the cylinder. Threads of both bolt ends showed radially
oriented contact damage, but no overall outward shearing or deformation of the thread forms.
The aft upper stud had been pulled from the case, and retained in the flange of the cylinder; its nut remained fully threaded onto the stud. Approximately four or
five case threads were stripped from the crankcase with the thread remnants retained in the stud threads. The cylinder fins directly outboard of this stud were
deformed consistent with contact with the end of the stud.
The examination revealed that the 7th stud had its nut present, but not the deck plate that in normal assembly was under the nut and in contact with the
adjacent cylinder flange. The metallurgical exam noted that the stud appeared intact with the stud threads showing some contact deformation on the number
six cylinder side. The contact area was in an area that in normal assembly was concealed by the deck plate.
Visual examinations of the mounting pad for cylinder number six revealed areas of fretting damage adjacent to both through bolts, at the two forward studs, and
the two remaining upper studs. The pad surface at the lower two rear studs had a raised lip of material corresponding to the edge of the cylinder, and this was
consistent with the cylinder rocking towards those studs.
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Accident Rpt# CEN13LA229
04/15/2013 945 CDT
Regis# N9414Y
Warren, AR
Acft Mk/Mdl BEECH N35
Acft SN D-6592
Eng Mk/Mdl CONT MOTOR IO-520-BA(6)
Acft TT
Fatal
Opr Name: WILLIAM M. MORRIS
Opr dba:
6266
0
Apt: Warren Municipal 3M9
Ser Inj
0
Aircraft Fire: NONE
Events
1. Initial climb - Loss of engine power (total)
Narrative
On April 15, 2013, about 0945 central daylight time, a Beech model N35 airplane, N9414Y, was substantially damaged during a forced landing following a loss
of engine power after takeoff from the Warren Municipal Airport (3M9), Warren, Arkansas. The pilot and passenger sustained minor injuries. The aircraft was
registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions
prevailed for the flight. An instrument flight rules flight plan had been filed, but not yet activated. The flight was originating at the time of the accident. The
intended destination was the Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas.
The pilot reported that he had departed from runway 21 (3,829 feet by 75 feet, asphalt) at 3M9 and climbed to 700 feet mean sea level (msl). As he started a
right turn to the west, about 1,000 feet msl, the engine lost power. He established a glide in an attempted to return to the airport. However, due to "strong"
winds, the airplane contacted the ground "abruptly short of the runway."
A postaccident engine teardown and subsequent metallurgical examination were conducted. The crankcase was cracked starting at the number 1 cylinder head
mounting stud and continuing to the top of the case. The crankcase number 2 main bearing saddle exhibited longitudinal deformation adjacent to the bore, with
fretting and galling on the saddle landings. The other saddles exhibited curvilinear marks on the split plane landings and helical marks on the saddle bores,
consistent with machining marks. The crankcase was re-assembled and the saddle bore diameter at the nose of the crankshaft was measured. The bore
diameter was within limits in the area centered 90-degrees from the split plane. However, the bore diameter was oversized in the area centered about
20-degrees from the split plane. The bore diameter measured 2.5660 inch; the bore diameter limits were 2.5625 inch to 2.5635 inch.
The crankshaft had fractured through the number 3 cheek, immediately aft of the number 2 main bearing journal. The fracture surfaces exhibited curvilinear
crack propagation marks consistent with fatigue. The main bearing surface exhibited circumferential abrasion marks. The main bearing journal diameters
measured within the limits for a reground crankshaft, with the exception of the number 2 journal.
The number 1 main bearing shells were deformed; the number 2 main bearing shells were worn, deformed and partially split. The remaining bearings exhibited
helical lines that matched the machining lines on the crankcase main bearing saddles. The tin coating on the backside of the bearings had been worn away
except around the oil transfer holes. Dimensional inspection of the number 3, 4 and 5 main bearing shells were within limits.
Engine maintenance records indicated that the engine was overhauled in January 2001, at 1,526.5 hours total time. According to the records, an annual
inspection was completed on December 10, 2009, at 1,696.7 hours total time, with 170.4 hours since overhaul. The next entry indicated that the engine was
removed from the previous airframe "for prop strike on or about 8 - 11." This entry noted the total time as 1,526.5 hours, which was the same as at overhaul
about 9 years earlier. However, the time since overhaul was the same as at the December 10th annual inspection.
An entry dated January 10, 2012, noted that the engine had been disassembled due to a propeller strike. At that time, the crankshaft was magnetic particle
inspected with negative findings. The crankcase mating surfaces were cut and the bores were resized to the manufacturer's limits. It was subsequently installed
on the accident airplane on March 5, 2013. An annual inspection was completed at that time. The recording tachometer time was noted as 216.8 hours. There
were no subsequent entries in the either the airframe or engine maintenance logbooks.
The recording tachometer indicated 233.31 hours after recovery of the airplane. Based on the tachometer time noted at the annual inspection, about 16.5 hours
had accumulated since the inspection.
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01/06/2013 1606 PST Regis# N35SD
Acft Mk/Mdl BEECH V35A
Acft SN D-8812
Eng Mk/Mdl CONTINENTAL MOTORS, INC IO-550-B12BAcft TT
Opr Name: FLOYD JOHNSTON CONSTRUCTION CO
INC
6646
Woody, CA
Apt: N/a
Acft Dmg: DESTROYED
Fatal
2
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Summary
During a visual flight rules cross-country flight, air traffic control was providing flight-following services. The pilot informed theÿcontroller that there was cloud
cover ahead and requested an instrument flight rules clearance and approach to the destination airport. The controllerÿgranted the clearance and
thenÿinstructed the pilot to maintain 14,000 ft; the pilot read back the clearance. The pilot thenÿrequested a lower altitude and was advised to expect a lower
altitude in 10 to 12 miles.ÿThe pilot was subsequentlyÿcleared for a descent to 7,000 ft and issued arrival instructions. Two minutes later, the controller advised
theÿaccident pilot of a pilot report of icing in the area. One minute later, the controller issued a clearance to 6,000 ft but received no response from the pilot.
The controllerÿissued the clearance again, and the pilot acknowledged the instruction. The controllerÿrelayed a nearby outside air temperature but received no
response from the pilot. The controllerÿmade several attempts to contact the pilot and also asked another pilot to try to establish contact; all attempts were
unsuccessful. Two minutes later, radar contact was lost. The wreckage was located aboutÿ1 mile from the last radar return and was distributed over the terrain
for about 1/2 mile, indicating that an in-flight breakup had occurred. A postaccident examination of the airframe or engine revealed no anomalies that would
have precluded normal operation.
A weather study indicated that the airplane likely encountered light-to-moderate precipitation, especially near the end of the radarÿflight track.ÿPrecipitation and
clouds would have reduced visibility. Considering the environmental freezing level, the airplane likely encountered supercooled liquid water and snowflakes
about the time that voice communication was lost. Pilot reports in the immediate area described increasing instrument meteorological conditions (IMC) along
with light-to-moderate icing conditions. The reports described the flight conditions as mostly smooth with some light turbulence when passing in and out of cloud
tops. Along with the likely IMC, the airplane likely experienced moderate or greater icing conditions around the accident time. The airplane likely developed ice
on the wings, which resulted in an aerodynamicÿstall followed by a loss of control and in-flight breakupÿduring the descent.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: An in-flight encounter with icing
conditions during descent, which resulted in the airplane exceeding its critical angle-of-attack and experiencing an aerodynamic stall followed by anÿin-flight
breakup.
Events
1. Enroute-descent - Loss of control in flight
2. Enroute-descent - Aircraft structural failure
3. Enroute-descent - Structural icing
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Capability exceeded - C
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Attain/maintain not possible - C
4. Aircraft-Aircraft structures-Empennage structure-(general)-Capability exceeded - C
5. Aircraft-Aircraft structures-Wing structure-(general)-Capability exceeded - C
6. Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-Conducive to structural icing-Ability to respond/compensate - C
Narrative
HISTORY OF FLIGHT
On January 6, 2013, about 1606 Pacific standard time (PST), a Beech V35A, N35SD, experienced an in-flight break-up near Woody, California. The pilot/owner
was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger sustained fatal injuries; the
airplane was destroyed. The cross-country personal flight departed Imperial, California, about 1415, with a planned destination of Fresno, California. Visual
meteorological (VMC) conditions prevailed, and no flight plan had been filed.
The Federal Aviation Administration (FAA) reported that the pilot obtained flight following, and the airplane climbed to 16,500 feet. At 1549, the pilot informed
Los Angeles Air Route Traffic Control Center (ARTCC) that there was cloud cover ahead, and requested an instrument flight rules (IFR) clearance into Fresno.
The clearance to Fresno via direct TULE ALTTA8 Arrival was granted at 1550. The controller instructed the pilot to maintain 14,000 feet, and the pilot read
back the clearance. At 1552 and 1558, the pilot requested a lower altitude, and was advised to expect a lower altitude in 10-12 miles. On the 1558
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transmission, the pilot stated they were waiting for some buildup, but hadn't gotten any yet (he did not specify what kind of buildup).
The pilot contacted Bakersfield Approach Control as instructed at 1600, and requested a lower altitude. The approach controller cleared the pilot for a descent
to 7,000 feet, and issued the TULE ALTTA8 Arrival. Two minutes later, the controller advised the accident pilot of a pilot report of icing in the area. At 1603, the
controller issued a clearance to 6,000 feet, but received no response from the pilot. At 1604, the controller issued the clearance again, and the pilot
acknowledged the instruction. The controller followed with a nearby outside air temperature of -6 degrees centigrade, but received no response from the pilot.
The controller made several attempts to contact the pilot, and also asked another pilot to try to establish contact; all attempts were unsuccessful. At 1606,
radar contact was lost 9 miles south of the Tule very high frequency omni-directional radio range (VOR).
The FAA issued an alert notice (ALNOT) at 1734. The wreckage was subsequently located about 1 mile from the last radar return.
A review of Federal Aviation Administration (FAA) airman records revealed that the 72-year-old pilot held a private pilot certificate with ratings for airplane
single-engine land, multiengine land, and instrument airplane.
The pilot's most recent medical certificate on file with the FAA Airman and Medical Records Center located in Oklahoma City, Oklahoma, was a third-class
certificate issued on April 27, 2009. It had the limitation that the pilot must wear corrective lenses. The pilot reported a total time of 7,000 hours with 0 hours in
the previous 6 months.
One logbook was found for the pilot that contained two pages of entries in 2012 for 14 flights; all of the flights were in the accident airplane. No totals were
entered in the data blocks, but the hours recorded indicated an estimated 23 hours of flight time with one IFR approach flown into Fresno.
The airplane was a Beech V35A, serial number D-8812. A review of the airplane's logbooks revealed that it had a total airframe/tachometer time of 6,646.92
hours at the last annual inspection dated September 20, 2012.
The airplane was not certified for flight in known icing conditions, and had no de-icing or anti-ice provisions installed other than pitot heat.
The engine was a Continental Motors, Inc. (CMI), IO-550-B12B, serial number 685906. It was installed as a new engine on August 20, 2001, at a tachometer
time of 4,879.6 hours. An entry in the engine logbook on March 13, 2012, indicated an engine total time of 1,500.23 hours at an airframe total time of 6,475.93
hours.
METEOROLOGICAL CONDITIONS
The National Transportation Safety Board's (NTSB) Meteorologist was not on scene for this investigation and gathered all the weather data for this investigation
from the NTSB's Washington D.C. office and from official National Oceanic and Atmospheric Administration (NOAA) National Weather Service (NWS) sources
including the National Climatic Data Center (NCDC). The meteorologist prepared a Weather Study report, which is in the public docket for this accident.
Pertinent parts of the report follow.
The NWS Surface Analysis Chart for 1600 PST indicated that the accident site was located in a region where clouds and precipitation would be expected.
The NWS Storm Prediction Center (SPC) Constant Pressure Charts for 1600 PST indicated that the accident site was located in a very favorable location for
vertical motion, clouds, and precipitation given the low, mid, and upper-level environment.
No thunderstorm products or convective outlooks were valid for the accident site at the accident time.
Surface observations for the area surrounding the accident site was documented utilizing official NWS Meteorological Aerodrome Reports (METARs) and
Specials (SPECIs).
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Meadows Field Airport (KBFL) was the closest official weather station to the accident site; it was located 3 miles northwest of Bakersfield, California, and had
an Automated Surface Observing System (ASOS) whose reports were supplemented by the air traffic control (ATC) tower. KBFL was located 18 miles
south-southwest of the accident site, at an elevation of 510 feet, and had a 14 degree easterly magnetic variation.
KBFL weather at 1554 PST was wind from 330 degrees at 6 knots, 10 miles visibility and light rain, an overcast ceiling at 3,600 feet agl, temperature of 10
degrees C, dew point temperature of 6 degrees C, and an altimeter setting of 30.08 inches of mercury. The remarks section noted that it was an automated
station with precipitation discriminator, and rain began at 1538 PST.
Porterville Municipal Airport (KPTV) was located 3 miles southwest of Porterville, California, and had an Automated Weather Observing System (AWOS) whose
reports were not supplemented by an official observer. KPTV was located 21 miles north-northwest of the accident site, at an elevation of 443 feet, and had a
15-degree easterly magnetic variation.
KPTV weather at 1535 PST was wind calm, 10 miles visibility, a broken ceiling at 4,800 feet agl, overcast skies at 9,500 feet agl, temperature of 9 degrees C,
dew point temperature of 6 degrees C, and an altimeter setting of 30.10 inches of mercury. The remarks section noted that it was automated station without a
precipitation discriminator.
Upper Air Data from a North American Mesoscale Model (NAM) upper air sounding was generated for the accident site. The 1600 PST sounding was plotted on
a standard Skew-T log P diagram with the derived stability parameters, and this data was analyzed utilizing the Rawinsonde Observation program (RAOB)
software package. The sounding depicted a conditionally unstable vertical environment with the Lifted Condensation Level (LCL) at 2,897 feet msl, a
Convective Condensation Level (CCL) of 4,066 feet, and a Level of Free Convection (LFC) at 3,625 feet. The freezing level was identified at 4,603 feet. The
precipitable water value was 0.49 inches.
The 1600 PST model sounding indicated a relatively moist conditionally unstable vertical environment, and this vertical environment would have been
supportive of clouds and rain showers with the other lifting mechanisms in the area of the accident. While this environment had very little Convective Available
Potential Energy (CAPE) the LCL and CCL were quite low so that any clouds or rain showers that developed would reduce visibility, but not grow that much
vertically. Icing conditions were indicated by RAOB from 5,000 to 7,000 feet msl. RAOB identified clouds from the surface through 10,000 feet msl, then
another layer of clouds between 14,000 feet and 21,000 feet msl.
The sounding wind profile indicated there was a surface wind from 321 degrees at 3 knots, and the wind backed around to the north through 30,000 feet msl
with the strongest winds around 55 knots at 27,000 feet msl. No low-level wind shear (LLWS) was indicated by RAOB. Two layers of possible clear-air
turbulence were indicated from 12,000 to 16,000 feet msl and 19,000 feet through 30,000 feet msl.
Visible and infrared data from the Geostationary Operational Environmental Satellite number 15 (GOES-15) data was obtained from the NCDC and processed
with the NTSB's Man-computer Interactive Data Access System (McIDAS) workstation. The visible imagery indicated a large amount of cloud cover at and
around the accident site at the accident time with the tops of the clouds to the north and west having a cumuliform-like top appearance. This would likely
correspond to the showers moving from north to south across the accident site. Based on the brightness temperatures above the accident site and the vertical
temperature profile provided by the 1600 PST model sounding, the approximate cloud-top heights over the accident site were around 13,000 feet at both 1600
and 1630 PST.
The closest NWS Weather Surveillance Radar-1988, Doppler (WSR-88D) was KHNX located near Hanford, California, approximately 51 miles northwest of the
accident site at an elevation of 243 feet. Level II archive radar data was obtained from the NCDC utilizing the NEXRAD Data Inventory Search and displayed
using the NOAA's Weather and Climate Toolkit software.
A radar summary image from 1615 PST had reflectivity values that indicated very light to moderate echoes near the accident site around the accident time. The
meteorologist reported that the airplane likely encountered light to moderate precipitation, especially near the end of the ATC flight track. It also likely
encountered a shower that was over 10,000 feet in depth; the shower activity was moving south-southeastward with time. There were no lightning strikes near
the accident site around the time of the accident.
A 3-dimensional view of the KHNX WSR-88D base reflectivity for the elevation scan was plotted on the Google Earth image for a time comparison with the
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base reflectivity images. The meteorologist reported that the image showed that the accident airplane likely encountered light to moderate precipitation while
flying generally northwestward. In addition, the precipitation and clouds would have reduced visibility.
The closest NWS WSR-88D with Dual-Polarization (dual-pol) technology was KHNX. Given the base reflectivity and dual-pol values, along with the
environmental freezing level, the accident airplane likely encountered ice crystals of different shapes and sizes, with a few snowflakes or supercooled liquid
water droplets mixed in as well. However, the majority of the meteorological targets would have likely been ice crystals. The accident airplane likely
encountered supercooled liquid water and snowflakes around 1604 PST. There was likely a mix between the supercooled liquid water and snowflakes. Along
with the likely IMC conditions the pilot was flying in due to the cloud cover and precipitation, the accident airplane likely experienced moderate or greater icing
conditions around the accident time.
AIRMETs Sierra, Tango, and Zulu were valid for the accident airplane's flight level at the accident time. They were issued at 1245 PST (with AIRMET Zulu
updated again at 1550 PST), and forecasted moderate icing conditions, moderate turbulence, and mountain obscuration by clouds, precipitation, and mist.
There was no record of the accident pilot receiving a weather briefing or looking at weather information before the flight. It was confirmed that the accident pilot
did not receive a weather briefing from official sources.
Another pilot flew through the Bakersfield area in a Cessna 421C on an IFR flight plan before the accident time frame, and the complete statement is provide as
attachment 1 to the factual report. The pilot described increasing IMC conditions as he flew in and out of cloud tops in and north of the Bakersfield area. Also,
the pilot experienced light to moderate icing conditions for which the deice boots were activated. The pilot had to increase the frequency of the deicing boots
the further north he traveled while the IMC conditions worsened with solid cloud cover. As the pilot descended into the Porterville area, the IMC conditions
continued until 1,500 feet agl, but the temperatures climbed above freezing around 3,500 to 4,000 feet agl. The pilot described the flight as "mostly smooth"
with some light turbulence when passing in and out of cloud tops. These statements matched the pilot reports (PIREPs) from around the accident area, which
are described in Section 7.0 of the meteorologist's factual report.
COMMUNICATIONS
The pilot was in contact with Bakersfield Approach Control on frequency 118.9.
The NTSB IIC examined the wreckage on site on January 8, 2013. The debris path was over « mile long. The first pieces were from the right ruddervator. Both
wings separated, and were in the middle of the debris field. The cabin separated into several sections that were scattered throughout the center of the debris
field. The inverted engine was the last major piece of debris; the engine exhibited significant damage to both top and bottom sides. The propeller remained
attached to the engine. Two blades were complete, but the third blade fractured and separated about 6 inches from the hub; the fracture surface was jagged
and irregular.
The Kern County Sheriff/Coroner completed an autopsy, and determined that the cause of death was multiple blunt force trauma. The FAA Forensic Toxicology
Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. They did not perform tests for carbon monoxide or
cyanide.
The report contained the following findings for tested drugs: Losartan detected in muscle and liver; Metropolol detected in detected in muscle and liver.
The report contained the following findings for volatile: 10 (mg/dL, mg/hg) ethanol detected in muscle; no ethanol detected in the brain. The report stated that
the ethanol found in this case was from sources other than ingestion.
TESTS AND RESEARCH
The NTSB IIC, the FAA, Beech, and CMI examined the wreckage at Aircraft Recovery Service, Littlerock, California, on March 15, 2013.
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A full report is contained within the public docket for this accident.
Airframe
There were multiple disconnects in the flight control system. All identified flight control cables were splayed. All fractured and separated components had
angular and jagged fracture surfaces.
The left wing sustained more damage than the right wing. It fragmented into two pieces, and both pieces exhibited spanwise creases. The wing separated
midspan along a jagged fracture surface. The spar at the separation point remained permanently deformed about 30 degrees in an upward direction. The
aileron separated into three sections. The inboard aileron tore along a jagged angular plane at the inboard hinge; the rod end separated at the hinge. The
inboard portion of the aileron's middle section also remained permanently deformed in an upward direction. The outboard hinge, and the aileron section
outboard of it, remained attached to the wing. The flap remained attached to the inboard half of the left wing.
The right wing separated at the wing root. There were chevron wrinkles from the front leading edge at the tip aft to the trailing edge. The chevrons were more
pronounced on the aft outboard third of the wing; this section exhibited permanent trailing edge up deformation.
The right side of the tail section sustained more damage than the left side. The inboard leading edge of the right horizontal stabilizer was bent down; the inboard
trailing edge of the right horizontal stabilizer was bent up. There was a deep chevron from inboard mid-chord to trailing edge midspan. The right ruddervator
fragmented into four pieces. The inboard piece contained the hinge; the second piece contained the entire trim tab. The third piece consisted of the outboard
section of the ruddervator. The fracture surfaces were angular and jagged. The right counterweight separated at the tip, the fracture surface was angular and
jagged.
The left horizontal stabilizer exhibited a shallow chevron from inboard mid-chord to the trailing edge quarter-span. The left ruddervator remained connected in
place; the counterweight separated at the tip along a jagged and angular fracture surface. The left trim tab remained connected in place with the control cables
connected at the control surface.
The ruddervator trim measured 1.25 inches, which equated to a position outside the permissible range.
The fuel selector valve was in an intermediate position.
Engine
Recovery personnel had removed the cowling, and slung the engine from a hoist. All cylinders sustained crush damage to the top cooling fins; the left (even)
side cylinders sustained the most distortion.
Removal of the top spark plugs revealed that all center electrodes were the fine wire type. The number six spark plug (front left cylinder) had fragmented. The
spark plug electrodes were gray, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.
A borescope inspection revealed no mechanical deformation on the valves, cylinder walls, or internal cylinder head. There was some debris in cylinder number
six (the spark plug had been breached).
The crankshaft rotated with resistance when manually rotated with the propeller. The top of the engine sustained crush damage, and the magneto drives were
impinging on the case. Removing the magneto drives and moving the fractured case metal freed the crankshaft, and allowed the engine to turn through 360
degrees, but with some difficulty. Several push rods were bent. The valves moved approximately the same amount of lift in firing order, except for the intake
valve on cylinder number six. After striking the valve with a hammer, it became free and moved. Thumb compression was obtained on all cylinders except
cylinder number six.
The gears in the accessory case turned freely.
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Both magnetos fragmented, and could not be tested.
The oil sump screen was clean and open. The governor screen was clean. Disassembling the oil filter revealed that the filter element was free of debris.
The engine driven fuel pump drive gear was not recovered. The rubber diaphragm in the fuel distribution valve was torn through 180 degrees of its
circumference, the screen was clean, and there was no observable contamination. The fuel nozzles were open, and the screens were clean.
Propeller blade one was the least damaged.
Propeller blade two separated about 6 inches from the hub, and was bent aft. The fracture surface was a grainy, matt surface, and angular. From the inboard
fracture surface, the blade curled aft about 45 degrees for 9 inches, forward 30 degrees for the next 10 inches, and then gradually aft 5 degrees for 9 inches.
The forward surface of the outboard half of the blade had spanwise striations.
The outer 2 inches of propeller blade three's tip curled aft 45 degrees.
At the conclusion of the postaccident airframe and engine examinations, no evidence of mechanical anomalies was revealed that would have precluded normal
operation.
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03/20/2014 2045
Regis# N28119
Salt Lake City, UT
Acft Mk/Mdl BELLANCA 17 31-ATC
Acft SN 78-31146
Eng Mk/Mdl LYCOMING IO-540 SER
Acft TT
Fatal
Opr Name: GREGORY G PAGE DDS PC
Opr dba:
2342
0
Ser Inj
Apt: Salt Lake City Intl Airport SLC
0
Aircraft Fire: NONE
Events
1. Landing-landing roll - Landing gear collapse
Narrative
On March 20, 2014 about 2045 mountain daylight time, a Bellanca 17-31ATC, N28119, sustained substantial damage after the landing gear collapsed at the
Salt Lake City International Airport (SLC), Salt Lake City, Utah. The pilot, the sole occupant, was not injured; the airplane sustained substantial damage to the
right wing aileron. The airplane was registered to, and operated by, the pilot under the provision of 14 Code of Federal Regulations Part 91 as a personal flight.
Visual meteorological conditions prevailed for the flight, and no flight plan was filed. The flight originated from the Roosevelt Municipal Airport (74V), Roosevelt,
Utah at about 1950.
The pilot reported that during the approach he conducted his usual pre-landing checklist, which included verifying the landing gear position and indicator lights
four separate times. He conducted a normal, uneventful landing. During the landing roll the landing gear warning indication light activated and the right main
landing gear green indicator light extinguished. The right wing dropped to the runway and the airplane slid before coming to a rest just off of the runway surface.
Postaccident examination of the landing gear by a mechanic and the pilot revealed that the right main landing gear extension spring appeared to be
compressed; when tested, it produced 19-20 pounds of pressure. The extension springs from the nose and left landing gear assemblies were also removed and
tested; they both produced about 40 pounds of pressure.
The pilot reported that he subsequently purchased and tested three new springs, all of which produced about 44 pounds of pressure. The new springs were
installed on the airplane and no further landing gear anomalies were noted.
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03/24/2015 1645 EDT Regis# N93715
Acft Mk/Mdl BELLANCA 17 31A
Opr Name: ROBERT E. DRAGOO
Page 24
Siler City, NC
Apt: Siler City Municipal Airport SCR
Acft SN 74-32-135
Acft Dmg: DESTROYED
Acft TT
Fatal
1356
0
Ser Inj
Opr dba:
Air Data Research
Rpt Status: Prelim
0
Prob Caus: Pending
Aircraft Fire: GRD
All Rights Reserved
03/12/2015 1100 EDT Regis# N7772J
Acft Mk/Mdl BOEING A75N1(PT17)-UNDESIGN
Opr Name: COX DAVID L
Page 25
St Marys, PA
Apt: St Marys Muni OYM
Acft SN 75-8175
Rpt Status: Prelim
Acft TT
Fatal
3650
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
Accident Rpt# GAA15CA039
02/15/2015 910 MST
Acft Mk/Mdl CAMERON Z90 - NO SERIES-NO S
Opr Name: COFFING STEPHEN
Regis# N681SJ
Bernalillo, NM
Acft SN 6710
Acft Dmg: NONE
Acft TT
Fatal
49
0
Apt: N/a
Ser Inj
Opr dba:
1
Aircraft Fire: NONE
AW Cert: STB
Events
2. Landing - Hard landing
Narrative
The pilot determined that the wind was faster than anticipated at the landing location. He maneuvered the balloon for a landing in an open field, the gondola
landed hard, and fell onto its side. One passenger sustained a broken leg and the balloon sustained no damage.
The pilot reported no mechanical malfunctions or failures with the balloon prior to the flight that would have precluded normal operation of the balloon.
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Acft Mk/Mdl CESSNA 140-G
Opr Name: CARL E CHANEY
Page 27
04/18/2015 1845 CDT Regis# N76452
Acft SN 10884
Mize, MS
Apt: N/a
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
1
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
02/08/2013 930 MST
Regis# N89059
Tucson, AZ
Acft Mk/Mdl CESSNA 152
Acft SN 15282614
Eng Mk/Mdl LYCOMING O-235 SERIES
Acft TT
Fatal
Opr Name: ARIZONA AERO-TECH
Opr dba:
8037
1
Apt: Ryan Field RYN
Ser Inj
0
Aircraft Fire: NONE
Summary
The pilot rented the airplane from the fixed-base operator (FBO) to fly to an airport about 11 miles away to practice takeoff and landings. He spoke briefly with
two people in the FBO office and then went out to the airplane to preflight it and have it fueled. Review of the departure airport air traffic control tower (ATCT)
communications and air traffic control radar tracking data did not reveal any abnormalities with the departure or flight. About 7 minutes after departure, the pilot
contacted the ATCT at his destination airport and advised the controller that he was planning to do three touch-and-go maneuvers. Per instructions from the
controller, the pilot entered a right downwind for his assigned landing runway. When the airplane was near a location consistent with it being established on the
base leg, several motorists observed it in a steep nose-down attitude and descending rapidly. The airplane impacted flat terrain about 1.5 miles from the airport.
Neither of the two ATCT controllers observed the descent or impact. Examination of the airframe and engine did not reveal any preimpact anomalies that would
have precluded continued engine operation or flight.The pilot had obtained his first Federal Aviation Administration (FAA) medical certificate about 10 years
before the accident, received annual recertification, and his most recent medical certificate was issued about 13 months before the accident. Review of the
pilot's FAA medical records indicated that, for the intervening 9 years, the pilot was being treated for multiple cardiac issues and was subject to repetitive
specialized medical testing. Further review indicated that the pilot had slow, essentially asymptomatic, progression of at least two components of his cardiac
disease that are both independently associated with a significantly increased risk of sudden cardiac death as a result of a sudden arrhythmia. Although autopsy
results indicated that the cause of death was blunt trauma, it isÿlikely that a complication of the pilot's cardiac disease caused him to become incapacitated,
which resulted in his loss of control of the airplane and the subsequent crash. The 0707 code found on the transponder was likely an artifact of the pilot's
attempt to switch to the 7700 emergency code to indicate a problem to the controllers, but neither the timing nor the underlying reason for that action could be
determined.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's incapacitation due to
his preexisting cardiac disease, which resulted in his degraded or complete loss of ability to control the airplane.
Events
1. Prior to flight - Miscellaneous/other
2. Approach-VFR pattern downwind - Miscellaneous/other
3. Approach-VFR pattern downwind - Collision with terr/obj (non-CFIT)
1. Personnel issues-Physical-Impairment/incapacitation-Cardiovascular-Pilot - C
Narrative
HISTORY OF FLIGHT
On February 8, 2013 about 0930 mountain standard time, after the Cessna 152, N89059, airplane was established on a right downwind leg for runway 6R at
Ryan Field (RYN), Tucson, Arizona, radio and visual contact was lost by the air traffic control tower (ATCT) controller. The airplane, which impacted terrain
about 1.5 miles southwest of RYN, was substantially damaged, and the private pilot received fatal injuries. The personal flight was conducted under the
provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan
was filed for the flight.
The 75-year-old pilot rented the airplane from Arizona Aero-Tech (AAT), located at Tucson International Airport (TUS), Tucson, with the stated intent of
practicing landings and takeoffs at RYN. RYN was located about 11 miles west of TUS. Although the airplane reportedly had sufficient fuel for the flight, the
pilot decided to have the fuel tanks filled; a total of 15.2 gallons were added before the flight. The pilot was observed to sump the tanks both before and after
the airplane was fueled. He was also observed to seat himself in, and start the airplane from, the right seat.
The airplane departed from TUS runway 11R about 0923, and was approved for an early turnout on-course. FAA ATC tracking radar data showed that the
airplane flew towards RYN from TUS, at a maximum indicated altitude of 4,300 feet. The pilot contacted the RYN ATCT and, as instructed, entered a right
downwind leg for runway 6R. Visual and radio contact was then lost by the controller. Shortly thereafter, the controller noticed a dust cloud rising from the
ground about 1.5 miles southwest of the airport.
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Multiple motorists on Ajo Highway, an east-west thoroughfare that passed just south of RYN, witnessed the airplane's final descent and resulting impact dust
cloud. The first motorists on scene cut the pilot's seat belt, and extracted him from the cockpit, while others summoned emergency services. The first Pima
County Sheriff Office (PCSO) officer arrived on scene about 0940, shortly after the motorists had extracted the pilot. Attempts by PCSO personnel and
paramedics to resuscitate the pilot were unsuccessful. In a telephone conversation shortly after the accident, an NTSB investigator guided the first responder
personnel in safing the airplane by shutting its systems and equipment off.
Three inspectors from the Scottsdale Flight Standards District Office (SDL FSDO) arrived on scene about 1130. Representatives of the NTSB and Cessna
Aircraft examined the wreckage in situ the day after the accident. The airplane was recovered by Air Transport of Phoenix, AZ later that same day, and
examined by representatives of the NTSB, FAA, and Cessna on February 11, 2013.
FAA records indicated that the pilot held a private pilot certificate with an airplane single-engine land rating. According to the pilot's flight logbook, as of
February 2, 2013, he had accumulated a total flight experience of about 302 hours. His most recent flight review was completed on June 29, 2012, with a
certificated flight instructor (CFI) and airplane from AAT.
FAA information indicated that the airplane was manufactured in 1979, and was equipped with a Lycoming O-235 series engine. The airplane was registered to
the president and owner of AAT. According to AAT records the airframe and engine had a total time in service of about 8,037 hours, and the engine had a total
time since overhaul of about 3,038 hours.
AWOS Data Capture
An automated weather observation sensor and radio transmitter known as AWOS (automated weather observation system) was installed and operating at RYN.
The system operated continuously, sensing/updating conditions, and then providing that information to the ATCT and also broadcasting the observations on a
radio frequency accessible by aircraft communications radios. The AWOS was commissioned by the FAA, but it was not maintained or controlled by the FAA.
In addition, hourly or more frequent observation sets of AWOS data were to be provided to the US National Airspace System (NAS) for distribution and
archiving purposes as METARs (Meteorological Aviation Reports). The methods for providing AWOS data to the NAS were automated datalink, manual
transmission/entry, or a combination of the two as a function of the time of day. RYN used this combination approach, where the automated datalink was used
overnight, and the ATCT controllers captured and sent the data manually during their normal operating hours. However, controller air traffic management
workload sometimes prevented the controllers from capturing and entering the data for the NAS archiving. Subsequent but unrelated to the accident, the RYN
ATCT implemented a continuous automated data-capture and archiving system.
RYN AWOS/METAR Information
Review of archived RYN METAR data for day of the accident revealed that the AWOS data was not captured every hour. The only recorded weather
observations for RYN near the time of the accident were for times of 0754 and 1051. Review of archived RYN AWOS/METAR data for the several days
surrounding the accident revealed that the AWOS/METAR data for those days also had gaps in the temporal coverage.
The 0754 RYN automated weather observation included winds from 110 degrees at 5 knots, visibility 10 miles, clear skies, temperature 8 degrees C, dew point
minus 1 degrees C, and an altimeter setting of 29.92 inches of mercury.
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Review of the recorded radio transmissions from the ATCT to the flight revealed that when the RYN ATCT controller cleared the flight for its first touch and go,
he advised the pilot that the wind was calm.
TUS METAR Information
The 0953 automated weather observation at TUS, which was located about 12 miles east of the accident site, included winds from 070 degrees at 5 knots,
visibility 10 miles, clear skies, temperature 15 degrees C, dew point minus 3 degrees C, and an altimeter setting of 29.94 inches of mercury.
COMMUNICATIONS
Review of audio recordings from TUS revealed that about 0917, the pilot contacted TUS clearance delivery for "departure to Ryan" and the airplane was
assigned a transponder code of 0405. The pilot then contacted TUS ground control for taxi clearance for departure. He was assigned runway 11R as the
departure runway. The flight was cleared for takeoff about 0923, and about 4 minutes later, the TUS ATCT controller instructed the pilot to contact departure
control. The pilot remained on the departure control frequency for less than 2 minutes before requesting a frequency change in order to contact RYN ATCT,
which the departure controller approved.
There were two controllers working in the RYN ATCT at the time of the accident. Neither controller witnessed the airplane's descent or impact.
The RYN ATCT audio information was not provided with any timing track/data. Therefore the times noted below represent the best estimates, but they could
not be synchronized exactly with the communications or radar data provided by TUS. TUS data indicated that the pilot left the TUS TRACON frequency no
earlier than 0929, but the RYN information indicated that the pilot checked on with RYN ATCT nearly 2 minutes prior.
Review of the recorded RYN ATCT communications indicated that the pilot first contacted the facility about 0926:38, and requested "touch and goes." The
controller instructed the pilot to enter a right downwind for runway 6R, verified that the pilot requested touch and goes, and asked if the pilot had the current
automated terminal information service (ATIS) information. The pilot confirmed that he had the ATIS information, and that he was assigned to 6R. About
0927:37, the controller cleared the pilot for touch and goes, and announced "wind calm." The pilot then initiated an exchange clarifying his intent to conduct
three landings, and then return to TUS, which the controller acknowledged by instructing the pilot to make "right closed traffic." About 0928:03, the pilot
responded with "right closed traffic runway six right zero five niner." That was the last recorded communication from the airplane.
The controller then began working with one departing and one arriving airplane. About 0929:20, the controller broadcast "Cessna zero five niner say position."
There was no response, and the controller repeated the broadcast. Twice more, in rapid succession, the controller tried to again contact the airplane. About 10
seconds later, the two controllers noticed the dust cloud to the southwest.
AIRPORT INFORMATION
According to FAA information RYN was equipped three paved runways designated 06-24 L and R, and 15-33. The intended landing runway, 6R, measured
5,500 by 75 feet. Airport elevation was 2,417 feet above mean sea level (msl). Traffic pattern altitude was 800 feet above ground level, or about 3,200 feet msl.
The airport was equipped with a non-federal ATCT operated by a private contractor Serco. The ATCT was located about 1,000 feet east of the threshold of
runway 6R, and about 800 feet south of that runway. ATCT cab elevation was 2,484 feet msl.
The accident site was located about 200 feet south of Ajo Highway, which passed just south of RYN. The main wreckage path was about 200 feet long, and
oriented along a magnetic heading of about 240 degrees. The airplane came to rest inverted, with the nose oriented about 090 degrees magnetic.
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The underside of the nose was crushed. The aft fuselage was deflected about 90 degrees airplane left, and almost fully fracture-separated from the cabin. The
empennage was essentially intact, and remained attached to the aft fuselage. The right wing was fracture-separated at its aft fuselage attach point, and the left
wing remained attached to the fuselage. Both wings exhibited some leading edge crush damage. There was no post-impact fire. No oil stains or puddles were
observed on any of the exterior surfaces of the engine or airplane, interior surfaces of the engine compartment, or on the ground below the airplane.
With the exception of a small segment of the outboard end of the left aileron, all flight control surfaces remained attached to their respective airfoils. The aileron
segment was found in the debris path between the initial impact point and the main wreckage. The two cockpit yokes remained linked to one another, and flight
control continuity from the cockpit controls to all respective flight control surfaces was established. The flap actuator extension corresponded to a flap setting of
about 20 degrees. The pitch trim actuator extension corresponded to a trim setting of neutral. The transponder was found set to a code of 0707.
The fuel selector valve was found between the ON and OFF positions, but its position was consistent with the airplane impact deformation.
The left seat belt assembly was partially buckled and uncut. The right shoulder harness was engaged in its lap belt receptacle, and the outboard lap belt was
cut, consistent with eyewitness reports that they found the pilot in the right seat.
The engine remained attached to its mount, which remained attached to the fuselage. Continuity from the cockpit controls to the respective engine components
was established. The engine did not exhibit any catastrophic failures of the case, cylinders, valve train, or intake or exhaust systems. All accessories remained
attached to the engine. Manual rotation of the engine yielded thumb compressions on all cylinders, and the vacuum pump drive shaft was observed to rotate.
The propeller was separated from the engine. Both ends of the propeller were bent aft at about 12 inches inboard from the tip, and bore some chordwise
scoring.
Both fuel tanks were intact, but both caps had been liberated by the impact, and were recovered on scene. Fuel stains were observed under the wreckage
when it was lifted for recovery, and approximately 3 cups of fuel drained from the left wing when it was placed on the recovery trailer.
Neither the on-scene nor the follow-up examination revealed any mechanical conditions, abnormalities, or failures that would have precluded continued engine
operation and normal flight.
Refer to the accident docket for additional details.
The pilot's most recent FAA third-class medical certificate was issued in December 2011; the resulting "Special Restriction Medical Certificate" was not valid for
any class medical certificate after December 31, 2013.
According to the pilot's FAA medical information, he was first medically certificated by the FAA in 2002, but his evaluation required a special issuance,
time-limited certification because he was initially disqualified by having paroxysmal atrial fibrillation, mitral valve prolapse with regurgitation, and hypertension.
At that time, he reported taking several medications for treating hypertension and heart failure.
The pilot's medical records indicated that he required annual FAA re-certification, with a variety of re-testing necessary for cardiac evaluation. He continued to
pass those re-tests with some minor anomalies, and maintained his FAA medical certification. Over the years from 2002 forward, the degree of mitral valve
regurgitation increased from "moderate" to "moderate to severe," and by 2012, his initially-mild heart enlargement became "severe bi-atrial enlargement," with
moderate enlargement of the right ventricle. Throughout the time period, the pilot's left ventricle was consistently described in the echocardiogram reports as
having mild diastolic dysfunction. The pilot remained asymptomatic from his cardiac disease.
The PCSO autopsy report indicated that the cause of death was blunt force trauma to the chest. Examination of the heart revealed significant cardiac disease.
The heart weighed 520 grams, compared to a normal value of about 341 grams. There was no significant coronary artery stenosis, but the medical examiner
found marked dilation of the right atrium and moderate dilation of the right ventricle.
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Forensic toxicology examinations revealed quinidine and triamterene in both urine and blood. Those findings were consistent with the pilot's medication history.
No carbon monoxide, cyanide, ethanol, or any screened drugs were detected.
Radar Data
Review of ATC radar tracking data revealed that the antenna sweep and data interval rate was 5 seconds. About 0934, the airplane entered a right downwind
leg for runway 6R, at an indicated altitude of 3,200 feet. About 0935:28, the airplane passed abeam of the 6R threshold, at an indicated altitude of 3,000 feet.
About 5 seconds later, the flight track deviated slightly south (away from the airport), before turning first northwest, and then almost south. The last secondary
radar target in the continuous data was recorded at 0936:33, and was located 1.6 miles southwest of the 6R threshold, with an indicated altitude of 3,000 feet.
The final, and only other, secondary target was recorded at 0936:56, and was located about 0.4 miles southeast of the previous point, with an indicated altitude
of 2,700 feet. The reason for the flight path deviations and the 20-second (three radar sweep) gap could not be determined.
No record of the 0707 code data which was found on the transponder was observed in the TUS radar target data.
Eyewitness Observations
A total of four eyewitnesses provided information for the investigation.
A motorist who was driving eastbound on Ajo Highway first saw the airplane to the southeast of his location. He estimated that the airplane was about 500
yards away, at an altitude of about 1,000 feet above the ground, and headed approximately north. He described the attitude as unusually nose down, and
stated that the airplane was descending very rapidly towards the ground. He saw the indications of ground impact, and stopped his car to render assistance.
A passenger in a westbound car on the highway first saw the airplane to his south, when it was about 150 feet above the ground, and descending very rapidly.
He initially thought the pilot was attempting to land on the road, but then he saw the airplane make a sharp turn to its left. The witness interpreted the turn as
the pilot's maneuver to avoid the powerlines just south of the road. When the airplane was about half-way through the run, the left (lower) wingtip was
approximately the same height as the top of the vegetation. The airplane continued the turn until it paralleled the road, and then disappeared behind the
vegetation. The driver of his car pulled over to help after they saw the dust cloud from the impact.
The witness reports did not yield any definitive information regarding whether the engine was running. All witnesses reported that the pilot was unresponsive,
and that they cut his seatbelt to extract him from the right seat of the airplane. The witnesses reported that they could smell fuel, and that electrical power was
continuing to operate mechanisms in the airplane.
Refer to the accident docket for additional details.
Information from the Fixed Base Operator
The owner and president of AAT also owned Velocity Air, which provide maintenance, fuel, and logistical services, including tie-down spaces and hangars.
Both AAT and Velocity Air were based at TUS. AAT shared an office with another FBO owned by the same president.
AAT airplane rental procedures were typical of many FBOs, including provision of initial documentation plus oral, written, and practical training and evaluation
of the pilots. Once checked out, pilots typically reserve airplanes by telephone; they normally speak to the office manager (OM). A 3-ring binder, specific to
each airplane, contains airplane maintenance status and flight log information, as well as a variety of other relevant procedural and operational information. The
binder resides in the AAT office, and is provided to the pilot when renting the airplane. The AAT airplanes cannot be seen from the office lobby
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According to the AAT office manager, the pilot arrived there about 0820, and left the office for the airplane about 10 minutes later. While he was still in the
office, the pilot mentioned to the president that he was planning to fly in the right seat to RYN to conduct some touch and go landings and takeoffs. Although
the president was unaware at that time, he was subsequently informed by one of his flight instructors that the pilot had recently flown in the right seat with that
CFI, and that the pilot had "plenty of right seat experience."
Records indicated that the pilot had flown about 13 hours each in AAT C-172 and C-152 airplanes, since starting with AAT in September 2012. The pilot's most
recent previous flight with AAT took place on February 2, 2013. That flight was in a C-172, where he trained in the right seat with his CFI. The pilot was
described as a "meticulous" individual, particularly with regard to his flying behaviors and practices.
Information from Pilot's Flight Instructor
The pilot's most recent certificated flight instructor (CFI) was employed by AAT. The CFI started flying with the pilot because the pilot wanted to practice his
"radio work," due to the pilot's lack of experience operating at towered airports. The CFI elaborated that his use of the term "radio work" denoted both the pilot
planning/skills and timing using the airplane radio hardware, as well as the pilot's communication and phraseology practices, and his proficiency with
transmitting and receiving messages. The early "radio-work" flights were conducted between TUS and RYN, since both were towered airports.
The CFI described the pilot as "meticulous." He reported that the pilot had good "stick skills," but he was "a numbers guy," meaning that he strongly preferred to
use specific values (airspeed, attitudes, etc.) to operate the airplane. The CFI reported that the pilot was highly confident in his flying skills, but less confident in
his radio skills. The CFI added that the pilot was proficient in his radio work, and the pilot did not give the CFI any cause for concern.
The pilot's traffic pattern habits were consistent for both the C-152 and C-172 airplanes, and his traffic patterns were about the same as the CFI would fly. The
pilot's typical airplane configurations in the traffic pattern included 10 degrees of flaps abeam the runway end, and 20 degrees on the base leg. According to the
CFI, the pilot always used the airplane checklists.
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01/22/2015 1640 CST Regis# N6300Q
Tulsa, OK
Apt: Richard Lloyd Jones Jr RVS
Acft SN 15285225
Eng Mk/Mdl LYCOMING O-235-L2C
Acft TT
Fatal
Opr Name: SPARTAN EDUCATION LLC
Opr dba:
13220
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STU
Summary
The student pilot reported that he was attempting to land after his first solo flight. He thought his airspeed was high; the airplane landed hard and bounced three
times, which resulted in the collapse of the nose landing gear. The nose of the airplane and the left wing impacted the runway. A postaccident examination of
the airplane revealed that the left wing spar, firewall and engine mount sustained substantial damage. The chief flight instructor reported no preimpact
mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's improper landing
technique which resulted in a hard landing and subsequent nose landing gear collapse.
Events
1. Landing-flare/touchdown - Hard landing
2. Personnel issues-Experience/knowledge-Experience/qualifications-Total experience-Pilot
Narrative
The student pilot reported that he was attempting to land after his first solo flight. He thought his airspeed was high; the airplane landed hard and bounced three
times, which resulted in the collapse of the nose landing gear. The nose of the airplane and the left wing impacted the runway. A postaccident examination of
the airplane revealed that the left wing spar, firewall and engine mount sustained substantial damage. The chief flight instructor reported no preimpact
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Accident Rpt# ANC15CA016
03/30/2015 1800 AKD Regis# N4582C
Acft Mk/Mdl CESSNA 170B-UNDESIGNAT
Opr Name: ROCHELEAU KENNETH RANEY
Page 35
Acft SN 25526
Wasilla, AK
Apt: Goose Bay Z40
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
01/19/2015 1730 EST Regis# N7854U
Lowell, MI
Apt: Lowell City Airport 24C
Acft Mk/Mdl CESSNA 172F
Acft SN 17251854
Eng Mk/Mdl CONT MOTOR 0-300 SER
Acft TT
Fatal
Opr Name: MAJESTIC AIR
Opr dba:
Page 36
4112
0
Ser Inj
Air Data Research
1
Aircraft Fire: NONE
All Rights Reserved
01/19/2015 1730 EST Regis# N7854U
Acft Mk/Mdl CESSNA 172F-G
Acft SN 17251854
Eng Mk/Mdl CONT MOTOR 0-300 SER
Opr Name: MAJESTIC AIR
Lowell, MI
Apt: Lowell City Airport 24C
Fatal
0
Ser Inj
Opr dba:
1
Aircraft Fire: NONE
Events
1. Approach-VFR go-around - Loss of control in flight
Narrative
On January 19, 2015, about 1730 eastern standard time, a Cessna 172F airplane, N7854U, impacted terrain during a go-around at the Lowell City Airport
(24C), Lowell, Michigan. The solo student pilot was seriously injured and the airplane was substantially damaged. The airplane was registered to and operated
by Majestic Air under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed for the local
flight, which departed without a flight plan.
The student stated that he was attempting a full stop landing and elected to go-around when he realized his anticipated touchdown point was too long for the
2,394 foot runway. During the go-around maneuver, the student stated that he did not apply full power due to disorientation, which included blurred vision and
dizziness. The airplane climbed slowly and approached the end of the runway at low altitude. Concerned with trees near the end of the runway, the student
began a crosswind turn at low altitude. The student subsequently lost control of the airplane, which descended rapidly and impacted terrain.
A video taken by the flight instructor captured the accident sequence; this video and the flight instructor's observations paralleled the student perspective of a
shallow climb with less than full engine power, followed by a crosswind turn at low altitude and rapid descent.
Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
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01/25/2015 1811 HST Regis# N422BP
Acft Mk/Mdl CESSNA 172N
Acft SN 17268917
Opr Name: REGGIE PERRY
Makaha, HI
Apt: Kalaeloa (john Rodgers Field) JRF
Fatal
0
Ser Inj
Opr dba: BARBERS POINT FLIGHT SCHOOL LLC
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that about 40 minutes into the over water flight between islands, he requested a descent to 3,400 feet, which was approved by air traffic
control. The pilot reduced the engine power to 2,000 rpm; however, the engine rpm dropped to 1,500. Actions by the pilot to restore engine power were
unsuccessful. Following a successful water landing, the occupants exited the airplane and were rescued by the United States Coast Guard about 30 minutes
later. The airplane subsequently sank and was not recovered.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A partial loss of engine power for
reasons that could not be determined because the airplane was ditched and not recovered.
Events
1. Enroute-change of cruise level - Loss of engine power (partial)
2. Emergency descent - Ditching
1. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C
Narrative
The pilot reported that about 40 minutes into the over water flight between islands, he requested a descent to 3,400 feet, which was approved by air traffic
control. The pilot reduced the engine power to 2,000 rpm; however, the engine rpm dropped to 1,500. Actions by the pilot to restore engine power were
unsuccessful. Following a successful water landing, the occupants exited the airplane and were rescued by the United States Coast Guard about 30 minutes
later. The airplane subsequently sank and was not recovered.
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02/21/2015 1200 CST Regis# N54974
Acft Mk/Mdl CESSNA 172P
Acft SN 17275096
Eng Mk/Mdl LYCOMING 0-320
Opr Name: ASSOCIATED AIR ACTIVITIES INC
Kankakee, IL
Apt: Greater Kankakee Airport KIKK
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The flight instructor and student pilot were practicing landings to a full stop. During the 6th landing, the student pilot over controlled the airplane during the
landing flare. The flight instructor attempted to correct the flight control inputs; however, he was unable to overcome the strength of the student pilot on the flight
controls. The airplane struck a bank of snow on the left side of the runway and nosed over. The left wing and fuselage were substantially damaged. The flight
instructor reported no pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's improper
flight control inputs resulting in the loss of control during the landing flare.
Events
1. Landing-flare/touchdown - Loss of control in flight
2. Landing-flare/touchdown - Collision with terr/obj (non-CFIT)
3. Landing-flare/touchdown - Nose over/nose down
1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot - C
Narrative
The flight instructor and student pilot were practicing landings to a full stop. During the 6th landing, the student pilot over controlled the airplane during the
landing flare. The flight instructor attempted to correct the flight control inputs; however, he was unable to overcome the strength of the student pilot on the flight
controls. The airplane struck a bank of snow on the left side of the runway and nosed over. The left wing and fuselage were substantially damaged. The flight
instructor reported no pre-impact mechanical malfunctions or failures with the airplane that would have precluded normal operation.
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Accident Rpt# ANC15FA021
04/14/2015 1330 ADT Regis# N9247C
Acft SN 31346
Opr Name: DALE A. CARLSON
Whittier, AK
Apt: N/a
Rpt Status: Prelim
Fatal
1
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: UNK
AW Cert: STN
Events
1. Enroute-descent - Loss of engine power (total)
Narrative
On April 14, 2015, about 1330 Alaska daylight time, a wheel-equipped Cessna 180 airplane, N9247C, is presumed to have sustained substantial damage during
impact with ocean waters, about 18 miles east of Whittier, Alaska, following a reported loss of engine power. The airplane was being operated as an instrument
flight rules (IFR) cross-country personal flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91, when the accident occurred. The
instrument rated private pilot, the sole occupant of the airplane, sustained fatal injuries. Instrument meteorological conditions (IMC) prevailed along the route of
flight, and the airplane was operating on an instrument flight rules (IFR) flight plan. The flight departed the Wasilla Airport, Wasilla, Alaska, about 1205, en route
to the Valdez Airport, Valdez, Alaska.
A postaccident review of archived Federal Aviation Administration (FAA) radar data and radio communication recordings revealed that, about 1315, the on-duty
Anchorage Air Route Traffic Control Center (ARTCC) radar controller cleared the airplane for the LDA/DME H instrument approach to the Valdez Airport. At that
time, the airplane was about 60 miles southwest of the Valdez Airport, at an altitude of about 10,000 feet mean sea level (msl). Shortly after the pilot began a
descent from 10,000 feet msl, he advised the ARTCC controller of an engine problem. The pilot stated his intentions to descend below a cloud layer and land
on a nearby island. Shortly after, radar contact with the airplane was lost. A radio communication from the accident airplane was relayed through another
airplane in the area that he was at 5,500 feet msl, and still in the clouds. No further radio transmissions were received from the airplane and an emergency
locator transmitter (ELT) signal was broadcasting shortly thereafter for approximately 20 seconds.
The area that the airplane descended into was a portion of the Prince William Sound, consisting of remote inland fjords, coastal waterways, and steep
mountainous terrain.
The airplane was equipped with a Spidertracks flight tracking system, which provides real-time aircraft flight tracking data. The flight tracking information is
transmitted via Iridium satellites to an internet based storage location, at two minute intervals. The airplane's last known location was near the eastern shoreline
of Culross Island, at an altitude of 69 feet, traveling at 80 knots, on a heading of about 270 degrees.
An alert notice was issued by the FAA Kenai Flight Service Station at 1336 and a search was conducted by personnel from the U.S. Coast Guard, Alaska State
Troopers and Alaska Air National Guard, as well as a Good Samaritan vessel.
On April 15, about 1700, searchers discovered the remains of the pilot along the eastern shoreline of Culross Island. Also recovered was the left main landing
gear strut and tire belonging to the accident airplane. The rest of the airplane has not yet been located, and it is presumed to have sunk in the ocean waters of
Prince William Sound.
The closest weather reporting facility is Valdez Airport, Valdez, Alaska, about 60 miles northeast of the accident site. At 1256, an aviation routine weather
report (METAR) from the Valdez Airport was reporting in part: Wind, calm; sky condition, few clouds at 6,000 feet AGL, broken at 7,500 feet AGL, overcast at
9,000 feet AGL; visibility, 10 statute miles; temperature 37 degrees F; dewpoint 14 degrees F; altimeter, 29.64 inHg.
The airplane was equipped with a Continental Motors O-470 series engine.
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05/13/2014 1430
Regis# N5281D
Nampa, ID
Acft SN 50179
Acft TT
Fatal
Opr Name: BRUCE LAPE
Opr dba:
6306
0
Apt: Nampa Municipal Airport MAN
Ser Inj
0
Aircraft Fire: NONE
Events
Narrative
On May 13, 2014, about 1430 mountain daylight time, a Cessna 180A, N5281D, sustained substantial damage to the left wing during a ground loop at the
Nampa Municipal Airport (MAN), Nampa, Idaho. The private pilot and one passenger were not injured. The airplane was owned and operated by the pilot under
the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight
originated from MAN at about 1415.
The pilot reported that after an uneventful approach to the runway, he landed the tailwheel equipped airplane in a tail low, three-point landing. About 30 feet into
the landing roll the airplane suddenly turned sharply to the right and ground looped. Subsequently, the landing gear collapsed and the left wing impacted the
ground.
Postaccident examination of the tailwheel by a Federal Aviation Administration inspector revealed the tailwheel was heavily worn; however, it castered freely,
and no anomalies were noted.
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02/11/2015 1510 PST Regis# N185NV
Acft Mk/Mdl CESSNA 185 - E-E
Acft SN 185-0984
Eng Mk/Mdl CONTINENTAL MOTOR IO-550-D15B
Opr Name: ANDREW T HOFFMAN
Carson City, CA
Apt: Careson City Airport CXP
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that immediately after touchdown he felt a very strong crosswind from the left that kicked the tail to the right. He then added full right rudder
and full power in an attempt to go around, however, the torque and P-factor, combined with the wind gust pulled the right wing to the ground. The pilot stated
that he subsequently reduced power and aborted the takeoff. With the right wing still in contact with the ground, the airplane rolled off of the runway into some
soft mud, which resulted in the airplane spinning around onto its nose, followed by the left wing contacting the ground; the airplane came to rest on its nose and
left wing. The airplane sustained substantial damage to the fuselage, both wings and associated ailerons, and both elevators. The pilot reported no preimpact
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain
directional control during landing with a crosswind which resulted in a ground loop.
Events
2. Landing-landing roll - Runway excursion
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained - C
3. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Contributed to outcome
Narrative
The pilot reported that immediately after touchdown he felt a very strong crosswind from the left that kicked the tail to the right. He then added full right rudder
and full power in an attempt to go around, however, the torque and P-factor, combined with the wind gust pulled the right wing to the ground. The pilot stated
that he subsequently reduced power and aborted the takeoff. With the right wing still in contact with the ground, the airplane rolled off of the runway into some
soft mud, which resulted in the airplane spinning around onto its nose, followed by the left wing contacting the ground; the airplane came to rest on its nose and
left wing. The airplane sustained substantial damage to the fuselage, both wings and associated ailerons, and both elevators. The pilot reported no preimpact
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Acft Mk/Mdl CESSNA 206H-H
04/04/2015 2200 HST Regis# N245RB
Acft SN 20608245
Honolulu, HI
Acft Dmg:
Fatal
0
Rpt Status: Prelim
Ser Inj
Opr Name: WORLDWIDE AIRCRAFT LEASING CORP Opr dba:
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Air Data Research
0
Prob Caus: Pending
Aircraft Fire:
All Rights Reserved
Accident Rpt# CEN15FA190
04/07/2015 6 CDT
Regis# N789UP
Bloomington, IL
Acft SN 414A0495
Rpt Status: Prelim
Fatal
Eng Mk/Mdl CONTINENTAL MOTORS TSIO-520-NB
Opr Name: MAKE IT HAPPEN AVIATION, LLC
7
Ser Inj
Opr dba:
Apt: Central Illinois Regional BMI
0
Prob Caus: Pending
Aircraft Fire: GRD
AW Cert: STN
Events
1. Approach-IFR missed approach - Loss of control in flight
Narrative
On April 7, 2015, about 0006 central daylight time (all referenced times will reflect central daylight time), a Cessna model 414A twin-engine airplane, N789UP,
was substantially damaged when it collided with terrain following a loss of control during an instrument approach to Central Illinois Regional Airport (BMI),
Bloomington, Illinois. The airline transport pilot and six passengers were fatally injured. The airplane was owned by and registered to Make It Happen Aviation,
LLC, and was operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 while on an instrument flight rules (IFR) flight plan. Night
instrument meteorological conditions prevailed for the cross-country flight that departed Indianapolis International Airport (IND), Indianapolis, Indiana, at 2307
central daylight time.
According to preliminary Federal Aviation Administration (FAA) Air Traffic Control (ATC) data, after departure the flight proceeded direct to BMI and climbed to
a final cruise altitude of 8,000 feet mean sea level (msl). According to radar data, at 2344:38 (hhmm:ss), about 42 nautical miles (nm) south-southeast of BMI,
the flight began a cruise descent to 4,000 feet msl. At 2352:06, the pilot established contact with Peoria Terminal Radar Approach Control, reported being level
at 4,000 feet mean sea level (msl), and requested the Instrument Landing System (ILS) Runway 20 instrument approach into BMI. According to radar data, the
flight was located about 21 nm south-southeast of BMI and was established on a direct course to BMI at 4,000 feet msl. The approach controller told the pilot to
expect radar vectors for the ILS Runway 20 approach. At 2354:18, the approach controller told the pilot to make a right turn to a 330 degree heading. The pilot
acknowledged the heading change. At 2359:16, the approach controller cleared the flight to descend to maintain 2,500 feet msl. At 2359:20, the pilot
acknowledged the descent clearance.
At 0000:01, the approach controller told the pilot to turn left to a 290 heading. The pilot acknowledged the heading change. At 0000:39, the approach controller
told the pilot that the flight was 5 nm from EGROW intersection, cleared the flight for the ILS Runway 20 instrument approach, issued a heading change to 230
degrees to intercept the final approach course, and told the pilot to maintain 2,500 feet until established on the inbound course. The pilot correctly read-back
the instrument approach clearance, the heading to intercept the localizer, and the altitude restriction.
According to radar data, at 0001:26, the flight crossed through the final approach course while on the assigned 230 degree heading before it turned to a
southerly heading. The plotted radar data showed the flight made course corrections on both sides of the localizer centerline as it proceeded inbound toward
EGROW. At 0001:47, the approach controller told the pilot to cancel his IFR flight plan on the approach control radio frequency, that radar services were
terminated, and authorized a change to the common traffic advisory frequency (CTAF). According to radar data, the flight was 3.4 nm outside of EGROW,
established inbound on the localizer, at 2,400 feet msl. At 0002:00, the pilot transmitted over the unmonitored CTAF, "twin Cessna seven eight nine uniform
pop is coming up on EGROW, ILS Runway 20, full stop." No additional transmissions from the pilot were recorded on the CTAF or by Peoria Approach Control.
According to radar data, at 0003:12, the flight crossed over the locator outer marker (EGROW) at 2,100 feet msl. The flight continued to descend while tracking
the localizer toward the runway. At 0003:46, the airplane descended below available radar coverage at 1,500 feet msl. The flight was about 3.5 nm from the end
of the runway when it descended below radar coverage. Subsequently, at 0004:34, radar coverage was reestablished with the flight about 1.7 nm north of the
runway threshold at 1,400 feet msl. The plotted radar data showed that, between 0004:34 and 0005:08, the flight climbed from 1,400 feet msl to 2,000 feet msl
while maintaining a southerly course. At 0005:08, the flight began a descending left turn to an easterly course. The airplane continued to descend on the
easterly course until reaching 1,500 feet msl at 0005:27. The airplane then began a climb while maintaining an easterly course. At 0005:42, the airplane had
flown 0.75 nm east of the localizer centerline and had climbed to 2,000 feet. At 0005:47, the flight descended below available radar coverage at 1,800 feet msl.
Subsequently, at 0006:11, radar coverage was reestablished at 1,600 feet msl about 0.7 nm southeast of the previous radar return. The next two radar returns,
recorded at 0006:16 and 0006:20, were at 1,900 feet msl and were consistent with the airplane continuing on an easterly course. The final radar return was
recorded at 0006:25 at 1,600 feet msl about 2 nm east-northeast of the runway 20 threshold.
At 0005, the BMI automated surface observing system reported: wind 060 degrees at 6 knots, an overcast ceiling at 200 feet above ground level (agl), 1/2 mile
surface visibility with light rain and fog, temperature 13 degrees Celsius, dew point 13 degrees Celsius, and an altimeter setting of 29.98 inches of mercury.
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02/15/2015 1845 PST Regis# N93810
Acft Mk/Mdl CESSNA T210 - L
Acft SN 21060418
Eng Mk/Mdl TELEDYNE CONTINENTAL TSIO-520-H4B Acft TT
Opr Name: WILLIAM F ALMON
4551
The Dalles, OR
Apt: Columbia Gorge Regional DLS
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot stated that prior to entering the traffic pattern, he did not visually verify or confirm that the landing gear positioning lights indicated that the gear was
extended and locked. After turning onto the base leg he deployed full flaps and conducted a memorized pre landing checklist, however he stated that he was
unsure if he verified that the gear was extended. The airplane subsequently touched down with the landing gear retracted; substantially damaging the lower
fuselage.
The pilot reported there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to extend the
landing gear prior to touch down. Contributing to the accident was the pilot's failure to utilize the pre-landing checklist.
Events
1. Landing-flare/touchdown - Landing gear not configured
1. Aircraft-Aircraft systems-Landing gear system-Gear extension and retract sys-Not used/operated - C
2. Personnel issues-Task performance-Use of equip/info-Use of checklist-Pilot - F
Narrative
The pilot stated that prior to entering the traffic pattern, he did not visually verify or confirm that the landing gear positioning lights indicated that the gear was
extended and locked. After turning onto the base leg he deployed full flaps and conducted a memorized pre landing checklist; however, he stated that he was
unsure if he verified that the gear was extended. The airplane subsequently touched down with the landing gear retracted, substantially damaging the lower
fuselage.
The pilot reported there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
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03/05/2015 1415 PST Regis# N8905R
Upland, CA
Apt: Cable CCB
Acft Mk/Mdl CHAMPION 7EC-NO SERIES
Acft SN 7EC-712
Eng Mk/Mdl CONTINENTAL MOTORS C90
Acft TT
Fatal
Opr Name: CABLE AIRCRAFT COMPANY INC
Opr dba:
2295
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Landing - Loss of control on ground
Narrative
The certificated pilot was receiving tailwheel instruction and stated he was practicing touch-and-go landings. On his seventh landing, the airplane went to the
right of the center line and he overcorrected. The flight instructor took the controls of the airplane. The right wing struck the ground and the airplane departed
the runway to the left. The airplane subsequently ground looped which resulted in substantial damage to the right wing.
The pilot reported no pre-impact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.
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Accident Rpt# ANC13FA090
08/29/2013 1300 AKD Regis# N9624S
Acft Mk/Mdl CHAMPION 7ECA
Acft SN 169
Opr Name: NORTON ADAM C
Sutton, AK
Apt: N/a
Fatal
2
Ser Inj
0
Opr dba:
Aircraft Fire: NONE
AW Cert: STN
Summary
Theÿpilot andÿpassenger were reported to be scouting for locations to hunt moose. When the pilot did not return home at his specified time, a search was
initiated for the airplane. The wreckage was located in an area of heavy alder brush, about 250 yards upslope of the floor of about a 3-mile-wide mountain
valley. The area surrounding the accident site was interlaced with game trails, and numerous moose tracks and signs were in the area. A large herd of moose
was also spotted in the same valley in the days after the accident.
The airplane collided with the ground in a nose-low attitude, and impact damage was consistent with a near-vertical descent, indicating that an aerodynamic
stall occurred. A postaccident examination revealed no evidence of a mechanical malfunction or failure with the airframe or engine before impact.
Toxicology tests on the pilot were found positive for metabolites of marijuana within the blood and lung tissue. Most behavioral and physiological effects return
to baseline levels within 3 to 5 hours after drug use, although some residual effects on specific behaviors, such as complex divided attention tasks, have been
demonstrated up to 24 hours after use. Psychomotor impairment can persist after the perceived high has dissipated. Based on the toxicology results, it is likely
that the pilot used marijuana on the day of the accident. Although the pilot's use of marijuana likely affected his ability to successfully manage this flight, the
exact degree of impairment in cognition, judgment, and motor function could not be determined.
Cause Narrative
airplane control while maneuvering at low altitude, which resulted in an aerodynamic stall/spin and collision with terrain. Contributing to the accident was the
pilot's use of marijuana, which likely degraded his psychomotor ability.
Events
1. Maneuvering-low-alt flying - Aerodynamic stall/spin
2. Maneuvering-low-alt flying - Loss of control in flight
3. Uncontrolled descent - Collision with terr/obj (non-CFIT)
1. Personnel issues-Psychological-Attention/monitoring-Task monitoring/vigilance-Pilot - C
3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
4. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Not attained/maintained - C
5. Personnel issues-Physical-Impairment/incapacitation-Illicit drug-Pilot - F
Narrative
HISTORY OF FLIGHT
On August 29, 2013, about 1300 Alaska daylight time, a Champion 7ECA (Citabria) airplane, N9624S, sustained substantial damage following a collision with
terrain about 7 miles north of Sutton, Alaska. The private pilot and one passenger were fatally injured. The airplane was registered to, and operated by the pilot
as a visual flight rules personal local flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no
flight plan was filed. The flight originated from the Wolf Lake Airport, Palmer, Alaska, around 1200.
According to a family member of the pilot, the purpose of the flight was to scout for locations to hunt moose, and the pilot said that they would return later that
afternoon.
When the airplane did not return to Wolf Lake, a family member of the passenger reported the airplane overdue to the 11th Air Force's Rescue Coordination
Center (RCC) about 1930. The RCC initiated a search for the missing airplane along its supposed route of flight. In the early morning hours of August 30, an Air
National Guard C-130 Hercules was able to locate the wreckage. Rescue personnel aboard a HH-60G helicopter were able to reach the site later that morning,
and confirmed the pilot and passenger were deceased.
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The pilot, age 30, held a private pilot certificate with a rating for airplane single engine land. He was issued a third class airman medical certificate on October
15, 2012.
No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from Federal Aviation
Administration (FAA) airman records on file in the Aerospace Medical Certification Division in Oklahoma City, Oklahoma. On the pilot's most recent application
for a medical certificate, he indicated his total aeronautical experience was 84.2 hours, of which 1 hour was in the previous 6 months. Additional time logs
found in the accident airplane indicated a total additional flight time since the pilot's last medical of approximately 40 hours.
The two-seat, high-wing, fixed-gear airplane, serial number (S/N) 169, was manufactured in 1966. It was powered by a Lycoming O-235-C1 engine, rated at 115
horsepower, driving a two-bladed metal fixed pitch propeller. The aircraft logbooks were not located during the investigation.
A note found inside the airplane revealed that, on August 27, 2013, the airplane had an oil and filter change, new wheels installed, and a new starter installed.
The tachometer time for this maintenance was recorded at 112.0 hours. The tachometer time recorded at the accident site was 112.8 hours.
The closest weather reporting facility is the Palmer Airport, about 14 miles south of the accident site. At 1353, an Aviation Routine Weather Report (METAR)
was reporting, in part: Wind, 060 degrees (true) at 6 knots; visibility, 10 statute miles; clouds and sky condition, overcast at 10,000 feet; temperature, 57
degrees F; dew point, 48 degrees F; altimeter, 29.73 inches.
The National Transportation Safety Board investigator-in-charge (IIC) along with an additional NTSB investigator reached the accident site on the morning of
August 31. The wreckage was located in an area of heavy alder brush, about 250 yards upslope of the floor of about a three mile wide mountain valley. The
area surrounding the accident site was interlaced with game trails, and there were numerous moose tracks and sign in the area. A large herd of moose was
also spotted in the same valley in the days after the accident.
The airplane came to rest upright, in a nose-low attitude, and was resting on several toppled and broken trees. The tail was against a tree supported by the
vertical stabilizer.
All control surfaces were identified at the accident site, and flight control continuity was verified from all of the flight control surfaces to the cockpit.
Both wings had spanwise leading edge crushing.
The empennage was mostly free of impact damage. The right elevator was resting against a tree and the trailing edge was crushed and bent upward.
The engine and propeller were partially buried in soft terrain; however the visible portions of the engine showed no anomalies to the case or accessories. The
visible portion of one propeller blade was relatively free of impact damage.
Both main landing gear were bent upward and aft from their connecting points and exhibited signs of left-side loading.
The cockpit area was extensively damaged. The engine and firewall were displaced upward and aft, and the instrument panel was displaced upward, almost to
the top of the windscreen. The mixture control was found in the full-forward position. The carburetor heat was in the off position. Throttle position could not be
determined due to damage to the throttle lever. The master switch was in the on position, and the both magneto switches were in the "ON" position.
A postmortem examination was conducted under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on September 3, 2013. The cause of
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death for the pilot was attributed to multiple blunt force injuries.
The FAA's Civil Aeromedical Institute performed toxicological examinations for the pilot on October 7, 2013. The tests were negative for carbon monoxide and
alcohol, and positive for the following drugs:
0.2044 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung
0.0871 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver
0.0094 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood
0.2495 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver
0.0146 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine
0.012 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood
0.0055 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung
Tetrahydrocannabinol (THC) is the psychoactive compound found in marijuana with therapeutic levels as low as 0.001 ug/ml. THC has mood altering effects
causing euphoria, relaxed inhibitions, sense of well-being, disorientation, image distortion, and psychosis. The ability to concentrate and maintain attention is
decreased during marijuana use, and impairment of hand-eye coordination is dose-related over a wide range of dosages. Impairment in retention time and
tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided attention tasks have all been reported. Users may
be able to "pull themselves together" to concentrate on simple tasks for brief periods of time. Significant performance impairments are usually observed for at
least one to two hours following marijuana use, and residual effects have been reported up to 24 hours.
Tetrahydrocannabinol carboxylic acid is the inactive metabolite of tetrahydrocannabinol.
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Accident Rpt# GAA15LA027
03/28/2015 2342 UTC Regis# N550BS
Acft Mk/Mdl CUB CRAFTERS CC18 180-NO SERIES
Acft SN CC18-0015
Eng Mk/Mdl LYCOMING O-360-C4P
Opr Name: SYME ROBERT P DBA
Westfield Towns, OH
Apt: Crazy Bob's Airport 2O14
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba: ROBERTS MARINE
1
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
2. Landing - Loss of control on ground
Narrative
On March 28, 2015, about 1942 eastern daylight time, an amphibious float-equipped, Cub Crafter CC18-180 airplane, N550BS, was substantially damaged
when it impacted a tree and terrain during landing at Crazy Bob's Airfield (K2OI4), Westfield Center, Ohio. The airplane was being operated by the commercial
pilot as a visual flight rules, personal flight under 14 Code of Federal Regulation, Part 91. Visual meteorological conditions prevailed and the pilot sustained
serious injury. The flight departed Lagrange Airport (92D) about 1900.
A witness who heard the accident said, when he looked up, the airplane was upside down on the turf runway. The runway is lined on both sides with tall trees,
and broken tree branches lay near the airplane.
Due to his injuries the pilot has not been interviewed. The investigation is continuing.
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01/27/2015 1500 PST Regis# N805ER
La Verne, CA
Apt: Brackett Field POC
Acft Mk/Mdl DIAMOND AIRCRAFT IND INC DA
Acft SN 40.316
Eng Mk/Mdl LYCOMING IO360 SER
Acft TT
Fatal
Opr Name: MILE HIGH LLC
Opr dba: SO CAL FLYING CLUB
4495
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The student pilot reported that the purpose of the solo flight was for him to practice soft-field takeoffs from a hard surface runway. During the takeoff roll, the
airplane encountered a sudden gust of wind and the student pilot was unable to maintain directional control. The airplane veered to the left of the runway
centerline and continued off the surface, colliding with several signs before coming to rest in a grassy area. The airplane sustained substantial damage to the
left wing. The student pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. The
student pilot further reported that the accident could have been prevented if he was more vigilant of sudden gusts of wind even in reported calm wind
conditions.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The student pilot's loss of
directional control during takeoff from a runway, which resulted in a collision with a sign.
Events
1. Takeoff - Loss of control in flight
2. Takeoff - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Directional control-Not attained/maintained - C
2. Personnel issues-Task performance-Use of equip/info-Aircraft control-Student/instructed pilot - C
3. Environmental issues-Physical environment-Object/animal/substance-Sign/marker-Contributed to outcome
Narrative
The student pilot reported that the purpose of the solo flight was for him to practice soft-field takeoffs from a hard surface runway. During the takeoff roll, the
airplane encountered a sudden gust of wind and the student pilot was unable to maintain directional control. The airplane veered to the left of the runway
centerline and continued off the surface, colliding with several signs before coming to rest in a grassy area. The airplane sustained substantial damage to the
left wing. The student pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. The
student pilot further reported that the accident could have been prevented if he was more vigilant of sudden gusts of wind even in reported calm wind
conditions.
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03/13/2015 1800
Acft Mk/Mdl ENSTROM F28 - C
Regis# N5688N
Shelby, MT
Acft SN 495-2
Fatal
Eng Mk/Mdl LYCOMING HIO-360
Opr Name: TROY P. WANKEN
0
Apt: N/a
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that while maneuvering at a low altitude over a machinery yard, he observed a low rotor rpm condition. When he lifted the collective the rpm
continued to bleed off, which resulted in the helicopter yawing to the left. The pilot stated that he managed to get the helicopter back under control, but then
entered the low rotor rpm condition a second time. Unable to keep the helicopter flying straight, the aircraft impacted up sloping terrain with its left skid, followed
by the main rotor blades striking the ground. The helicopter sustained substantial damage due to the impact with terrain.
The pilot reported no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
Cause Narrative
main rotor RPM during a low altitude operation, which resulted in a loss of aircraft control and collision with terrain.
Events
1. Maneuvering-low-alt flying - Low altitude operation/event
2. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Prop/rotor parameters-Not attained/maintained - C
Narrative
The pilot reported that while maneuvering at a low altitude over a machinery yard, he observed a low rotor rpm condition. When he lifted the collective the rpm
continued to bleed off, which resulted in the helicopter yawing to the left. The pilot stated that he managed to get the helicopter back under control, but then
entered the low rotor rpm condition a second time. Unable to keep the helicopter flying straight, the aircraft impacted up sloping terrain with its left skid, which
was followed by the main rotor blades striking the ground. The helicopter sustained substantial damage due to the impact with terrain.
The pilot reported no preimpact mechanical malfunctions or failures with the helicopter that would have precluded normal operation.
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03/07/2015 1500 CDT Regis# N87EV
St Jacob, IL
Apt: St Louis Metro-east 3K6
Acft Mk/Mdl ERCOUPE 415 C-C
Acft SN 958
Eng Mk/Mdl CONT MOTOR A&C75 SERIES
Acft TT
Fatal
Opr Name: PILOT
Opr dba:
2411
0
Ser Inj
0
Aircraft Fire: NONE
Events
1. Approach-VFR go-around - Loss of engine power (total)
Narrative
On March 7, 2015, about 1500 central daylight time, an Ercoupe 415-C airplane, N87EV, impacted terrain during a forced landing following a loss of engine
power during a go-around near the St Louis Metro-East Airport/Shafer Field (3K6), St Jacob, Illinois. The private pilot was uninjured. The airplane sustained
substantial firewall and wing damage. The airplane was registered to an individual and operated by the pilot under the provisions of 14 Code of Federal
Regulations Part 91 as a ferry flight. Day visual flight rules conditions prevailed for the flight, which did not operate on a flight plan. The flight originated from the
A Paul Vance Fredericktown Regional Airport (H88), near Fredericktown, Missouri, about 1400.
The pilot stated in his accident report that he was flying the accident airplane under a ferry permit from H88 to Sackman Field Airport (H49), near Columbia,
Illinois. However, due to unsafe runway conditions at H49, 3K6 was chosen as an alternate airport. Upon arrival at 3K6, the pilot executed an aborted landing.
He applied engine power and climbed about 150-200 feet. The engine lost power without any "coughing" or warning.
At 1358, the recorded weather at the Scott Air Force Base/MidAmerica Airport, near Belleville, Illinois, was: Wind 230 degrees at 2 knots; visibility 10 statute
miles; sky condition clear; temperature 18 degrees C; dew point 1 degree C; altimeter 30.13 inches of mercury.
A Federal Aviation Administration inspector examined the accident airplane. He observed that the fuel exiting from the header fuel tank was not aviation
gasoline. The inspector observed the accident airplane during a subsequent engine run. The engine started, ran rough, and it would not accelerate smoothly
when it was fed fuel from the header tank containing fuel from the accident flight. The header tank was drained and fresh aviation gasoline was added to the
tank. The engine ran smoothly and accelerated normally.
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03/29/2015 1245 PDT Regis# N381BA
Acft Mk/Mdl LET L23 - NO SERIES-NO S
Opr Name: LOS ALAMITOS GLIDER TRAINING
SQAUDRON 41
Los Alamitos, CA
Apt: Los Alamitos Aaf SLI
Acft SN 018801
Acft TT
Fatal
391
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
2. Initial climb - Loss of lift
Narrative
The glider instructor was giving an introduction flight. During the tow-plane assisted launch, the glider's air brakes were inadvertently deployed. The tow plane
was unable to obtain a positive rate of climb, so the tow-plane pilot signaled for a glider disconnect. The glider pilot released the glider from the tow plane, about
175 feet above the ground. After the release the pilot made a 125 degree right turn to land on an adjacent taxiway and touched down with a high descent rate.
During the landing the glider sustained substantial damage to the right wing, right aileron, and fuselage. The pilot sustained minor injuries. The passenger was
not injured.
The pilot reported no mechanical malfunctions or failures with the glider prior to the accident that would have resulted in abnormal operation of the glider. In
addition, he reported that he accomplished a pre-launch checklist prior to the flight and that the launch was more turbulent than normal. He remarked that the
accident could have been prevented if he would have landed straight ahead instead of making the right turn.
Witnesses on the ground reported seeing the air brakes deploy during the launch.
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03/28/2014 830 CDT
Acft Mk/Mdl MAULE MX 7-180B-180B
Opr Name: PARTHENON LLC
Regis# N10503
Dora, AR
Acft SN 22016C
Acft TT
Fatal
726
0
Apt: N/a
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot performed one stop and go landing on the unimproved landing area. During the second landing attempt he bounced the initial landing, added power to
recover, and attempted to land again about midfield. The pilot evaluated the distance remaining and elected to go around. After adding power and committing to
the takeoff, the pilot recognized he would not be able to maintain obstacle clearance and attempted to maneuver to a fly over a low fence crossing. The
airplane impacted the fence, and came to an immediate stop. The airplane's right main landing gear was bent aft resulting in substantial damage to the
fuselage. The pilot reported no anomalies with the airplane prior to the accident.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's bounced landing and
delayed decision to go around, which resulted in collision with a fence during the go around.
Events
1. Takeoff - Loss of control in flight
2. Takeoff - Collision with terr/obj (non-CFIT)
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Not attained/maintained - C
2. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - F
3. Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Ability to respond/compensate
4. Environmental issues-Physical environment-Object/animal/substance-Fence/fence post-Effect on equipment
Narrative
The pilot performed one stop and go landing on the unimproved landing area. During the second landing attempt he bounced the initial landing, added power to
recover, and attempted to land again about midfield. The pilot evaluated the distance remaining and elected to go around. After adding power and committing to
the takeoff, the pilot recognized he would not be able to maintain obstacle clearance and attempted to maneuver to a fly over a low fence crossing. The
airplane impacted the fence, and came to an immediate stop. The airplane's right main landing gear was bent aft resulting in substantial damage to the
fuselage. The pilot reported no anomalies with the airplane prior to the accident.
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07/14/2014 1220
Regis# N562BG
Durango, CO
Acft Mk/Mdl MOONEY AIRPLANE CO INC M20TN-NO
Acft SN 31-0031
Eng Mk/Mdl CONT MOTOR TSIO-550-G
Acft TT
Fatal
Opr Name: JOHN B HARRINGTON
Opr dba:
335
0
Apt: Durango-la Plata County DRO
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Landing-flare/touchdown - Loss of control in flight
Narrative
The pilot reported the airplane ballooned up after touchdown onto the runway. He applied "moderate power" to hold the airplane above the runway, while the
airspeed decreased and the airplane settled onto the runway again. When "moderate power" was applied, the airplane climbed and the stall warning horn
sounded. The pilot applied full power to go-around. The airplane banked left off the runway, bounced 2 to 3 times and came to rest on the opposite side of the
parallel taxiway. The airplane sustained substantial damage to the left wing.
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01/29/2015 1530 PST Regis# N918TF
Ridgefield, WA
Apt: N/a
Acft Mk/Mdl PIPER PA 12
Acft SN 12-2232
Acft TT
Fatal
Opr Name: NICOLAI JANE G
Opr dba:
3010
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
The pilot reported that 15 minutes after takeoff, during cruise flight, the engine experienced a total loss of power. She pulled the carburetor heat control knob
on, and initiated a forced landing to a grassy field. During the landing roll, the airplane collided with heavy vegetation, which resulted in substantial damage to
the left wing.
About 30 minutes prior to the accident, a weather station located about 10 nautical miles from the accident site reported a temperature of 48 degrees F and
dew point of 43 degrees F. These weather conditions were conductive to the high probability of carburetor ice formation, with the potential for serious icing at
cruise power.
During the postaccident engine examination, the engine was prepared for an engine run. The engine was started and run with no mechanical failures or
malfunctions noted that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's delayed action to use
carburetor heat before the engine experienced a total loss of power while operating at cruise flight in conditions conducive to carburetor icing.
Events
1. Enroute-cruise - Loss of engine power (total)
2. Landing-landing roll - Collision with terr/obj (non-CFIT)
1. Environmental issues-Conditions/weather/phenomena-Temp/humidity/pressure-Conducive to carburetor icing-Effect on equipment - C
2. Personnel issues-Action/decision-Action-Delayed action-Pilot - C
Narrative
The pilot reported that 15 minutes after takeoff, during cruise flight, the engine experienced a total loss of power. She pulled the carburetor heat control knob
on, and initiated a forced landing to a grassy field. During the landing roll, the airplane collided with heavy vegetation, which resulted in substantial damage to
the left wing.
About 30 minutes prior to the accident, a weather station located about 10 nautical miles from the accident site reported a temperature of 48 degrees F and
dew point of 43 degrees F. These weather conditions were conductive to the high probability of carburetor ice formation, with the potential for serious icing at
cruise power.
During the postaccident engine examination, the engine was prepared for an engine run. The engine was started and run with no mechanical failures or
malfunctions noted that would have precluded normal operation.
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Accident Rpt# ANC15CA022
04/19/2015 1530 ADT Regis# N2894Z
Acft Mk/Mdl PIPER PA 18A 150-A150
Acft SN 18-7078
Nondalton, AK
Acft Dmg: UNK
Fatal
Opr Name: KEITH MANTERNACH
Page 58
Apt: Nondalton 5NN
0
Ser Inj
Opr dba:
Air Data Research
Rpt Status: Prelim
1
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved
03/01/2015 1900 CST Regis# N1513J
Kansas City, MO
Apt: Charles B Wheeler Downtown Apt KMKC
Acft Mk/Mdl PIPER PA 28-140-140
Acft SN 28-23907
Eng Mk/Mdl LYCOMING 0-320-E2A
Acft TT
Fatal
Opr Name: ETHINGTON
Opr dba:
4339
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
Shortly after takeoff, following a touch and go landing, the engine sputtered and lost power. The left wing and empennage were substantially damaged during
the forced landing. An examination of the airplane, engine, and related systems revealed no anomalies. The left fuel tank was empty and the right fuel tank
contained 10 gallons of fuel. The pilot wrote that the loss of engine power was the result of fuel starvation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The loss of engine power due to
fuel starvation.
Events
1. Takeoff - Fuel starvation
2. Takeoff - Loss of engine power (total)
3. Landing-flare/touchdown - Dragged wing/rotor/float/other
1. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid management - C
2. Personnel issues-Task performance-Use of equip/info-Use of available resources-Pilot - C
Narrative
Shortly after takeoff, following a touch and go landing, the engine sputtered and lost power. The left wing and empennage were substantially damaged during
the forced landing. An examination of the airplane, engine, and related systems revealed no anomalies. The left fuel tank was empty and the right fuel tank
contained 10 gallons of fuel. The pilot wrote that the loss of engine power was the result of fuel starvation.
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02/24/2015 845 MST
Regis# N963WW
Phoenix, AZ
Acft Mk/Mdl PIPER PA 28R-201
Acft SN 2844023
Eng Mk/Mdl LYCOMING IO-360-C1C6
Acft TT
Fatal
Opr Name: WESTWIND SCHOOL OF AERONAUTICS
Opr dba:
8548
0
Apt: Phoenix Deer Valley DVT
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Summary
According to both the flight instructor and the pilot undergoing instruction (PUI), during the landing rollout, the PUI inadvertently retracted the landing gear. The
landing gear handle was immediately selected to down; however, they felt the airplane sink to the left. The airplane sustained structural damage to the left wing,
stabilator, and empennage. Both pilots reported no mechanical malfunctions that would have precluded normal operation.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot under instruction's
inadvertent retraction of the landing gear during the landing rollout.
Events
1. Landing-landing roll - Abrupt maneuver
2. Landing-landing roll - Attempted remediation/recovery
1. Personnel issues-Action/decision-Action-Incorrect action selection-Student/instructed pilot - C
2. Aircraft-Aircraft systems-Landing gear system-Landing gear selector-Incorrect use/operation - C
3. Personnel issues-Task performance-Use of equip/info-Use of equip/system-Student/instructed pilot - C
Narrative
According to both the flight instructor and the pilot undergoing instruction (PUI), during the landing rollout, the PUI inadvertently retracted the landing gear. The
landing gear handle was immediately selected to down; however, they felt the airplane sink to the left. The airplane sustained structural damage to the left wing,
stabilator, and empennage. Both pilots reported no mechanical malfunctions that would have precluded normal operation.
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04/27/2014 2116 CDT Regis# N8700E
Highmore, SD
Apt: N/a
Acft Mk/Mdl PIPER PA 32R-300
Acft SN 32R-7680159
Acft Dmg: DESTROYED
Eng Mk/Mdl LYCOMING IO-540-K1G5D
Acft TT
Fatal
Opr Name: FISCHER DONALD J
Opr dba:
4766
4
Ser Inj
0
Aircraft Fire: GRD
Summary
During a dark night cross-country flight, the instrument-rated pilot was approaching the intended airport for landing when the airplane collided with the blades of
a wind turbine tower. The weather had started to deteriorate and precipitation echoes were observed on radar. Witnesses in the area described low clouds,
windy conditions, and precipitation. In addition, weather briefing records and statements made to a witness indicate that the pilot was aware of the current and
forecast weather conditions for the route of flight. Investigators were unable to determine why the airplane was operating at a low altitude; however, the pilot
was likely attempting to remain clear of the clouds even though both the pilot and the airplane were capable of flying in instrument meteorological conditions. An
examination of the airplane, systems, and engine revealed no anomalies that would have precluded normal operation. Toxicology findings revealed a small
amount of ethanol in the pilot's blood, which was unlikely due to ingestion since no ethanol was found in liver or muscle tissue.The investigation revealed that
the wind turbine farm was not marked on either sectional chart covering the accident location; however, the pilot was familiar with the area and with the wind
turbine farm. Investigators were not able to determine what the pilot was using for navigation just before the accident. The light on the wind turbine tower that
was struck was not operational at the time of the accident, and the outage was not documented in a notice to airmen. The wind turbine that was struck was the
5th tower in a string of towers oriented east to west, then the string continued south and southwest with an additional 13 towers. If the pilot observed the lights
from the surrounding wind turbines, it is possible that he perceived a break in the light string between the wind turbines as an obstacle-free zone.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's decision to continue
the flight into known deteriorating weather conditions at a low altitude and his subsequent failure to remain clear of an unlit wind turbine. Contributing to the
accident was the inoperative obstruction light on the wind turbine, which prevented the pilot from visually identifying the wind turbine.
Events
1. Enroute - Controlled flight into terr/obj (CFIT)
1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C
2. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C
3. Environmental issues-Physical environment-Object/animal/substance-(general)-Effect on operation - F
4. Environmental issues-Conditions/weather/phenomena-Ceiling/visibility/precip-Low ceiling-Effect on operation
5. Environmental issues-Conditions/weather/phenomena-Light condition-Dark-Effect on operation
6. Environmental issues-Physical environment-Object/animal/substance-(general)-Compliance w/ procedure
Narrative
HISTORY OF FLIGHT
On April 27, 2014, about 2116 central daylight time (CDT), a Piper PA-32R-300 airplane, N8700E, was destroyed during an impact with the blades of a wind
turbine tower 10 miles south of Highmore, South Dakota. The commercial pilot and three passengers were fatally injured. The airplane was registered to and
operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Dark night instrument meteorological
conditions prevailed for the flight, which operated without a flight plan. The flight originated from Hereford Municipal Airport (KHRX), Hereford, Texas,
approximately 1700, and was en route to Highmore Municipal Airport (9D0), Highmore, South Dakota.
According to family members, the pilot and three passengers had been in Texas for business. The pilot's family reported that they had intended to leave earlier
in the day, on the day of the accident, but elected to delay, and subsequently left later than they had planned. The family stated that most likely, the flight was
going to stop at 9D0 to drop off one passenger before continuing to Gettysburg Municipal Airport (0D8), Gettysburg, South Dakota.
A fixed base operator employee at KHRX witnessed the pilot fuel the accident airplane at the self-serve fuel pump just prior to the accident flight. He reported
that the fuel batch report showed 82.59 gallons of fuel had been dispensed. The pilot commented to the employee that he was going to "top it off" as he had
"pushed his luck on the trip down." The pilot also discussed the weather conditions in South Dakota, noting that it was raining there. The pilot also added that
the only reason they were leaving was because one of the passengers was anxious to get home.
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The pilot contacted the Fort Worth Lockheed Martin Contract Flight Service Station at 1711 when the airplane was 38 miles west of Borger, Texas, on a direct
flight to North Platte, Nebraska. The pilot requested and obtained an abbreviated weather briefing. During this briefing, winds aloft and weather advisories for
the reported route of flight were provided. The pilot also provided a pilot report for his position.
At 1812 the pilot sent a text stating that they were "Into KS aways" (sic). At 1923 he sent a text stating that they were "into NE". At 2054 he stated that they
were flying by Chamberlain, South Dakota.
Several witnesses in the area reported seeing an airplane fly over their homes the evening of the accident. The first witness, located near the shore of the
Missouri River, near Fort Thompson, South Dakota, reported seeing an airplane about 200 feet above the ground, flying to the northeast, about 2045. He stated
that the airplane was low and was moving quickly. The second witness, located a few miles southwest of the accident site, reported seeing an airplane flying at
a very low altitude, headed north, about 2115. Neither witness reported hearing problems with the engine.
According to the Federal Aviation Administration (FAA), the airplane was reported missing by a concerned family member when the airplane did not arrive in
Gettysburg, South Dakota, on the evening of April 27, 2014. The wreckage of the airplane was located by members of the Hyde County Fire Department and
the Hyde County Sheriff's department around 0330 on the morning of April 28, 2014. The pilot was not communicating with air traffic control at the time of the
accident and radar data for the accident flight was not available.
OTHER DAMAGE
Wind turbine tower #14, part of the South Dakota Wind Energy Center owned by NextEra Energy Resources, was damaged during the accident sequence. One
of the three blades was fragmented into several large pieces. One large piece remained partially attached to a more inboard section of the turbine blade. The
inboard piece of this same turbine blade remained attached at the hub to the nacelle. The outboard fragmented pieces of the wind turbine blade were located in
a radius surrounding the base of the wind turbine tower. The other two wind turbine blades exhibited impact damage along the leading edges and faces of the
blades.
The pilot, age 30, held a commercial pilot certificate with airplane single engine land, multiengine land, and instrument ratings. He was issued a second class
airman medical certificate without limitations on January 19, 2014. The pilot was a professional agricultural pilot and had flown agricultural airplanes in the area
for several seasons.
The family provided investigators the pilot's flight logbook. The logbook covered a period between April 22, 2010, and April 20, 2014. He had logged no less
than 3,895.8 hours total time; 100.7 hours of which were in the make and model of the accident airplane and 95.1 hours of which were in the accident airplane.
This time included 76.2 hours at night, 1.1 hours of which had been recorded within the previous 90 days. The pilot was current for flight with passengers at
night. He successfully completed the requirements of a flight review on January 18, 2013. He successfully completed an instrument proficiency check in a
PA-32R on February 7, 2014.
According to the FAA, the pilot was familiar with the accident area. Specifically, the pilot was familiar with the wind turbine farm and had expressed his concern
about the wind turbine farm to the FAA Flight Standards District Office in Rapid City, South Dakota. The details of his concerns were not available.
The accident airplane, a Piper PA-32R-300 (serial number 32R-7680159), was manufactured in 1976. It was registered with the FAA on a standard
airworthiness certificate for normal operations. A Lycoming IO-540-K1G5D engine rated at 300 horsepower at 2,700 rpm powered the airplane. The engine was
equipped with a 2-blade Hartzell propeller. The airplane was equipped and certified for flight in instrument meteorological conditions.
The airplane was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been
completed on April 17, 2013, at an airframe total time of 4,766 hours.
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The closest official weather observation station was Pierre Regional Airport (KPIR), Pierre, South Dakota, located 35 miles west of the accident location. The
elevation of the weather observation station was 1,744 feet mean sea level (msl). The routine aviation weather report (METAR) for KPIR, issued at 2124,
reported wind from 010 degrees at 19 knots, visibility 10 miles, light rain, sky condition broken clouds at 1,000 feet, overcast at 1,600 feet, temperature 6
degrees Celsius (C), dew point temperature 5 degrees C, altimeter 29.37 inches, remarks ceiling variable between 800 and 1,200 feet.
The METAR issued at 2139 for KPIR reported wind from 070 degrees at 19 knots, visibility 4 miles, rain, mist, sky condition ceiling overcast clouds at 800 feet,
temperature 6 degrees C, dew point temperature 5 degrees C, altimeter 29.37 inches, remarks ceiling variable between 600 and 1,300 feet.
Huron Regional Airport (KHON) in Huron, South Dakota, was located 53 miles to the east of the accident site at an elevation of 1,289 feet. The METAR issued
at 2055 for KHON reported wind from 100 degrees at 20 knots, gusting to 27 knots, visibility 10 miles, sky condition ceiling overcast at 1,000 feet, temperature
9 degrees C, dew point temperature 7 degrees C, altimeter 29.36 inches, remarks peak wind of 29 knots from 090 degrees at 2015, rain began at 1956 and
ended at 2006.
The National Weather Service (NWS) Surface Analysis Chart for 2200 CDT depicted a low-pressure center in southern Nebraska, with an occluded front
extending into northeastern Kansas. A stationary front extended from northeastern Nebraska southeast through southern Iowa. Surface wind east of the
accident location was generally easterly, with surface wind to the west of the accident location generally northerly. Station models across the state of South
Dakota depicted overcast skies, with temperatures ranging from the high 30's Fahrenheit (F) to the mid-50's F. Rain and haze were depicted across the state.
A regional Next-Generation Radar (NEXRAD) mosaic obtained from the National Climatic Data Center (NCDC) for 2115 identified a large portion of South
Dakota under light to moderate values of reflectivity, including the region surrounding the accident site. WSR-88D Level II radar data obtained at 2114 from
Aberdeen, South Dakota, (KABR), depicted altitudes between 5,460 and 13,200 feet at the accident site. The KABR data identified an area of light reflectivity
coincident with the accident location approximately two minutes prior to the accident time.
Advanced Very High Resolution Radiometer (AVHRR) data from the NOAA-16 satellite data were obtained from the National Oceanic and Atmospheric
Administration and identified cloudy conditions at or near the accident site. Cloud-top temperatures in the region varied between -53 degrees C and 6 degrees
C. The temperature of -53 degrees C corresponded to heights of approximately 35,000 feet. Due to a temperature inversion in the ABR sounding near 4,000
feet, the temperature of 6 degrees C may correspond to various cloud heights ranging from at or very near the surface to between 3,500 and 6,500 feet.
An Area Forecast that included South Dakota was issued at 2045 CDT. The portion of the Area Forecast directed toward the eastern two-thirds of South
Dakota forecasted for the accident time: ceiling overcast at 3,000 feet msl with cloud tops to flight level (FL)180, widely scattered light rain showers, and wind
from the east at 20 knots with gusts to 30 knots. Prior to the 2045 CDT Area Forecast, another Area Forecast that included South Dakota was issued at 1345
CDT. The portion of the Area Forecast directed toward the central and eastern portions of South Dakota forecasted for the accident time: ceiling overcast at
3,000 feet msl with clouds layered up to FL300, scattered thunderstorms with light rain, cumulonimbus cloud tops to FL400, wind from the southeast at 20
knots with gusts to 35 knots.
Airmen's Meteorological Information (AIRMET) SIERRA for IFR conditions was issued at 1959 CDT for a region that included the accident location. AIRMET
TANGO for moderate turbulence for altitudes below 15,000 feet was issued at 1545 CDT for a region that included the accident location. The AIRMET also
addressed strong surface winds for a region that did not include the accident location. AIRMET ZULU for moderate ice for altitudes between the freezing level
and FL200 was issued at 1545 CDT for a region that included the accident location.
There were no non-convective Significant Meteorological Information (SIGMET) advisories active for the accident location at the accident time. There were two
Convective SIGMETs issued for convection close to the accident location in the two hours prior to the accident time
According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 2037 and the end of
civil twilight was 2109. The moon rose at 0615 on the following day.
At the time of the accident the wind turbine tower #14 recorded the wind velocity at 9.7 meters per second or 21 miles per hour and the ambient temperature
was 7 degrees C.
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The pilot logged on to the CSC DUAT System on April 26, 2014, at 2141:36 and requested a low altitude weather briefing quick path service. The pilot identified
the route of flight as a direct flight between KHRX and 0D8, at an altitude of 8,500 feet.
AIDS TO NAVIAGATION
The FAA Twin Cities Sectional Chart 87th edition, dated 9 January, 2014, through 26 June, 2014, depicted the city of Highmore, South Dakota, and the
Highmore Airport on the southern edge of the chart boundary. The city of Highmore and the airport were both within the same boundary box with a maximum
elevation figure of 24 or 2,400 feet msl. The maximum elevation figure immediately south of Highmore was 27 or 2,700 feet msl. An obstacle at an elevation of
276 feet above ground level (agl) and 2,180 feet msl was depicted immediately south of the city of Highmore. A wind farm was depicted south and east of Ree
Heights, South Dakota - this wind farm was at an elevation of 420 feet agl and 2,447 feet msl. The wind farm involved in this accident was not depicted on this
sectional chart.
The FAA Omaha Sectional Chart 89th edition, dated 6 February, 2014, through 24 July, 2014, depicted the city of Highmore, South Dakota, and the Highmore
Airport on the northern edge of the chart boundary. The city of Highmore and the airport were both within the same boundary box with a maximum elevation
figure of 24 or 2,400 feet msl. The maximum elevation figure immediately south of Highmore was 27 or 2,700 feet msl. A wind farm was depicted south and
east of Ree Heights, South Dakota - this wind farm was at an elevation of 420 feet agl and 2,447 feet msl and 420 feet agl and 2,500 feet msl.
A single obstruction was depicted on the chart about 7 miles south of the city of Highmore, just to the east of highway 57. The obstruction was at an elevation
of 215 feet agl and 2,335 feet msl. A group of obstructions was depicted on the chart about 9 miles south of the city of Highmore, just to the west of highway
57. The obstructions were at an elevation of 316 feet agl and 2,496 feet msl. The wind farm involved in this accident was not depicted on this sectional chart as
a wind farm.
According to the FAA, the 90th edition of the Omaha Sectional Chart, effective from 24 July, 2014, through 5 February, 2015, added the depiction of the
accident wind farm just south of the city of Highmore. This depicted the wind farm west and southwest of highway 57 at an elevation of 2,515 feet msl. In
addition, an unlit obstruction at an elevation of 415 feet agl and 2,597 feet msl was depicted just south of the wind farm boundary.
There are no instrument approach procedures into 9D0. There are two RNAV (GPS) approaches, runway 13 and runway 31, into 0D8.
FLIGHT RECORDERS
The accident airplane was equipped with an Apollo GX-50 panel-mount 8-channel GPS receiver. The unit includes a waypoint database with information about
airports, VOR, NDB, en route intersections, and special use airspace. Up to 500 custom user-defined waypoints may be stored, as well. The GX-50 is a
TSO-C129a class unit capable of supporting IFR non-precision approach operations. Thirty flight plans composed of a linked list of waypoints may be defined
and stored. The real-time navigation display can be configured to show: latitude/longitude, bearing, distance to target, ground speed, track angle, desired track,
distance, and an internal course deviation indicator (CDI). The unit stores historical position information in volatile memory; however, by design there is no
method to download this information.
The unit was sent to the NTSB Vehicle Recorders Lab in Washington D.C. for download. Upon arrival at the Vehicle Recorders Laboratory, an exterior
examination revealed the unit had sustained significant structural damage. An internal inspection revealed most internal components, including the battery,
were dislodged. Since the internal battery was dislodged and the unit relied upon volatile memory to record information, no further recovery efforts were
attempted.
The accident scene was located in level, vegetated terrain, in the middle of a wind turbine farm, about 10 miles south of Highmore, South Dakota. The terrain
was vegetated with short and medium grass. The wreckage of the airplane was fragmented and scattered in a radius to the north, through to the west, and then
through the south, surrounding the base of wind turbine tower #14. The fragmented pieces of the fuselage, empennage, engine and propeller assembly, and
both wings were accounted for in the field of debris.
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The autopsy was performed by the Sanford Health Pathology Clinic on April 29, 2014, as authorized by the Hyde County Coroner's office. The autopsy
concluded that the cause of death was multiple blunt force injuries and the report listed the specific injuries.
The FAA's Civil Aerospace Medical Institute (CAMI), Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests
on specimens that were collected during the autopsy (CAMI Reference #201400071001). Results were negative for all carbon monoxide and drugs. Testing of
the blood detected 11 mg/dL ethanol; however, none was detected in the muscle or liver. Tests for cyanide were not conducted.
TESTS AND RESEARCH
Wreckage Examination
The wreckage was recovered and relocated to a hangar in Greeley, Colorado, for further examination. The wreckage was examined by investigators from the
National Transportation Safety Board, Piper Aircraft, and Lycoming Engines.
The left wing separated from the fuselage and was fragmented. The fuel tanks were impact damaged and the left main landing gear separated from the wing
assembly. The aileron and the flap separated from the wing assembly and were impact damaged.
The right wing separated from the fuselage and was fragmented. The fuel tanks were impact damaged. The right main landing gear was extended and remained
attached to the right wing spar. The aileron and the flap separated from the wing assembly and were impact damaged.
The fuel selector valve was impact damaged. The position of the selector handle was at the left main fuel tank. Disassembly of the valve found the selector in
an intermediate position between off and the left main tank. The fuel screen was clear of debris.
The instrument panel was fragmented and many of the instruments, radios, and gauges were destroyed. The ADI case and the directional gyro exhibited
signatures of rotational scoring. The tachometer exhibited a reading of 2,400 to 2,500 rpm. The altimeter was broken and the needles separated. The Kollsman
window was set at 29.27 inches. The airspeed indicator exhibited a reading of 235 miles per hour.
The pitot static system was impact damage and fragmented. The pitot tube and static port were clear and free of debris or mechanical blockage. Due to the
damage, the system could not be functionally tested.
The empennage separated from the fuselage and was impact damaged. The aft portion of the vertical stabilizer was impact damaged and remained partially
attached to the rudder at the hinge points. The stabilator was impact damaged and fragmented.
Flight control continuity to the ailerons, stabilator, and rudder could not be confirmed. The flight control cables were fractured in overload in multiple locations.
The position of the flaps and landing gear could not be determined due to impact damage.
The engine was impact damaged impeding examination and testing for functionality. The spark plugs exhibited worn out normal signatures when compared to
the Champion Aviation Check-A-Plug chart. The fuel injectors for the 1, 3, and 5 cylinders were clear of debris. The fuel injectors for the 2, 4, and 6 cylinders
were impact damaged. The oil pick-up screen was clear of debris. The fuel servo and fuel pump were impact damaged and could not be functionally tested.
The fuel flow divider was clear of debris. The vacuum pump case was bent and exhibited internal scoring consistent with operation at the time of the accident.
The propeller separated from the engine at the propeller flange. One blade exhibited S-bending, a curled tip, chord-wise scratches, and nicks and gouges along
the leading edge of the propeller blade. The second blade exhibited chord-wise scratches, nicks and gouges along the leading edge of the propeller blade, and
grey angular pain transfer near the tip of the propeller blade.
Wind Turbine Tower #14 Obstruction Light Power Supply, Flash Head, and Photocell Examination
The obstruction light, which included the power supply, flash head, and photocell (44812A), was removed from wind turbine tower #14 by an employee of ESI
at the request of the wind turbine company. All of the components were shipped to Hughey & Phillips for further examination.
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During the examination the following observations were made:
The flash head gasket was broken into 5 pieces. The day lens was crazed and a screw was loose in flash head.
The photocell which was in the container is an aftermarket unit and not as supplied by Hughey & Phillips.
An aftermarket transformer was added to the power supply above the TB1 terminal block. This was not wired into the power supply and two wires hung
from the transformer.
The power supply was placed on test jig and the power supply and flash head were connected via a 7-wire power cable, 7 feet in length, provided by Hughey &
Phillips. When power was applied to the unit the flash head did not work - the red lamp attempted to flash and the white lamp did not flash.
The lower flash tube was black consistent with age/use
The power supply - capacitor C3 - was bulged at the top consistent with a bad capacitor
The capacitor was replaced and the red lamp functioned as designed. The white lamp did not function. The white flash tube was replaced with a new flash tube.
When it was in day mode the white light activated
When in night mode the red light activated
When in auto mode, light was applied to the photocell sensor and after 30 seconds it switched from night to day mode. When light was removed and the
sensor was covered to remove light, it switched back to night mode after 30 seconds.
The photocell was placed in a test chamber. When all light was removed, one light bulb illuminated. When 5 candelas was applied there was no change. The
candelas were increased incrementally to 30 with no change. When the candelas were increased to 50, the test chamber switched to night mode within a
minute or more.
The flash rate of the unit was tested.
The red lamp tested at a rate of 25 flashed per minute - This is within the FAA specifications for the L-864 fixture, 20 to 40 flashes per minute.
The white lamp tested at a rate of 40 flashes per minute- This is within the FAA specifications for the L-865 fixture, 40 flashes per minute.
The alarm function tested as designed.
The entire system operated normally with basic replacement of the flashtube and capacitor. The system was not operational in its as removed state.
Wind Turbine
The wind turbine farm south of Highmore, South Dakota, was constructed in 2003. There are 27 towers in the entire farm oriented from east to west across
highway 57. It was reported to the NTSB, on scene, that each turbine tower is about 213 feet tall (from the ground to the center of the hub) and the blade length
is 100 feet long. Each tower is equipped with three blades and FAA approved lighting. The blades are constructed from carbon fiber.
On June 2, 2003, the FAA issued a Determination of No Hazard to Air Navigation, regarding the installment of wind turbine tower #14 near Highmore, South
Dakota. The document identified that the wind turbines would be 330 feet agl and 2,515 feet msl. A condition to the determination included that the structure be
marked and/or lighted in accordance with FAA Advisory Circular 70/7460-1K Change 1.
The wind turbine tower #14 was located to the west of highway 57, and was the 5th wind turbine tower in a string of wind turbine towers, oriented from east to
west. Wind turbine tower #14 was 0.3 miles to the west of the 4th wind turbine tower and 0.5 miles to the west of the 3rd wind turbine tower. The string of wind
turbine towers changed direction after wind turbine tower #14 and continued to the south and south west for about 2 additional miles with 13 additional wind
turbine towers in the string. The next closest wind turbine tower to #14 was 0.5 miles south.
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The wind turbine tower #14 recorded an alert in the system when the airplane and the turbine blade collided and the turbine went offline. The impact was
recorded at 2116:33. The blades were pitched at -0.5 degrees and the nacelle was at 112 degrees yaw angle (not a compass heading, rather nacelle rotation).
There were no employees at the wind farm maintenance facility when the accident occurred. The NextEra control center in Juno Beach, Florida, received an
immediate alert when the collision occurred. The company response would have been to send an employee to the wind turbine the next morning to determine
why the turbine had gone offline.
Maintenance records for wind turbine tower #14, for 5 years prior to the accident, were submitted to the NTSB investigator in charge for review. These records
included major and minor inspection sheets for 2010 and 2011 in addition to work management records for general maintenance, repairs, and fault
troubleshooting that occurred between June 2010, and October of 2014 (after the accident). The major and minor inspection sheets for 2010 and 2011 indicated
that the FAA lighting was inspected and found to be "normal" or "OK." No other maintenance records were provided which illustrated maintenance that was
conducted or performed on the FAA lighting system between 2010 and the accident.
It was reported to the NTSB IIC that the light on tower #14 was not functioning at the time of the accident and had been inoperative for an undefined period.
The actual witness to the inoperative light did not return telephone calls in attempt to confirm or verify this observation.
FAA Lighting Requirements
The US Department of Transportation - FAA issued Advisory Circular AC 70/7460-1K Obstruction Marking and Lighting on February 1, 2007.
Section 23. Light Failure Notification states in part that ".conspicuity is achieved only when all recommended lights are working. Partial equipment outages
decrease the margin of safety. Any outage should be corrected as soon as possible. Failure of a steady burning side or intermediate light should be corrected
as soon as possible, but notification is not required. B. Any failure or malfunction that lasts more than thirty (3) minutes and affects a top light or flashing
obstruction light, regardless of its position, should be reported immediately to the appropriate flight service station (FSS) so a Notice to Airmen (NOTAM) can
be issued."
Section 44. Inspection, Repair, and Maintenance states in part that "Lamps should be replaced after being operated for not more than 75 percent of their rated
life or immediately upon failure. Flashtubes in alight unit should be replaced immediately upon failure, when the peak effective intensity falls below specification
limits or when the fixture begins skipping flashes, or at the manufacturer's recommended intervals. Due to the effects of harsh environments, beacon lenses
should be visually inspected for ultraviolet damage, cracks, crazing, dirt, build up, etc., to insure that the certified light output has not deteriorated."
Section 47. Monitoring Obstruction Light stated in part that "Obstruction lighting systems should be closely monitored by visual or automatic means. It is
extremely important to visually inspect obstruction lighting in all operating intensities at least once every 24 hours on systems without automatic monitoring."
Chapter 13, Sections 130 through 134, addressed Marking and Lighting Wind Turbine Farms. Wind turbine farms are defined as "a wind turbine development
that contains more than three (3) turbines of heights over 200 feet above ground level." In addition, a linear configuration in a wind farm is "a line-like
arrangement. The line may be ragged in shape or be periodically broke, and may vary in size from just a few turbines up to 20 miles long."
Section 131. General Standards states in part that "Not all wind turbine units within an installation or farm need to be lighted." "Definition of the periphery of the
installation is essential; however, lighting of interior wind turbines is of lesser importance." "Obstruction lights within a group of wind turbines should have
unlighted separations or gaps of no more than « statute mile if the integrity of the group appearance is to be maintained."
Section 134. Lighting Standards states in part that "Obstruction lights should have unlighted separations or gaps of no more than « mile. Lights should flash
simultaneously. Should the synchronization of the lighting system fail, a lighting outage report should be made in accordance with paragraph 23 of this advisory
circular." Section c. Linear Turbine Configuration states in part "Place a light on each turbine positioned at each end of the line or string of turbines. Lights
should be no more than « statute mile, or 2,640 feet from the last lit turbine."
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11/21/2012 1820 EST Regis# N40781
Hillsdale, MI
Apt: Hillsdale Minucipal Airport JYM
Acft Mk/Mdl PIPER PA-28-180
Acft SN 28-7405065
Eng Mk/Mdl LYCOMING O-360-A4A
Acft TT
Fatal
Opr Name: CLARENCE J AVERY
Opr dba:
2541
1
Ser Inj
0
Aircraft Fire: NONE
Events
1. Approach - Controlled flight into terr/obj (CFIT)
Narrative
HISTORY OF FLIGHT
On November 21, 2012, approximately 1820 eastern standard time, a Piper PA-28-180, N40781, registered to the pilot, impacted trees and terrain while on a
VFR straight-in approach to the Hillsdale Municipal Airport (JYM), Hillsdale, Michigan. The private pilot, who was the sole occupant, sustained fatal injuries. The
airplane was substantially damaged. Night visual meteorological conditions (VMC) prevailed in the vicinity and a flight plan was not filed for the cross country
flight being conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight originated about 1700 from the Lebanon-Warren County
Airport, Lebanon, Ohio.
According to a family member, the pilot planned the cross country flight to fly from Hillsdale and then have lunch at a restaurant located near the
Lebanon-Warren County Airport. After lunch, the family member assisted the pilot in his preflight prior to departing for return to Hillsdale. The family member
stated that the takeoff and departure was normal. He also stated that the pilot's wife had been concerned that the pilot return before darkness because she
knew that the pilot did not like to fly or drive at night. It was close to sunset when the pilot departed from Lebanon-Warren County Airport.
Minutes prior to the accident, about 18 miles from the airport, the pilot contacted Hillsdale on UNICOM frequency and requested that the lights for runway 28 be
turned on. The airport manager who was monitoring the UNICOM turned on the lights. He reported that the pilot sounded normal and estimated the weather
conditions at the time of the call to be marginal VMC with haze.
A pilot who had landed shortly before the accident time reported that the local weather was hazy with a clear sky at Hillsdale. He stated that he specifically
chose to land on runway after circling the airport because he was aware the PAPI's (glide slope lights) were out of service on runway 28 and it was quite dark
on that side of the airport in addition to the haze. He reported that the pilot controlled lighting was functioning and visible from at least 5 miles away.
Local law enforcement officers who initially responded to the accident site found the wreckage about 1.25 miles east of the approach end of runway 28 at JYM.
The initial impact points were found about 60 feet above the ground in trees. After on scene examination by the NTSB, the aircraft wreckage was recovered
from the scene and relocated to a secure hangar at the Lenawee County airport (ADG) on November 23, 2012.
The pilot held a valid pilot certificate with a single-engine land rating. A review of the pilot's flight logbooks showed that he had a total of 765 hours of flight time.
The pilot flew the accident airplane about 10.1 hours in the 90 days prior to the accident. according to logbook entries, the pilot's total night flight time was 16.4
hours. His most recent logged night time flight was about 10 years ago, on June 6, 2002. The pilot held a valid FAA Class 3 medical certificate, dated March
22, 2012.
Entries in the aircraft maintenance logbooks indicated that an annual inspection was completed on October 5, 2012, at a total airframe time of 2,533.5 hours.
The most recent altimeter checks were completed on September 8, 2010. According to a family member the pilot had stated that the airplane was in good
mechanical condition and had not had recent problems.
Official sunset at Hillsdale was 1713 and official twilight was 1743. The Hillsdale AWOS recorded weather conditions at the time of the accident were calm
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wind, 7 miles visibility, temperature 9 degrees Celsius, Dew Point 6 degrees Celsius, and Altimeter setting 3017. METAR KJYM 212314Z AUTO 00000KT 7SM
CLR 09/06 A3017 RMK AO2. The airport manager's assessment of the weather at the time of the accident was marginal VMC with haze.
The airplane wreckage was about 1.25 miles east of the approach end of runway 28 at JYM, located within a tree line adjacent to an open field just prior to the
tree line. The trees ranged in height from 50-75 feet. The initial impact points were found about 60 feet above the ground in trees. The debris path extended
about 750 feet through the trees and the airplane was found resting on its left side, with the engine embedded in the ground at a shallow angle. The
approximate heading of the path through the trees was 255 degrees magnetic. The fuselage and empennage section were found primarily intact with its left
wing separated and folded under the aft portion of the fuselage. Local law enforcement officers who initially responded to the accident site confirmed a strong
odor of fuel within the wreckage.
The main fuselage was lying on its left side about 742 feet from the initial tree impact point. at GPS coordinates of North 41.55182 degrees / West 084.33069
degrees, at a GPS measured elevation of 1,211 feet MSL. The left wing was lying under the fuselage. The right wing was separated and lying in the debris path.
The empennage (vertical fin, rudder and stabilator) were still attached and the cabin door was noted to be attached and closed by first responders. The door's
window was fractured with pieces missing. The door and upper latch handles were intact. The aft baggage door was attached and closed. The windshields were
intact with minimal damage noted to the right side and a few pieces missing from the left side. The cabin side windows were impact damaged. The engine was
attached to its mount and the mount was attached to the firewall. The propeller hub assembly was attached to the engine crankshaft flange and exhibited some
power signature indications (bending, twisting, scarring). It also exhibited tree and ground impact damage. The nose gear was attached to the engine mount and
exhibited impact damage. The top portion of the engine cowl was partially attached and exhibited impact damage.
The cabin interior contained debris from tree and ground impact. The pilot and co-pilot seats were partially attached to their respective tracks and the rear sears
were separated from their mounts. The pilot's lap belt was attached to the airframe and the shoulder harness was attached to the lap belt. Both control wheels
were intact and exhibited impact damage with some movement obtained in all axes'. All engine fuel pressure / oil temp and pressure gages were electric
powered and offered no useful information, as were the fuel gauges. The fuel selector was on the right fuel tank position and could not readily be moved from
that position. The rudder trim indicator showed an approximate neutral position. Some movement of the rudder pedals was obtained. The stabilator trim
indicator position was not obtainable, trim drum thread protrusion exhibited six exposed threads, which equates to a stabilator at neutral trim setting.
The flap handle position indicated a flaps full-up position. The engine primer pump appeared in the locked position. The magneto switch was in the 'OFF'
position. The carb heat control was in the 'OFF' position. The EGT gauge needle was at "0" and the vacuum gage read "0". The engine throttle and mixture
control were full forward and were free to move. All electrical switches except the Anti-Collision lights were in the 'OFF' position. The panel light and navigation
light rheostats were free to rotate. The circuit breaker panel was missing the alternator output breaker and the alternator field breaker was activated. The cabin
heat control was in the 'ON' position and the defrost lever was in the 'ON' position. The magnetic compass was in place and indicated a 090 degree heading. All
avionics systems were in place in the instrument panel with some exhibiting minor impact damage. The auto-pilot switch was 'OFF'. The audio selector panel
was in the Auto position. The altimeter's Kollsman window indicated a setting of 30.38 inches Hg and an altitude of about 1,400 feet MSL. The VSI indicated a
100 foot per minute climb rate. The DG indicated a 275 degree heading and the Artificial Horizon indicated a 90 degree left bank. The airspeed needle was on
"0".
The vertical fin was attached to the fuselage with some evidence consistent with tree strikes. The rudder was attached to the vertical fin at its hinge points. The
control cables were attached to the rudder horn. Control continuity was traced forward to the rudder pedals in the cabin. Some movement was noted when the
cables were pulled. The balance weight was present. Some ground and tree impact damage was noted to the side skins. The control stops were in place and
no bending or peening was noted on the stops. The stabilator was attached to its mounting brackets on the aft bulkhead. The stabilator was bent to the right in
relation to the fuselage and the left tip section incurred impact damage. The stabilator trim tabs were attached to the trailing edge via a hinge pin. The trim drum
exhibited 9 exposed threads, indicative of a slightly nose-up condition. The balance weight was in place with control cables attached. The primary stops were
noted to have no bending or peening condition. Control continuity was traced forward to the cabin area and movement of the control column was noted.
The left wing outboard section with aileron attached was lying in the debris field to the right and aft of the main wreckage. This section was about 7 feet in
length. The aileron with balance weight attached was attached at its outboard hinge. The aileron was bent upward about 45 degrees and exhibited tree strike
and ground impact damage. The fiberglass wing tip was missing and remnants were located in the debris field. The flap was separated from the wing and
exhibited leading edge separation. The main landing gear assembly was separated and noted to be lying under the wing. It exhibited tree and ground impact
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damage. The left fuel tank was breached along the rivet seams and the leading edge exhibited crushing aft consistent with tree strike. The fuel cap was in place
in the fuel filler neck. The tank was devoid of fuel. The tank vent was open. The Pitot / Static Mast was in place and appeared to be void of any obstruction in
the pitot and static ports. The stall warning vane was not observed. The aileron control continuity was traced from the wing mounted Sector through the cable
tension-overload breaks to the fuselage mounted control cables to the Control system "T"-bar assembly. The sector stops were in place and exhibited no
bending or peening condition.
The right wing was completely separated at its root from the fuselage and was close to the initial impact area. The root section was separated from the inboard
section. The flap and aileron were attached at their respective locations. The main landing gear assembly was attached. The flap control rod was impact
separated from the flap, the flap exhibited skin damage at its root section. The aileron was attached at it hinges. The trailing edge exhibited a wavy condition.
The balance weight was attached. The aileron control sector with control cables attached was impact separated from the wing structure due to cable tension
overload. The primary and balance cables were noted to be attached to the sector. The sector arms exhibited a bending condition. Control cable continuity was
established at the wing root and at the fuselage through the cable separations due to tension overload. The control stops at the sector exhibited some impact
damage due to bending and twisting of the sector bracket. The wing leading edge exhibited impact damage consistent with tree and ground impact. The right
fuel tank was breached consistent with tree impact. There was no residual fuel present.
The engine was an AVCO Lycoming 180HP, O-360-A4A.The s/n was: L-18416-036A. The tachometer indicated 1,671.3 hours. The electric fuel pump and
carburetor were readily accessible at this time and what appeared to be Aviation grade blue fuel was noted in a fuel line attached to it. A small quantity of fuel
was noted at a carburetor line. The engine driven pump was not examined for operation. The throttle and mixture cables appeared to be connected. The
propeller was attached to the engine and was partially buried in the ground impact area. There was significant power signature on one blade (bending / twisting).
The other blade exhibited some scaring and leading edge erosion and was relatively straight.
Findings from an autopsy performed by the Lucas County Coroner's Office did not reveal any pre-existing physical conditions that could have contributed to the
accident, with fatal injuries due to blunt force trauma. Toxicology tests were negative.
TESTS AND RESEARCH
At the request of the NTSB IIC, the altimeter (United Instruments Inc. P/N 5934P1 S/N P6015) was removed from the accident aircraft and taken to a certified
avionics facility to verify its functionality and sensitivity. The tests were conducted under the supervision of a FAA Avionics Inspector. The test was to verify the
functionality, not certify, the subject altimeter. Verification results were compared to calibrated Pitot/Static test box from Repair Station VDJR395X, in the
0500-6000 foot range. The altimeter appeared to be functional and operating normally during the tests.
FAA inspectors arrived at the accident site about 2200 on November 21. They reported that the airplane's altimeter read about 1,400 feet MSL, with 30.38
inches Hg set in the Kollsman window of the instrument. The area barometric pressure at the time of the accident and at the time of the inspectors'
observations was 30.17, as reported by Hillsdale AWOS
The airplane was released to the owner's representative.
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01/11/2013 1553 CST Regis# N36VE
Maxwell, NE
Apt: North Platte Rgnl Airport LBF
Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY 58
Acft SN TH-1957
Acft Dmg: DESTROYED
Eng Mk/Mdl CONT MOTOR IO-550 SERIES
Acft TT
Fatal
Opr Name: BOTTORFF CONSTRUCTION INC
Opr dba:
1740
4
Ser Inj
0
Aircraft Fire: GRD
AW Cert: STN
Events
2. Enroute-climb to cruise - Loss of control in flight
Narrative
HISTORY OF FLIGHT
On January 11, 2013, about 1553 central standard time, N36VE, a Raytheon Aircraft Company 58, multi-engine airplane, was destroyed after impacting terrain
near Maxwell, Nebraska. The pilot and three passengers were fatally injured. The airplane was registered to and operated by Bottorff Construction, Inc.;
Atchison, Kansas. Instrument meteorological conditions (IMC) prevailed at the time of the accident and an instrument flight rules (IFR) flight plan had been filed
for the 14 Code of Federal Regulations Part 91 business flight. The airplane departed North Platte Regional Airport (LBF), North Platte, Nebraska, about 1545,
and was en route to York Municipal Airport (JYR), York, Nebraska.
About 1550 the pilot reported to a radar controller at Denver Air Route Traffic Control Center that he was climbing to a planned cruise altitude of 9,000 feet
mean sea level (msl) . At 1552 the pilot requested the tops of the clouds; however, a current report on the cloud tops was not available. At 1553 a "mayday"
call was heard and a simultaneous loss of radio and radar contact was reported by the radar controller.
At 1855 the wreckage was found in a remote area about 11 miles north east of LBF by emergency responders who had been searching for the missing airplane.
The pilot, age 54, held a Federal Aviation Administration (FAA) private pilot certificate with ratings for airplane single engine and multiengine land, and
instrument airplane. His private pilot certificate in airplane single engine land was initially issued on March 9, 1988, his rating in instrument airplane was issued
on March 20, 2002, and his rating in airplane multiengine land was issued on February 25, 2003.
The pilot also held an FAA third-class medical certificate, issued on August 15, 2012, with a restriction "must have available glasses for near vision".
A review of portions of the pilot's three logbooks showed entries beginning on February 17, 1986, with the last entry in pilot's logbook number three on January
1, 2013. Based on only the incomplete entries in pilot's logbook number three, his total pilot experience was estimated at 1,377 hours, with about 457 hours in
multi-engine airplanes, and the remainder in single-engine airplanes. His instrument flying experience was estimated at 171 hours. Logbook entries for the
previous calendar year showed he had flown about 103 total hours, of which about 80 hours were in the accident airplane.
A pilot logbook endorsement on December 6, 2011, showed he had completed an instrument proficiency check and a course in BE 58P Differences, including 4
hours of simulator flight training and 2.5 hours of classroom training. The most recent instruction from a certified flight instructor was on February 20, 2012,
showing a flight review was completed in a Beechcraft 58P airplane which included 2.0 hours of flight instruction and 0.5 hours of actual instrument flying.
The low-wing, retractable conventional landing gear, multi-engine airplane, serial number (s/n) TH-1957, was manufactured in 2000. It was powered by two
285-horsepower Continental Motors, Inc. engines; s/n 1005940 installed on the left side, and s/n 1005978 installed on the right side. Each engine drove a
Hartzell model PHC-J3YF-2UF, 3-blade metal alloy full feathering propeller.
The airplane was equipped with ice protection systems which included a surface deice system, electrothermal propeller deice, pitot heat, stall warning anti-ice,
and heated fuel vents.
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A postaccident review of original aircraft maintenance documents provided by the operator showed that an annual inspection was completed on May 21, 2012,
at an airplane total time and Hobbs meter time of 1,740.9 hours. Entries also noted that both engines were installed on that date and were factory new "zero
time" engines.
The last aircraft maintenance logbook entry on December 7, 2012, showed that the aircraft total time and Hobbs meter time was then 1,835.0 hours.
Fuel records at LBF showed that the pilot had the main fuel tanks "topped off" with a total of 80.0 gallons of 100LL aviation gasoline and the credit card fuel slip
was time-stamped at 1443.
At 1534 the Automated Surface Observation System at LBF reported wind from 350 degrees at 14 knots, visibility 4 miles in mist, ceiling overcast at 1,000 feet
above ground level (agl), temperature minus 2 degrees Celsius (C), dew point minus 4 degrees C, altimeter 29.42 inches of mercury. Remarks included: ceiling
700 variable 1,300 feet agl.
At 1553 LBF reported wind from 340 degrees at 14 knots gusting to 20 knots, visibility 3 miles in light freezing rain and mist, ceiling broken at 900 feet agl,
overcast clouds at 1,200 feet, temperature minus 2 degrees Celsius (C), dew point minus 4 degrees C, altimeter 29.45 inches of mercury. Remarks included:
freezing rain began at 1546, ceiling 600 variable 1,100 feet agl, pressure rising rapidly, hourly precipitation less than 0.01 inch.
The National Weather Service Aviation Weather Centers (AWC) Area Forecast issued at 1425 expected overcast clouds at 5,000 feet mean sea level (msl)
with tops to 16,000 feet msl with visibility 3 miles in mist over southern Nebraska. The forecast was amended by AIRMET Sierra for IFR conditions over the
region, which forecasted ceilings below 1,000 feet and visibility below 3 miles in precipitation, mist, and blowing snow, over all of Nebraska. AIRMET Zulu was
issued at 1445 which called for moderate icing conditions below 17,000 feet msl.
The pilot had contacted the FAA contract Automated Flight Service Station (AFSS) several times during the day for each of his flights. On the last call at 1452
the pilot was advised of the AIRMET for icing conditions and turbulence below 8,000 feet, and the pilot made a comment that he was expecting those
conditions to be developing over the area. At that time a SIGMET or a Center Weather Advisory warning of severe icing conditions had not been issued.
Two helicopter flight crews operating into LBF immediately after the accident reported they had not anticipated the lower than forecast weather conditions and
the wintery mix they encountered. The first flight crew was operating a group of U.S. Army Blackhawk helicopters that landed at LBF about a half hour after the
accident. They encountered lowering ceilings less than 500 feet with light freezing rain and mist which changed to a combination of freezing rain, ice pellets,
and snow with increasing winds. When the next flight of four Blackhawk helicopters landed a short time later they encountered blowing snow with low visibility.
Statements from the crew of a U.S. Army King Air indicated they were inbound to LBF and observed a weather cell north and west of the area moving eastward
on their airborne weather radar. Upon descending below 11,000 feet they entered the clouds and encountered icing at approximately 9,000 feet. The icing
became heavy to severe icing at 5,000 feet. After they received a field condition report of braking action nil on the runway at LBF they executed a missed
approach and diverted to an alternate airport. After landing at the alternate airport, the flying pilot commented on a large area of residual ice that remained in an
unprotected area on the airplane.
A multi-engine instrument rated pilot who was in a duck blind immediately northwest of the airport witnessed the accident airplane on climb-out after takeoff
from runway 30. He reported mist conditions and fog that was "freezing to surfaces". He was also indicated that surface conditions deteriorated shortly
afterward with visibility as low as a quarter mile when it began to "snow hard".
COMMUNICATIONS AND RADAR
At 1448:32 the pilot of N36VE called the Fort Worth Federal Contract Flight Service Station (FCFSS) via telephone to file two IFR flight plans. He obtained an
abbreviated pilot weather briefing for a flight from LBF to JTY, and a second proposed IFR flight from JTY to St. Joseph, Missouri. The pilot's telephone
conversation with the FCFSS ended at 1454:14.
Following is a timeline of selected communications between the pilot of N36VE and Federal Aviation Administration (FAA) Air Traffic Control (ATC). A summary
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of the FAA ATC radar contacts is included.
1544 N36VE reported to ATC that he was on the ground at LBF and ready for departure
1545 ATC cleared N36VE to JYR "as filed" with instructions to climb and maintain 9,000 feet
1547:03 Radar showed N36VE was at a transponder reported altitude of 3,000 feet
1548:57 N36VE reported to ATC that he was at 4,700 feet and climbing to 9,000 feet
1552:35 N36VE asked ATC if they had any reports on the tops of the clouds
1552:39 ATC responded that they did not
1553:15 N36VE (voice identified as the pilot) said "mayday mayday mayday three six ." (there was a change in the sense of urgency noted in the voice of the
pilot and the end of the transmission was cut off)
No further communications from N36VE were received
Radar contact was then lost.
The wreckage was located in remote ranch land about 11 miles northeast from LBF and about 8 miles north from Maxwell, Nebraska. The wreckage was
extensively fragmented and included evidence of a postimpact fire. The wreckage was spread out over sandy soil in hilly terrain that was covered with grass
and snow. The elevation of the initial impact crater was estimated as 2,925 feet msl.
The debris path was oriented from southwest to northeast on a magnetic bearing of 057 degrees. The debris path was about 417 feet long and about 215 wide
at the widest points. The initial impact scars were created by the left wing, left engine, the lower nose section of the airplane, and the right engine.
The initial impact crater was a large ground scar which measured 25 feet long and 2 feet 4 inches at its deepest point. The west side of the ground scar was 10
feet wide and the east side of the ground scar was 7 feet 5 inches at its widest point. This ground scar contained the left engine propeller assembly, torn
fragmented and accordion crushed metal, a propeller blade from the right engine, and the nose gear assembly. Two of the propeller blades from the left engine
and one propeller blade from the right engine were imbedded in the ground. Dirt in the ground scar was ejected to the northeast.
A second ground scar branched off from the west side of the large ground scar. The second scar measured 17 feet long, 2 feet 5 inches at its widest point, and
9 inches at its widest point. The ground immediately adjacent the large ground scar exhibited exposure to heat and fire. The burned area extended for 120 feet
towards the north and was 62 feet at its widest point. The empennage, both engines, the right propeller assembly, fragmented portions of the left wing and
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fuselage, and some personal effects were all located within the burn area.
The left wing was fragmented into several large pieces and included the left aileron, left flap, and left main landing gear assembly. These pieces were located in
the burn area to the north of the empennage. The left main landing gear was charred, melted, and partially consumed by fire. The left aileron and left flap
exhibited exposure to heat and fire. Both the aileron and flap were bent and wrinkled.
The empennage included the horizontal and vertical stabilizer, the left and right elevator, and the rudder. The left horizontal stabilizer de-ice boot was burned
and torn. The elevator was bent and charred, and partially melted or consumed by fire. The left stabilizer was bent and torn and exhibited exposure to heat and
fire. The vertical stabilizer was crushed aft and the de-ice boots were torn. The rudder exhibited exposure to heat and fire. The right horizontal stabilizer de-ice
boot was burned. The leading edge exhibited aft accordion crushing and both the stabilizer and the elevator exhibited exposure to heat and fire.
The right wing was fragmented into several large pieces and included the right aileron, right flap, and right main landing gear assembly. These pieces were
located to the east of the burn area. The right main landing gear separated from the wing assembly and was otherwise unremarkable. The right aileron and right
flap were bent and wrinkled.
The fuselage was fragmented and the pieces were located within the debris field. A large portion of the forward fuselage was found at the north end of the
debris field, 60 feet north of the end of the burned field. The forward portion of the fuselage included upper and lower skin from the forward fuselage, portions of
the flight control cables, the fragmented instrument panel, and wiring harnesses.
The airplane fuel system was fragmented and scattered among the debris path. Both fuel selector valves, located in each main landing gear wheel well, were
separated from the airplane and from their cable controlled fuel selector valve handles, located in the cockpit. The left fuel selector valve handle was found at
the approximate 10:00 position. The right fuel selector valve handle was found at the approximate 12:00 position (12:00 position being forward and ON
position). Four fuel tank caps were observed in the debris path. The cabin seats, seatbelts, personal effects, and the remainder of the airplane were highly
fragmented and scattered to the north and east from the main ground scar, both inside and outside of the burn area.
The on-scene examination of the wreckage revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation.
An autopsy was performed on the pilot by the Nebraska Institute of Forensic Sciences, Inc.; Lincoln, Nebraska.
Forensic toxicology was performed on specimens from the pilot by the FAA, Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The
toxicology report stated that tests for Carbon Monoxide and for Cyanide were not performed. The report also stated that Ethanol was not detected in Muscle or
in Liver, and that no Drugs were detected in Liver.
TESTS AND RESEARCH
The wreckage was moved to another location and examined.
Left Engine
The left engine was separated from the airframe and located in the burned area of the debris field and exhibited impact and thermal damage. The crankcase
was fractured in several places and the accessory section was fractured and portions were not observed. Both magnetos were separated from the engine and
severely fragmented. The spark plugs were removed and exhibited normal signatures when compared to the Champion Check A Plug Chart. The electrodes
exhibited dark grey combustion deposits.
The separated throttle body / metering unit was examined. The fuel pump, fuel screen, fuel manifold valve, and fuel nozzles were examined. The oil pump was
disassembled and examined. The cylinders remained attached to the crankcase and exhibited impact damage. Portions of the number 6 cylinder head were
separated and not observed. The combustion chambers were examined with a lighted bore scope. All of the valve covers were fragmented and breached and
the overhead areas of the cylinders contained dirt and debris.
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The left propeller was separated from the engine, and the crankshaft propeller flange remained attached to the propeller hub. Examination of the engine
crankshaft propeller flange separations revealed that it exhibited signatures consistent with torsional overload. One of the three propeller blades was fractured
free from the hub. All three blades exhibited various bends, polishing, and multi-directional scratches.
The left vacuum pump was separated from the engine and exhibited impact damage. It was disassembled and the vanes were intact. The rotor was impact
fragmented and the vacuum pump housing was unremarkable.
Right Engine
The right engine was separated from the airframe and located in the burned area of the debris field and exhibited impact and thermal damage. The crankcase
was fractured and portions of the accessory section were not observed. The right crankshaft propeller flange was separated and remained attached to the
propeller. Both magnetos were separated from the engine and fractured into several pieces. The spark plugs were removed and exhibited normal signatures
when compared to the Champion Check A Plug Chart. The electrodes exhibited dark colored combustion deposits.
The separated throttle body / metering unit was examined. The fuel pump was disassembled and examined. The fuel screen, fuel manifold valve, and fuel
nozzles were examined. The oil pump was partially disassembled and examined. The cylinders remained attached to the crankcase and exhibited impact
damage. Portions of the number 6 cylinder head were separated and not observed. The combustion chambers were examined with a lighted bore scope. All of
the valve covers were fragmented and breached and the overhead areas of the cylinders contained dirt and debris.
The right propeller was separated from the engine, and the crankshaft propeller flange remained attached to the propeller hub. Examination of the engine
crankshaft propeller flange separations revealed that it exhibited signatures consistent with torsional overload. One of the blades was fractured free of the hub.
The blades exhibited scratches, nicks, polishing, and multidirectional bends.
The right vacuum pump was separated the engine and exhibited impact damage. It was disassembled and the vanes were intact. The rotor was impact
fragmented and the vacuum pump housing was unremarkable.
The postaccident examination of the engines revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
Other Examination:
A Garmin GPSMAP 696 device was removed from the wreckage and was sent to the NTSB Vehicle Recorder Laboratory. An exterior examination revealed the
unit had sustained catastrophic impact damage and the integrated circuit containing track log memory was ejected from the main printed circuit board and was
not recovered.
No data was recovered from the Garmin GPSMAP 696.
According to the FAA Approved Airplane Flight Manual (AFM) for the Raytheon Aircraft Beech Baron 58, the Limitations section on page 2-12 showed that the
minimum airspeed during icing conditions was 130 knots.
The AFM also noted additional limitations when encountering severe icing conditions:
"WARNING Severe icing may result from environmental conditions outside of those for which the airplane is certificated. Flight in the freezing rain, freezing
drizzle, or mixed icing conditions (supercooled liquid water and ice crystals) may result in ice build-up on protected services exceeding the capability of the ice
protection system, or may result in ice forming aft of the protected services. This ice may not be shed using the ice protection systems, and may seriously
degrade the performance and controllability of the airplane.
1. During flight, severe icing conditions that exceed those for which the airplane is certificated shall be determined by the following visual cues. If one or more of
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these visual cues exist, immediately request priority handling from Air Traffic Control to facilitate a route or an altitude change to exit the icing conditions.
a. Unusually extensive ice accumulation on the airframe and windshield in areas not normally observed to collect ice.
b. Accumulation of ice on the upper surface of the wing, aft of the protected area.
c. Accumulation of ice on the engine nacelles and propeller spinners farther aft than normally observed.
2. Since the autopilot, when installed and operating, may mask tactile cues that indicate adverse changes in handling characteristics, use of the autopilot is
prohibited when any of the visual cues specified above exist, or when unusual lateral trim requirements or autopilot trim warnings are encountered while the
airplane is in icing conditions.
3. All wing icing inspection lights must be operative prior to flight into known or forecast icing conditions at night. [NOTE: This supersedes any relief provided by
the Master Minimum Equipment List (MMEL).]"
According to the FAA Instrument Flying Handbook FAA-H-8083-15B; Chapter 10 on page 10-24: "The very nature of flight in instrument meteorological
conditions (IMC) means operating in visible moisture such as clouds. At the right temperatures, this moisture can freeze on the aircraft, causing increased
weight, degraded performance, and unpredictable aerodynamic characteristics. Understanding avoidance and early recognition followed by prompt action are
the keys to avoiding this potentially hazardous situation . Structural icing is a condition that can only get worse. Therefore, during an inadvertent icing
encounter, it is important the pilot act to prevent additional ice accumulation. Regardless of the level of anti-ice or deice protection offered by the aircraft, the
first course of action should be to leave the area of visible moisture. This might mean descending to an altitude below the cloud bases, climbing to an altitude
that is above the cloud tops, or turning to a different course. If this is not possible, then the pilot must move to an altitude where the temperature is above
freezing. Pilots should report icing conditions to ATC and request new routing or altitude if icing will be a hazard."
According to the FAA "Aeronautical Information Manual"; section 8-1-5, Illusions Leading to Spatial Disorientation: "Various complex motions and forces and
certain visual scenes encountered in flight can create illusions of motion and position. Spatial disorientation from these illusions can be prevented only by visual
reference to reliable, fixed points on the ground
or to flight instruments ...A rapid acceleration . can create the illusion of being in a nose up attitude. The disoriented pilot will push the aircraft into a nose low,
or dive attitude. A rapid deceleration by a quick reduction of the throttles can have the opposite effect, with the disoriented pilot pulling the aircraft into a nose
up, or stall attitude .. An abrupt change from climb to straight and level flight can create the illusion of tumbling backwards. The disoriented pilot will push the
aircraft abruptly into a nose low attitude, possibly intensifying this illusion".
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11/03/2013 1230 CST Regis# N981PA
Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY A36
Acft SN E-3599
Eng Mk/Mdl CONTINENTAL IO550
Opr Name: ANDERSON GREG
Hayden, CO
Apt: Yampa Valley HDN
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Summary
During a straight in approach to land to runway 28, the pilot flew the airplane with a side slip while maintaining runway centerline. At about ten feet above the
runway a gust of wind blew the airplane right of centerline and the pilot corrected the airplane back to the runway's centerline. Upon touchdown, the pilot
reported that a crosswind blew the airplane's nose to the right, the airplane touched down 10 to 20 degrees right of runway heading, and exited the right side of
the runway, making contact with objects off the runway. Both wings sustained substantial damage. Winds reported on the field about the time of the accident
were 250 degrees at 23 knots with gusts to 29 knots. The pilot reported no mechanical malfunctions or failures with the airplane prior to the accident that would
have resulted in abnormal operation of the airplane.
Cause Narrative
THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's inadequate
compensation for the crosswind, which resulted in a loss of directional control and runway excursion.
Events
1. Landing-flare/touchdown - Loss of control on ground
2. Landing-flare/touchdown - Runway excursion
1. Environmental issues-Conditions/weather/phenomena-Wind-Crosswind-Response/compensation - C
Narrative
During a straight in approach to land to runway 28, the pilot flew the airplane with a side slip while maintaining runway centerline. At about ten feet above the
runway a gust of wind blew the airplane right of centerline and the pilot corrected the airplane back to the runway's centerline. Upon touchdown, the pilot
reported that a crosswind blew the airplane's nose to the right, the airplane touched down 10 to 20 degrees right of runway heading, and exited the right side of
the runway, making contact with objects off the runway. Both wings sustained substantial damage. Winds reported on the field about the time of the accident
were 250 degrees at 23 knots with gusts to 29 knots. The pilot reported no mechanical malfunctions or failures with the airplane prior to the accident that would
have resulted in abnormal operation of the airplane.
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06/19/2014 1030 CDT Regis# N784SH
Moscow Mills, MO
Apt: Greensfield Airport M71
Acft Mk/Mdl ROBINSON R22 - BETA
Acft SN 3622
Eng Mk/Mdl LYCOMING O-360-J2A
Acft TT
Fatal
Opr Name: HELICOPTER SERVICES AND
TECHNOLOGIES, LLC
Opr dba: HELISAT
111
0
Ser Inj
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Autorotation - Loss of control in flight
Narrative
On June 19, 2014, at 1030 central daylight time, a Robinson Helicopter Company R-22 Beta, N784SH, impacted terrain during a practice autorotation at
Greensfield Airport (M71), Moscow Mills, Missouri. The helicopter sustained substantial damage. The flight instructor and student pilot sustained minor injuries.
The helicopter was operated by Helicopter Services and Technologies, LLC (DBA HeliSat) under 14 CFR Part 91 as an instructional flight. Visual
meteorological conditions prevailed at the time of the accident. The flight was not operating on a flight plan and departed from the operator's facility in Moscow
Mills, Missouri, about 0930 on a local flight
The flight instructor stated that training flight began about 0930 with normal takeoffs, landings, and autorotations at M71. At approximately 10:30, the student
pilot began to perform a 180-degree autorotation. While turning towards the runway during a 180-degree autorotation, with the RPM just above the green arc
and with an airspeed of 65 knots, helicopter began to "fall" through about 100 feet above ground level. The instructor took the flight controls and tried to roll on
the throttle and flare the helicopter before it touched down onto the ground.
Examination of the helicopter by a Federal Aviation Administration maintenance inspector revealed no mechanical anomalies that would have precluded normal
operation. The sprag clutch was removed and examined at Robinson Helicopter Company under the supervision of personnel from the Los Angeles Aircraft
Certification Office and Manufacture Inspection District Office.
The report of the sprag clutch examination (A166-1 clutch shaft serial number 9795, A188-2 sprag assembly serial number 10453, and the A184-1 support
bearing) stated, in part:
The sheave was rotated by hand in the direction of normal rotation, the clutch shaft moved with the sheave, as the sheave was rotated opposite the direction of
normal rotation, the sheave freewheeled on the shaft. A slight roughness was felt when rotating the shaft.
Both yokes and support bearing were removed. The forward retainer plate was removed and the oil was drained from the assembly. The oil appeared black but
still had a red tint to it. The oil did not smell burnt. Approximately 9 milliliters was recovered from the assembly (typical clutch assembly contains approximately
17 milliliters). The recovered oil was scanned with a magnet and a small, thin metallic chip was recovered.
The bearings were pressed out of the sheave and off of the shaft and the sprag assembly removed. Both bearings had rough spots when rotated by hand. Both
bearings were flushed with solvent and afterward the bearings rotated smoothly. The flushing solvent from both bearings was scanned with a magnet and
several very small, metallic slivers were recovered. The bearing contact surface of the inner and outer races were visually examined, no discoloration or
damage was noted.
The inner contact surface of several sprags of the sprag assembly had small areas of the surface plating (proprietary to Formsprag) gouged/chipped away with
one sprag having a larger area damaged. The outer surface of the sprags appeared normal.
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The sprag surface of the clutch shaft and the sheave had several scuff marks that appeared to match the size and spacing of the sprags with two areas on the
shaft that match the shape of the more damaged sprag. There was no other rotational scoring of the sprag surfaces. The diameter of the sprag surface on the
clutch shaft was measured and verified to be within production specifications.
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07/02/2014 1500 CDT Regis# N225TV
Acft Mk/Mdl ROBINSON HELICOPTER
Acft SN 0253
Eng Mk/Mdl LYCOMING 0-540 SERIES
Opr Name: KC COPTERS
Olathe, KS
Apt: Johnson County Executive OJC
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
AW Cert: STN
Events
1. Standing-engine(s) shutdown - Miscellaneous/other
Narrative
The pilot reported he landed at the airport without incident. During engine shutdown, he applied rotor brake to slow the main rotor blades. When the pilot
released the brake, he heard a bang and felt an impact to the aircraft on the rear left side. He reapplied the main rotor brake intermittently until the blades
stopped. The pilot exited the aircraft and noticed a tail boom strike occurred. He stated he input aft cyclic during landing to accommodate landing slightly
downhill and did not place the controls in neutral during shutdown. According to the manufacture's shutdown procedures, the cyclic and pedals should be in the
neutral position.
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07/27/2013 1255
Regis# N25WH
Thompson Falls, MT
Apt: N/a
Acft Mk/Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 10481
Eng Mk/Mdl LYCOMING IO-540 SER
Acft TT
Fatal
Opr Name: ROCKY MOUNTAIN ROTORS
Opr dba:
786
1
Ser Inj
1
Aircraft Fire: NONE
Summary
The helicopter was flying northeast following a line of utility poles for the aerial survey flight. A surviving passenger, who occupied the left rear seat, reported
that the helicopter began to rotate in a clockwise direction just before impact. A second surviving passenger, who occupied the left front seat, stated that the
helicopter was flying straight and level before it began to spin. He added that, before impact, he heard the low rotor rpm warning horn. The helicopter impacted
heavily forested terrain in a steep nose-down, right-bank attitude. At the time of the accident, the helicopter was about 200 lbs below its maximum gross weight.
Wind was calculated to be between 2 and 16 knots from the southwest with maximum gusts of about 20 knots near the accident site, which would have
resulted in a tailwind condition. Examination of the helicopter did not reveal any anomalies that would have precluded normal operation.
Video footage recorded by a passenger showed the helicopter traveling about 39 knots on a northeasterly heading and at an altitude of about 200 ft above
ground level. The groundspeed then began to decay to about 30 knots over a period of about 30 seconds. The helicopter then yawed right, and the
groundspeed dropped to 22.6 knots. The helicopter then appeared to develop an uncontrollable right spin, and the video ended with the helicopter crashing into
the forest below. It is likely that the combination of the helicopter's high gross weight, the reduction in airspeed, and the tailwind condition led to a loss of tail
rotor effectiveness, which resulted in the right yaw from which the pilot did not recover control.
Cause Narrative
helicopter control while operating in conditions conducive to a loss of tail rotor effectiveness.
Events
1. Maneuvering-low-alt flying - Loss of tail rotor effectiveness
2. Maneuvering-low-alt flying - Loss of control in flight
3. Maneuvering-low-alt flying - Collision with terr/obj (non-CFIT)
2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Prop/rotor parameters-Capability exceeded - C
3. Environmental issues-Conditions/weather/phenomena-Wind-Tailwind-Effect on equipment - C
4. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Airspeed-Not attained/maintained - C
5. Aircraft-Aircraft oper/perf/capability-Aircraft capability-Maximum weight-Not specified
Narrative
***This report was modified on April 16, 2015. Please see the docket for this accident to view the original report.***
HISTORY OF FLIGHT
On July 27, 2013, about 1255 mountain daylight time, a Robinson R44 II helicopter, N25WH, was substantially damaged following a loss of control and
subsequent impact with terrain near Thompson Falls, Montana. The helicopter was registered to Zoot Helicopter I LLC, of Bozeman, Montana, and operated by
Rocky Mountain Rotors, of Belgrade, Montana. The certified commercial pilot received fatal injuries; one passenger sustained serious injuries, and a second
passenger suffered minor injuries. Visual meteorological conditions prevailed for the aerial survey flight, which was being conducted in accordance with 14
Code of Federal Regulations Part 91, and no flight plan was filed. The flight departed the Polson Airport (8S1), about 2 hours prior to the time of the accident.
The intended destination was Thompson Falls.
According to the passenger who sustained minor injuries, the purpose of the flight was to photo document the condition of cross-country power lines and their
supporting wooden structures. The passenger reported that the pilot occupied the right front seat, his associate, who was operating videotaping equipment,
occupied the left front seat, and he occupied the left rear seat taking still photographs. The passenger stated that initially everything was going fine, and that
they were about 50 feet from the power lines and about 50 feet above them. However, the helicopter started to rotate in a clockwise orientation, about 4
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revolutions prior to impact with terrain. He described the impact attitude of the helicopter as being very steep, nose down, and banked to the right. There was
no postcrash fire.
About 6 months after the accident, the left-front-seat passenger, who was assigned to operate the onboard video camera, was interviewed via telephone by the
National Transportation Safety Board (NTSB) investigator-in-charge (IIC). The passenger stated that prior to the start of the helicopter spinning it was flying
straight and level, and the next thing he remembered was the helicopter impacting a tree. He further stated that prior to impact he heard the Low Rotor rpm
warning horn, as he had heard several times [during the starting of the helicopter's engine]. The passenger further stated that prior to the start of the spin, he
did not recall any adverse wind conditions.
An NTSB Vehicle Recorder Specialist was able to download recorded data from an onboard Sony Handycam HDR CX550 recorder; the unit was equipped with
a Global Positioning System (GPS) receiver. The recorder captured the entire accident sequence. The specialist's review of the data revealed the following:
The helicopter was initially observed operating about 8.5 nautical miles west-southwest of Thompson Falls, Montana, along the Montana Secondary Highway
471. About 1248, the helicopter was circling over a power substation at a groundspeed between 40 to 50 knots, at an altitude of about 3,400 feet mean sea
level (msl). About 1250, the helicopter departed the substation and began following a line of utility poles northeast bound. About 1251, the helicopter was
observed in a left-hand circle around a group of utility poles near a creek at an altitude of 3,226 feet msl. At 1251:38, the helicopter departed back to the
northeast and continued to follow utility poles at a speed of 42 knots at an altitude of 3,220 feet msl. The helicopter then entered two more circles to the left at
1252:12, at which time its speed varied between 30 to 40 knots. At 1254:26, the helicopter was re-established on a northeast heading along the utility line at an
altitude of 3,162 feet msl and a groundspeed of 39 knots; by 1255:00, the helicopter's groundspeed had decayed to 30 knots. At 1255:02, the helicopter began
to yaw to the right as its speed further decayed to 22.6 knots at 1255:04. The helicopter completed a 360-degree spin by 1255:06 and continued to spin to the
right. The GPS track continued to deviate for the remainder of the recording, and the groundspeed fluctuated below 22.6 knots until the recorded data
terminated. Just before impact, the pilot's feet are shown and the left pedal is deflected forward. The helicopter struck trees about 1255:13, then the recording
ended.
The pilot, age 35, possessed a commercial pilot certificate with ratings for rotorcraft-helicopter and instrument helicopter. He also held a certified flight instructor
certificate with ratings for rotorcraft-helicopter and instrument helicopter. Additionally, the pilot held private pilot privileges for airplane single-engine land.
A review of the pilot's personal logbook, together with records provided by the Federal Aviation Regulation (FAR) Part 135 aeromedical company that he was
employed by, revealed that about 1 month prior to the accident the pilot had accumulated a total flying time of 3,299.5 hours, of which 376.9 hours were in the
same make and model as the accident helicopter.
Records also revealed that the pilot had completed his most recent Federal Aviation Administration (FAA) flight review in accordance with FAR 61.56 on July
24, 2013. The pilot's most recent second-class FAA airman medical certificate was issued on February 13, 2013, with no limitations noted.
The helicopter was a Robinson R44 II, serial number 10481, manufactured in 2004. The operator reported that the helicopter's maximum gross weight was
2,500 pounds, that it seated four, and that it would have weighed about 2,300 pounds at the time of the accident.
The helicopter was powered by a 245-horsepower Lycoming IO-540-AE1A5 engine. The last annual maintenance inspection was conducted on July 8, 2013, at
a total airframe and engine time of 786.2 hours. The helicopter had a total of 799 hours at the time of the accident, as it had operated 13 hours since its last
maintenance inspection.
The examination of the maintenance records also revealed that on December 27, 2012, at a total airframe time of 778.9 hours, "Fuel bladder tanks installed.
Aircraft returned to service." Additionally, the entry noted that this work "Complied with Robinson Helicopter Company SB-78B, using Robinson Helicopter Kit
KI-196-2, IAW kit instruction KI-196-2, Revision "B" dated 10 Jan 2011. Revised Weight and Balance."
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An NTSB Meteorological Specialist reported that a review of the available weather in the area of where the accident occurred, included the following:
The National Weather Surface (NWS) Surface Analysis Chart for 1200 MDT depicted that a low pressure center was located at the central portion of Montana's
border with Canada. A stationary front extended south-southeastward from the low pressure center into north-central Colorado. Another low pressure center
was identified along the eastern portion of the Washington/Oregon border.
Many station models in the accident region depicted clear skies, with winds across the region generally 10 knots or less, with direction variable. Temperatures
near the accident site were from the mid-70 degrees F to the mid-80 degrees F, with dew points ranging from about 30 degrees F to 60 degrees F.
A composite radar imagery mosaic at 1300 MDT of the accident region from the National Severe Storms Laboratory's National Mosaic and Q2 System did not
identify any areas of reflectivity near the accident site.
An Automated Surface Observing System station (ASOS) named KMLP, was located near the Mullan Pass VOR in Mullan Pass, Idaho, about 8 nautical miles
(nm) to the southwest of the accident site at an elevation of about 6,000 feet mean sea level (msl). At 1253 MDT, KMLP reported wind variable at 4 knots,
visibility of 10 miles or greater, clear skies, temperature 19 degrees C, dew point 2 degrees C, and an altimeter setting of 30.17 inches of mercury.
U.S. Bureau of Land Management/USDA Forest Service Remote Automated Weather System (RAWS) station THAM8, was located about 10 miles to the
east-northeast of the accident site at an elevation of about 2,426 feet msl. At 1302, THAM8 reported a temperature of 88 degrees F, a dew point temperature of
47.9 degrees F, relative humidity of 17 percent, and wind from 317 degrees at 7.8 knots with gusts to 17.4 knots. Feedback from the NWS Office in Missoula,
Montana, regarding the THAM8 revealed that there was no reason to question wind speeds reported at 1302, and that they appeared to be consistent with the
increasing westerly winds reported on the day of the accident at similarly sited (valley) stations.
The NTSB Specialist reported that a Weather Research and Forecasting Model (WRF) simulation was run to estimate wind conditions in the area of the
accident site at 1300. WRF simulations of the wind identified sustained wind magnitudes of generally between 2-16 knots through the region, with the wind
being from nearly the southwest at the accident site. Wind gust simulations yielded a maximum gust magnitude of close to 20 knots near the accident site.
An Area Forecast Discussion was issued at 0930 MDT by the NWS Forecast Office in Missoula for an area that included the accident location. In part, the
discussion revealed that a trough moving through British Columbia would flatten the ridge in Idaho and western Montana, with an increase in winds expected
during the afternoon as a westerly pressure gradient developed, with afternoon winds approaching 25 knots at times.
A Red Flag Warning was issued at 0402 by the NWS Forecast Office in Missoula for an area east of the accident location effective at 1200. The warning
message advised of west winds of 15 to 20 miles-per-hour (mph) with gusts to 30 mph. The warning indicated that winds would begin to increase around
mid-day, and peak in the late afternoon/early evening.
The accident pilot did not receive a DUAT, DUATS or Lockheed Martin Flight Services telephone weather briefing prior to the accident flight. It is not known if
the pilot received preflight weather information from another source.
(Refer to the NTSB Group Chairman's Factual Meteorology Report, which is located in the docket for this report.)
On July 28, 2013, representatives from the NTSB, the FAA, Robinson Helicopters, and Lycoming Motors examined the helicopter at the site of the accident.
The examination revealed that the helicopter had impacted heavily forested terrain in a steep nose low, right bank attitude, at an elevation of 2,915 feet msl,
and subsequently came to rest on its right side, on a measured magnetic heading of 178 degrees. The impact heading could not be determined. All
components necessary for flight were accounted for at the accident site. The helicopter was recovered to a secured location for further examination.
On July 30, 2013, under the supervision of the IIC, an examination of the engine and airframe was conducted at the facilities of a local salvage company
located in Belgrade, Montana. The results of the examination failed to reveal any anomalies, which would have precluded normal operation with the helicopter.
(Refer to the Summary of Aircraft Examination report, which is located in the docket for this accident.)
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An autopsy of the pilot was performed at the Montana Division of Forensic Science, Missoula, Montana, on July 29, 2013. The cause of death was listed as
"blunt force injuries."
Toxicological testing on the pilot was performed by the FAA Civil Aeromedical Institute's (CAMI) Forensic Toxicology and Accident Research Center at
Oklahoma City, Oklahoma. The toxicological tests were negative for alcohol and drugs.
TESTS AND RESEARCH
Examination of Fuel Tanks
On August 29, 2013, under the supervision of an NTSB accident investigator, both the main and auxiliary fuel tanks, along with the instrument cluster,
underwent functional testing at the facilities of Robinson Helicopter Company, Torrance, California. The results of the examination revealed the following:
Main Fuel Tank
The main fuel tank, which held a total of 30.5 US gallons, was visually examined. The aluminum skins were dented and/or creased, and the mounting holes
were torn away at the edges. Portions of the mounting brackets remained attached to the tank. The tank was temporarily fitted to an exemplar airframe,
ensuring proper angles. The instrument cluster was wired to the fuel quantity sending unit, and a warning light was wired to the Low Fuel Warning (LFW)
sending unit. With power applied, the Main Fuel Tank Operating Indicator (MFI) read EMPTY, and the LFW light illuminated. Subsequent to 30 gallons of water
poured into the tank, the MFI read FULL. When 9.5 gallons was drained, the MFI continued to read FULL. A light tap on the tank resulted in the MFI dropping to
just below the 3/4 mark. When the MFI was observed at the 1/2 mark, 14.34 gallons of fuel had been drained, 14.55 gallons remained. When the MFI was at
the 1/4 mark, 21.28 gallons had been drained, leaving 7.61 gallons remaining. After draining 24.46 gallons, the LFW light illuminated; 4.43 gallons of fuel
remained. When the MFI was at the EMPTY mark and the flow of water stopped, 28.89 gallons had been drained, leaving about 1.11 gallons of unusable liquid
in the tank.
Auxiliary Fuel Tank
A visual inspection of the tank, which had a capacity of 17.2 US gallons, revealed that the aluminum skins were dented, which reduced the capacity of the tank,
and the mounting holes were torn away at the edges. The tank was temporarily fitted to an exemplar airframe, which insured proper angles. The instrument
cluster was wired to a power source and the sending unit. When power was applied, the Auxiliary Fuel Tank Operating Indicator (AFI) read empty.
Approximately 17 gallons of water was poured into the tank; the AFI needle read FULL. When the AFI was at the 1/2 mark, 8.80 gallons had been drained, with
8.2 gallons remaining. When the AFI was at the 1/4 mark, 12.91 gallons had been drained, with 4.09 gallons remaining. When the AFI was observed at the
EMPTY mark and the flow of water halted, 17 gallons had been drained.
Both fuel quantity sending units, the Low Fuel Sending unit, and both indicators were observed to have functioned within factory specifications.
The FAA Rotorcraft Flying Handbook, publication FAA-H-8030-21, Unanticipated Yaw/Loss of Tail Rotor Effectiveness (LTS), states in part that unanticipated
yaw is the occurrence of an uncommanded yaw rate that does not subside of its own accord and, which, if not corrected, can result in the loss of helicopter
control. This uncommanded yaw rate is referred to as a loss of tail rotor effectiveness (LTE) and occurs to the right in helicopters with counter-rotating main
rotor and to the left in helicopters with a clockwise main rotor rotation. LTE is not related to an equipment or maintenance malfunction and may occur in all
single-rotor helicopters at airspeeds less than 30 knots. It is the result of the tail rotor not providing adequate thrust to maintain directional control. The required
tail rotor thrust is modified by the effects of the wind. The wind can cause an uncommanded yaw by changing tail rotor effective thrust.
FAA Advisory Circular (AC) 90-95, Unanticipated Right Yaw in Helicopters, dated February 26, 1995 states that the loss of tail rotor effectiveness (LTE) is a
critical, low-speed aerodynamic flight characteristic which could result in an uncommanded rapid yaw rate which does not subside of its own accord and, if not
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corrected, could result in the loss of aircraft control. It also states, "LTE is not related to a maintenance malfunction and may occur in varying degrees in all
single main rotor helicopters at airspeeds less than 30 knots."
Paragraph 6 of the AC covered conditions under which LTE may occur. It states:
"Any maneuver which requires the pilot to operate in a high-power, low-airspeed environment with a left crosswind or tailwind creates an environment where
unanticipated right yaw may occur."
Paragraph 8 of the AC states:
"OTHER FACTORS...Low Indicated Airspeed. At airspeeds below translational lift, the tail rotor is required to produce nearly 100 percent of the directional
control. If the required amount of tail rotor thrust is not available for any reason, the aircraft will yaw to the right."
Paragraph 9 of the AC states: "When maneuvering between hover and 30 knots: (1) Avoid tailwinds. If loss of translational lift occurs, it will result in an
increased high power demand and an additional anti-torque requirement. (2) Avoid out of ground effect (OGE) hover and high power demand situations, such
as low-speed downwind turns. (3) Be especially aware of wind direction and velocity when hovering in winds of about 8-12 knots (especially OGE). There are
no strong indicators to the pilot of a reduction of translation lift. (4) Be aware that if considerable amount of left pedal is being maintained a sufficient amount of
left pedal may not be available to counteract an unanticipated right yaw. (5) Be alert to changing aircraft flight and wind conditions which may be experienced
when flying along ridge lines and around buildings. (6) Stay vigilant to power and wind conditions."
Robinson Helicopters Safety Notice SN-42, UNANTICIPATED YAW, issued May, 2013, states that a pilot's failure to apply proper pedal inputs in response to
strong or gusty winds during hover or low-speed flight may result in an unanticipated yaw. Some pilots mistakenly attribute this yaw to loss of tail rotor
effectiveness (LTE), implying that the tail rotor stalled or was unable to provide adequate thrust. Tail rotors on Robinson helicopters are designed to have more
authority than many other helicopters and are unlikely to experience LTE. To avoid unanticipated yaw, pilots should be aware of conditions (a left crosswind, for
example) that may require large or rapid pedal inputs. Practicing slow, steady-rate hovering pedal turns will help maintain proficiency in controlling yaw. Hover
training with a qualified instructor in varying wind conditions may also be helpful.
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04/15/2015 1630 CDT Regis# N754R
Dunlap, IL
Acft Mk/Mdl ROBINSON HELICOPTER COMPANY R44 Acft SN 11318
Rpt Status: Prelim
Eng Mk/Mdl LYCOMING IO-540-AE1A5
Fatal
Opr Name:
0
Ser Inj
Opr dba:
0
Prob Caus: Pending
Aircraft Fire: NONE
AW Cert: STN
Events
1. Enroute-climb to cruise - Sys/Comp malf/fail (non-power)
Narrative
On April 15, 2015, at 1630 central daylight time, a Robinson R44II helicopter, N754R, rolled over during an off airport precautionary landing in Dunlap, Illinois.
The commercial pilot and passenger were not injured. The helicopter was substantially damaged. The helicopter was registered to and operated by the pilot
under the provisions of 14 Code of Federal Regulations Part 91 as an aerial observation flight. Visual meteorological conditions prevailed for the flight, which
was not operated on a flight plan. The flight originated from the Pekin Municipal Airport (C15), Pekin, Illinois.
The pilot stated they had been counting geese at an altitude of 300 feet above the ground at an airspeed of 60 knots just prior to the accident. He stated he
increased the collective to transition to another area when he noticed an increase in engine rpm and a decrease in rotor rpm along with a main rotor warning
light. The pilot initiated a downwind autorotation to a plowed field. The pilot stated that due to the tailwind and forward speed, the helicopter tipped forward on
its skids, the main rotor contacted the ground and the helicopter rolled over.
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08/10/2014 1020 PDT Regis# N4533K
Acft Mk/Mdl RYAN NAVION-B
Acft SN NAV-4-1533
Eng Mk/Mdl CONTINENTAL MOTORS IO-520 SERIES Acft TT
Opr Name: FLAUGHER JONATHAN
3548
Fresno, CA
Apt: Sierra Sky Park Airport E79
Fatal
0
Ser Inj
Opr dba:
0
Aircraft Fire: NONE
Events
1. Approach-VFR pattern final - Loss of engine power (partial)
Narrative
On August 10, 2014, about 1020 Pacific daylight time, a Ryan Navion, N4533K, experienced a partial loss of engine power during approach to land at Sierra
Skypark Airport (E79) in Fresno, California. The pilot and two passengers were uninjured and the airplane sustained substantial damage to the left wing. The
airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological
conditions prevailed for the flight, and no flight plan was filed. The flight originated from Madera Municipal Airport (MAE), Madera, California at about 0950.
The pilot reported that the accident flight was the second flight of the day; the airplane was operating as usual and showed no indications of a potential
malfunction. When approaching the destination airport to land, the pilot entered the traffic pattern for the runway. While on short final, the pilot increased power
to maintain the glideslope when he heard a muffled bang or chug followed by the engine sounding "as if it was drowning." The airplane started to descend, and
the pilot executed an off airport landing. During the landing sequence, the left wing impacted a fence, before the airplane traversed across a median, and came
to rest against a second fence.
A postaccident examination by a Federal Aviation Administration Inspector revealed that the fuel system was intact and evidence of fuel was noted throughout.
The spark plugs were removed and no damage was noted. The engine was rotated by hand and compression was evident on all six cylinders, the magneto
impulse coupling also fired. The oil filter was removed and found to be clear of debris. The propeller blade tips were curled forward.
At the conclusion of the engine examination no preimpact mechanical malfunctions or failures were revealed that would have precluded normal operation.
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04/15/2015 2300 EDT Regis# N688AN
Acft Mk/Mdl SHORT BROS SD 360-300-VARIANT30
Opr Name: AIR CARGO CARRIERS
Page 88
Acft SN SH3633
Greer, SC
Apt: Greenville Spartanburg Intl GSP
Rpt Status: Prelim
Fatal
0
Ser Inj
Opr dba:
Air Data Research
0
Prob Caus: Pending
Aircraft Fire: NONE
All Rights Reserved

National Transportation Safety Board

Transcription

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